Transjugular intrahepatic portosystemic shunt
Encyclopedia
A Transjugular Intrahepatic Portosystemic Shunt
(commonly abbreviated as TIPS or TIPSS, for "Stented Shunt") is an artificial channel within the liver
that establishes communication between the inflow portal vein and the outflow hepatic vein
. It is used to treat portal hypertension
(which is often due to liver cirrhosis) which frequently leads to intestinal bleeding (esophageal varices
) or the buildup of fluid within the abdomen (ascites
).
An Interventional Radiologist
creates the shunt using an image-guided endovascular
(via the blood vessel
s) approach, with the jugular vein
as the usual entry site.
The procedure was first described by Josef Rosch in 1969. It was first used in a human patient by Dr. Ronald Colapinto, of the University of Toronto
, in 1982, but did not become reproducibly successful until the development of endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the University of Freiburg
. The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical portocaval shunt in that role.
of the liver. The result is a reduced pressure drop
over the liver and a decreased portal venous pressure. This, in turn, lessens the pressure on the blood vessels in the intestine so that future bleeding is less likely to occur. The reduced pressure also makes less fluid develop, although this benefit may take weeks or months to occur.
guidance. Access to the liver, as the name transjugular suggests, is gained via the jugular vein
in the neck
. Once access to the jugular vein is confirmed, a guidewire and introducer sheath are typically placed to facilitate the shunt
's placement. This enables the interventional radiologist to gain access to the patient's hepatic vein
via the vena cava. The shunt is created by advancing a special needle through the sheath system to connect the hepatic vein to the large portal vein, near the center of the liver. The channel for the shunt is next created by inflating an angioplasty balloon within the liver along the tract created by the needle. The shunt is completed by placing a special mesh tube known as a stent
or endograft to maintain the tract between the higher pressure portal vein and the lower pressure hepatic vein. After the procedure, fluoroscopic images are made to show placement. Pressure
measurements in the portal vein and inferior vena cava are often done.
.
. In general, this can be managed with a reduction in dietary protein and medication that reduces the absorption of nitrogen.
A less common but more difficult complication is hepatic ischemia. Portal hypertension—the condition shared by all TIPS patients regardless of etiology—generally causes compensatory hypertrophy of the hepatic artery and a decreased reliance of the liver upon the portal vein for its oxygenation. For this reason, shunting of the portal blood away from hepatocytes is usually well tolerated. In some cases, however, TIPS creation can cause an ischemic injury to the liver. Acute hepatic dysfunction after TIPS may require emergent closure of the shunt.
A complication of umbilical hernia
has been recently reported.
Shunt (medical)
In medicine, a shunt is a hole or a small passage which moves, or allows movement of fluid from one part of the body to another. The term may describe either congenital or acquired shunts; and acquired shunts may be either biological or mechanical.* Cardiac shunts may be described as...
(commonly abbreviated as TIPS or TIPSS, for "Stented Shunt") is an artificial channel within the liver
Liver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
that establishes communication between the inflow portal vein and the outflow hepatic vein
Hepatic vein
In human anatomy, the hepatic veins are the blood vessels that drain de-oxygenated blood from the liver and blood cleaned by the liver into the inferior vena cava....
. It is used to treat portal hypertension
Portal hypertension
In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 10 mmHg or greater.-Causes:Causes can be divided into prehepatic, intrahepatic, and posthepatic...
(which is often due to liver cirrhosis) which frequently leads to intestinal bleeding (esophageal varices
Esophageal varices
In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
) or the buildup of fluid within the abdomen (ascites
Ascites
Ascites is a gastroenterological term for an accumulation of fluid in the peritoneal cavity.The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis and severe liver...
).
An Interventional Radiologist
Interventional radiology
Interventional radiology is a specialty of radiology, in which image-guided procedures are used to diagnose and treat a multitude of diseases across all body systems...
creates the shunt using an image-guided endovascular
Endovascular surgery
Endovascular surgery is a form of minimally invasive surgery that was designed to access many regions of the body via major blood vessels.Endovascular techniques were originally designed for diagnostic purposes. Basic techniques involve the introduction of a catheter percutaneously into a large...
(via the blood vessel
Blood vessel
The blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
s) approach, with the jugular vein
Jugular vein
The jugular veins are veins that bring deoxygenated blood from the head back to the heart via the superior vena cava.-Internal and external:There are two sets of jugular veins: external and internal....
as the usual entry site.
The procedure was first described by Josef Rosch in 1969. It was first used in a human patient by Dr. Ronald Colapinto, of the University of Toronto
University of Toronto
The University of Toronto is a public research university in Toronto, Ontario, Canada, situated on the grounds that surround Queen's Park. It was founded by royal charter in 1827 as King's College, the first institution of higher learning in Upper Canada...
, in 1982, but did not become reproducibly successful until the development of endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the University of Freiburg
University of Freiburg
The University of Freiburg , sometimes referred to in English as the Albert Ludwig University of Freiburg, is a public research university located in Freiburg im Breisgau, Baden-Württemberg, Germany.The university was founded in 1457 by the Habsburg dynasty as the...
. The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical portocaval shunt in that role.
