B-27: Transjugular Intrahepatic Portosystemic Shunt (TIPS)
  • Indications
    • Portal hypertension with recurrent or intractable variceal bleeding
    • Portal hypertension with refractory ascites or hepatic hydrothorax
  • Contraindications
    • Contrast allergy (premedicate)
    • Platelets count < 50,000
  • Patient Evaluation
    • Able to lie flat on table and cooperate during procedure
    • Need for anesthesia (unstable, uncooperative, etc.)
    • Ultrasound and Doppler evaluation of portal vein
  • Preprocedure Orders
  • Tools
    • Micropuncture access set and vascular dilators size 6, 8 and 10 Fr.
    • Bentson and 180cm Amplatz wires
    • 5 Fr. pigtail catheter, pressure transducer set up
    • Ring portal venous access set
    • Angioplasty balloons (8mm and 10mm), WallStents
  • Entry site
    • Right internal or external jugular
    • Left internal jugular vein
  • Technique
    • Micropuncture entry into jugular vein. Dilate entry and place 9 Fr. sheath into IVC. Record IVC and RA pressures through sheath. Perform IVC-gram. Withdraw sheath into RA. Measure simultaneous portal and right atrial pressures. Perform portal venogram.
    • Select right or middle hepatic vein with curved catheter and advance sheath into vein. Perform non-wedged venogram.
    • Insert Colapinto needle and guiding catheter through sheath and puncture through hepatic vein wall and into portal vein. Confirm portal vein entry by aspiration and contrast injection. Advance Bentson wire into portal vein. Advance guiding catheter over needle, and sheath over guiding catheter. Remove needle. Insert Van Andal catheter into portal vein over Bentson and exchange for Amplatz wire. Remove Van Andal and guiding catheter and insert pigtail into portal vein.
    • Pre-dilate parenchymal tract with 8mm angioplasty balloon. Introduce and implant WallStent(s). Dilate with 10mm angioplasty balloon. Reintroduce pigtail and measure simultaneous portal and RA pressures. Repeat portal venogram. If shunt is satisfactory, remove catheter and exchange sheath for standard 9 Fr. x 10cm vascular sheath. Suture sheath in place and place to TKO drip.
    • If shunt is unsatisfactory, additional angioplasty or stenting will be required. Occasionally a second shunt will be necessary. Some patients will also require embolization of varices during procedure.
  • Post-procedure Note
    • Record pre- and post-TIPS pressure gradients
    • Report ancillary procedures such as biopsy or embolization
  • Post-procedure Orders
    • Use preprinted standard orders for TIPS (see Appendix C6)

| Previous | Next |