How Does a Transjugular Intrahepatic Portosystemic Shunt (TIPS) Work?

A transjugular intrahepatic portosystemic shunt (TIPS) connects the hepatic vein and portal vein in the liver with a stent.

A transjugular intrahepatic portosystemic shunt (TIPS) is an artificial connection that is created by a radiologist between two veins (hepatic vein and portal vein) in the liver. These veins are connected by a small tube known as a stent.

The TIPS procedure is performed in patients who have increased pressure in their portal vein (portal hypertension), which is usually due to scarring and hardening of the liver (liver cirrhosis).

A transjugular intrahepatic portosystemic shunt (TIPS) procedure is used to treat the complications of portal hypertension that fail to respond to medicines. These complications are as follows:

• Variceal bleeding (bleeding from any of the veins that normally drain the digestive organs into the liver)
• Severe ascites (accumulation of fluid in the abdomen)
• Hepatic hydrothorax (fluid accumulation in the chest due to liver disease)

The TIPS procedure is also performed in patients

• After liver transplantation
• With hepatorenal syndrome (development of kidney failure with advanced chronic liver disease)
• With Budd-Chiari syndrome (a blockage in any of the hepatic veins)

Blood from all the veins of the digestive system drains into the superior and inferior mesenteric veins; these two vessels are then joined by a splenic vein to form the portal vein. Thus, the portal vein carries blood from the digestive organs to the liver. Then, there are hepatic veins that carry blood away from the liver back to the heart.

Conditions such as liver cirrhosis increase the pressure in the portal veins, which puts back pressure in the veins of the digestive tract. This results in enlarged veins (engorged veins) that may lead to bleeding.

By creating a transjugular intrahepatic portosystemic shunt (TIPS), the blood flow from the enlarged veins of the digestive organs is redirected to the hepatic veins. This reduces the increased blood pressure in the portal veins and thus prevents subsequent complications.

Before the procedure

• The doctor orders either ultrasonography (USG) report or computed tomography (CT) scan of the abdomen to check the status of the veins in the liver.
• The doctor instructs the patient to discontinue certain medicines for a few days before the procedure.
• The patient is asked not to eat or drink anything—except a few necessary medicines—for 8-12 hours before the procedure.

During the procedure

• The patient may be given a sedative medicine to make him relax during the procedure.
• The doctor inserts a flexible tube into the patient’s neck by making a small incision of ≤1 cm. On the end of this tube is a tiny balloon attached to a metal stent.
• Using a medical dye and an X-ray machine (fluoroscopy) that help in visualizing the internal structures, the doctor directs the tube into the portal vein.
• The balloon is inflated to fix the stent at an appropriate place in the vein. The patient may feel a little pain at this time.
• The doctor uses the stent to connect the portal vein to one of the three hepatic veins.
• The portal vein pressure is measured to check if it has been reduced with this procedure.
• The tube and balloon are then removed from the patient’s neck.
• After the procedure, the wound is cleaned and covered with a sterile bandage.
• The procedure is completed in about 60-90 minutes.

After the procedure

• The patient is monitored for a few hours. During this period, the patient’s head is kept elevated. Usually, they get discharged on the next day of the procedure. 
• If there is significant bleeding, the patient is shifted to the intensive care unit (ICU) and discharged after a few days.

Possible risks associated with the transjugular intrahepatic portosystemic shunt (TIPS) procedure are as follows:

• Internal bleeding
• Injury to the liver and heart
• Infection of the stent
• Hepatic encephalopathy (an advanced liver disease that leads to brain damage/coma)
• Heart failure
• Allergic reaction to the dye
• Blockage in the stent

• The transjugular intrahepatic portosystemic shunt (TIPS) procedure is much safer than surgery, and its recovery period is fast. Most people recover well.
• The TIPS procedure improves the condition in about 80 to 90% of the patients with portal hypertension.
• Many people can resume their routine activities within 7-10 days.
• After a few weeks, the doctor will ask the patient for an ultrasonography (USG) report to check if the stent is working correctly.