Mechanism of action
A TIPS decreases the effective vascular resistanceVascular resistance
Vascular resistance is a term used to define the resistance to flow that must be overcome to push blood through the circulatory system. The resistance offered by the peripheral circulation is known as the systemic vascular resistance , while the resistance offered by the vasculature of the lungs...
of the liver. The result is a reduced pressure drop
Pressure drop
Pressure drop is a term used to describe the decrease in pressure from one point in a pipe or tube to another point downstream. "Pressure drop" is the result of frictional forces on the fluid as it flows through the tube. The frictional forces are caused by a resistance to flow. The main...
over the liver and a decreased portal venous pressure. This, in turn, lessens the pressure on the blood vessels in the intestine so that future bleeding is less likely to occur. The reduced pressure also makes less fluid develop, although this benefit may take weeks or months to occur.
Implantation
Transjugular intrahepatic portosystemic shunts are typically placed by an interventional radiologist under fluoroscopicFluoroscopy
Fluoroscopy is an imaging technique commonly used by physicians to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope. In its simplest form, a fluoroscope consists of an X-ray source and fluorescent screen between which a patient is placed...
guidance. Access to the liver, as the name transjugular suggests, is gained via the jugular vein
Jugular vein
The jugular veins are veins that bring deoxygenated blood from the head back to the heart via the superior vena cava.-Internal and external:There are two sets of jugular veins: external and internal....
in the neck
Neck
The neck is the part of the body, on many terrestrial or secondarily aquatic vertebrates, that distinguishes the head from the torso or trunk. The adjective signifying "of the neck" is cervical .-Boner anatomy: The cervical spine:The cervical portion of the human spine comprises seven boney...
. Once access to the jugular vein is confirmed, a guidewire and introducer sheath are typically placed to facilitate the shunt
Shunt (medical)
In medicine, a shunt is a hole or a small passage which moves, or allows movement of fluid from one part of the body to another. The term may describe either congenital or acquired shunts; and acquired shunts may be either biological or mechanical.* Cardiac shunts may be described as...
's placement. This enables the interventional radiologist to gain access to the patient's hepatic vein
Hepatic vein
In human anatomy, the hepatic veins are the blood vessels that drain de-oxygenated blood from the liver and blood cleaned by the liver into the inferior vena cava....
via the vena cava. The shunt is created by advancing a special needle through the sheath system to connect the hepatic vein to the large portal vein, near the center of the liver. The channel for the shunt is next created by inflating an angioplasty balloon within the liver along the tract created by the needle. The shunt is completed by placing a special mesh tube known as a stent
Stent
In the technical vocabulary of medicine, a stent is an artificial 'tube' inserted into a natural passage/conduit in the body to prevent, or counteract, a disease-induced, localized flow constriction. The term may also refer to a tube used to temporarily hold such a natural conduit open to allow...
or endograft to maintain the tract between the higher pressure portal vein and the lower pressure hepatic vein. After the procedure, fluoroscopic images are made to show placement. Pressure
Pressure
Pressure is the force per unit area applied in a direction perpendicular to the surface of an object. Gauge pressure is the pressure relative to the local atmospheric or ambient pressure.- Definition :...
measurements in the portal vein and inferior vena cava are often done.
Use in hepatorenal syndrome
TIPS has shown some promise for patients with hepatorenal syndromeHepatorenal syndrome
Hepatorenal syndrome is a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure...
.
Complications
Procedural complications during a TIPS procedure, including bleeding and direct injury to the liver, are uncommon. In the hands of an experienced physician, operative mortality is less than 1%. On the other hand, because TIPS reduces or eliminates first-pass clearance of nitrogen from the gut, up to 25% of patients who undergo TIPS will experience transient post-operative hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathy is the occurrence of confusion, altered level of consciousness and coma as a result of liver failure. In the advanced stages it is called hepatic coma or coma hepaticum...
. In general, this can be managed with a reduction in dietary protein and medication that reduces the absorption of nitrogen.
A less common but more difficult complication is hepatic ischemia. Portal hypertension—the condition shared by all TIPS patients regardless of etiology—generally causes compensatory hypertrophy of the hepatic artery and a decreased reliance of the liver upon the portal vein for its oxygenation. For this reason, shunting of the portal blood away from hepatocytes is usually well tolerated. In some cases, however, TIPS creation can cause an ischemic injury to the liver. Acute hepatic dysfunction after TIPS may require emergent closure of the shunt.
A complication of umbilical hernia
Umbilical hernia
Congenital umbilical hernia is a congenital malformation, common in infants of African descent. Among adults, it is three times more common in women than in men; among children, the ratio is roughly equal...
has been recently reported.
See also
- Distal splenorenal shunt procedureDistal splenorenal shunt procedureIn medicine, a distal splenorenal shunt procedure , also splenorenal shunt procedure and Warren shunt, is a surgical procedure in which the distal splenic vein is attached to the left renal vein...
- Gastric antral vascular ectasiaGastric antral vascular ectasia*Please note that Wikipedia does not give medical advice, and that the information in this article is intended to be solely for informational purposes....
- Interventional radiologyInterventional radiologyInterventional radiology is a specialty of radiology, in which image-guided procedures are used to diagnose and treat a multitude of diseases across all body systems...
- Portal venous systemPortal venous systemIn human anatomy, the hepatic portal system is the system of veins comprising the hepatic portal vein and its tributaries. It is also called the portal venous system, although it is not the only example of a portal venous system, and splanchnic veins, which is not synonymous with hepatic portal...
External links
- RadiologyInfo: Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- Transjugular Intrahepatic Portosystemic Shunt - eMedicine.com.
- A schematic representation of a TIPS - University of MichiganUniversity of MichiganThe University of Michigan is a public research university located in Ann Arbor, Michigan in the United States. It is the state's oldest university and the flagship campus of the University of Michigan...
.
