What Is Meant by Transjugular Intrahepatic Portosystemic Shunt (TIPS)?
Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure done within the liver to connect two veins using X-ray guidance. First, a stent is placed to keep the shunt. An interventional radiologist does this procedure with the use of image guidance. Next, a tunnel is made through the liver to connect the portal vein, which carries the blood from the digestive organs to the liver to the hepatic vein (the vein that carries blood from the liver to the heart). After that, a stent is placed in the shunt to keep it open. This procedure is done in patients with portal hypertension.
Portal hypertension can result in the backflow of blood from the liver back to the veins in the spleen, intestines, and lower esophagus, resulting in enlarged vessels, bleeding, and blood pooling in the chest or abdomen. This condition is seen in people with chronic liver conditions like cirrhosis. This may also be seen in children, but they do not require a transjugular intrahepatic portosystemic shunt.
Why Is It Done?
In a normal individual with a normal liver, the blood from the intestines, spleen, and stomach flows through the liver. But when there is damage or blockage in the liver, the blood cannot flow through it. This condition is known as portal hypertension. The increased pressure results in a backflow of blood to the organs in the abdomen from the portal veins. Due to this increased pressure, the vein can rupture and cause bleeding.
Common causes of portal hypertension are:
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Cirrhosis - Excessive alcohol use resulting in scarring of the liver tissue.
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Blood Clots - Blood clots in the vein that carries blood to the heart from the liver.
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Hemochromatosis - Increased iron levels in the liver.
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Hepatitis B or Hepatitis C - This can cause excessive liver scarring.
The symptoms of portal hypertension are:
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Variceal Bleeding - Bleeding from the intestines, stomach, or esophagus veins.
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Ascites - Pooling of fluid in the abdomen.
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Hydrothorax - Collection of fluid in the chest.
This procedure allows proper blood flow into the heart, back from the liver, esophagus, and intestines.
How Is It Done?
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TIPS is done by inserting a flexible tube called the catheter through the skin into the vein in the neck called the jugular vein. The catheter has a tiny balloon and a metal mesh stent at the end of the catheter.
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The catheter is inserted into the vein in the liver using an X-ray machine.
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To make it more visible, a dye, which is a contrast material, is inserted into the vein.
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The balloon is then inflated to place the stent; the patient might experience pain during this time.
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The doctor connects the portal vein to the hepatic vein using a stent.
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The portal vein pressure is measured at the end of the procedure to ensure it is controlled.
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Then the catheter is then removed.
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A small bandage is placed over the neck area, and there are usually no stitches.
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The procedure lasts for about 60 to 90 minutes to complete.
What Are the Benefits and the Risks Associated With TIPS?
The benefits of the transjugular intrahepatic portosystemic shunts are:
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A TIPS is designed in such a way as to produce a physiological result similar to a surgical shunt or bypass without doing the surgery.
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TIPS has a shorter recovery time than surgery as it is minimally invasive.
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The TIPS procedure will have less effect on future liver transplantation if required than an open surgical bypass as there is minimal scar formation in the abdomen.
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The stent placed to keep the shunt open is placed entirely inside the affected liver so it is removed during transplantation.
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The TIPS is effective in reducing variceal bleeding in the majority of cases.
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There is no requirement for an incision on the skin; instead, a small nick is made in the skin and does not require stitches.
The risks of TIPS are mentioned below:
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The procedure which requires penetration through the skin will have the risk of infection, but the risk of getting an infection and requiring antibiotic treatment is less than one in 1000 people.
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The chance of allergic reaction towards the contrast material used for the venograms. There is a concern for kidney failure (permanent or temporary) from using the contrast material, especially in people with affected kidney function.
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There are certain risks in cases where the catheter is inserted inside the blood vessels. There is a risk of damage to the blood vessels, bruising, or bleeding at the puncture site and infection. The doctor will take appropriate measures to prevent these infections.
Other possible complications of the procedure include:
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Stiffness of muscles in the neck.
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There is bruising at the point of insertion in the neck.
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There can be a delay in stenosis or narrowing inside the stent, but it is less common with the new generation stents.
Other serious complications were seen in very few people, less than five percent of people, and they include:
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Complete blockage of the stent and rapid occurrence of the symptoms.
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Infection of the stent.
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There may be abdominal bleeding that requires a blood transfusion.
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There can be severe liver injury or bleeding resulting from a laceration to the hepatic artery, requiring immediate intervention or transfusion.
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Congestive heart failure or heart arrhythmias.
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A rare complication is radiation injury to the skin (it may happen in complex and lengthy procedures requiring extended fluoroscopy use).
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Death.
What Are the Limitations of TIPS?
When the patient has advanced-stage liver disease, there are chances of worsening the liver condition after the transjugular intrahepatic portosystemic shunt. Therefore, if the liver failure is severe, a transjugular intrahepatic portosystemic shunt might not be used to treat the disease. Instead, a different treatment method might be opted to control the symptoms. The patient might also develop encephalopathy, a condition in which the patient is in an altered and confused mental state due to an alteration of brain function. This results from a build-up of toxic material in the blood, usually filtered out by the liver. This procedure will let these toxic substances bypass the liver, so a patient with encephalopathy due to liver disease will not be the best person to receive this treatment. Encephalopathy may be treated with a special diet, medications, or by revising the stent, but sometimes the stent must be blocked intentionally to solve the problem.
Conclusion
Transjugular intrahepatic portosystemic shunts is a procedure done to connect the portal veins to the adjacent blood vessels guided through X-ray. The shunt is kept open by using a stent. Since it is an X-ray-guided procedure, there is no need for open surgery. However, this is done in patients with interrupted blood flow through the liver and can result in other complications. Hence if one notices any symptoms of liver disease, consult a doctor as soon as possible to avoid complications from a late diagnosis of the condition.
