Transjugular Intrahepatic Portosystemic Shunt: State of the Art

Abstract

Since the first description of transjugular portal venography and radiologic portacaval shunt placement by Rosch n 19691 and the subsequent introduction of the transjugular intrahepatic portasystemic shunt (TIPS) into clinical medicine by Colapinto in 1982, TIPS has been increasingly adopted as a means of reducing portal pressures in patients with complications related to portal hypertension, such as refractory variceal bleeding. The procedure has also evolved to encompass other indications, such as refractory ascites2,3 and ts related complications, such as hepatorenal syndrome4 and epatic hydrothorax.5,6 In addition TIPS has also been sucessfully applied to patients with Budd–Chiari syndrome,7,8 portal vein occlusion,9 and ectopic variceal bleeding.10 Created with the use of catheters, balloons, and stents inserted under radiologic guidance, TIPS intrinsically functions as a side-to-side porta-caval shunt. The 2 major drawbacks of the TIPS procedure are progressive encephalopathy caused by direct portosystemic shunting and shunt dysfunction. Since the late 1990s the practice of TIPS has been greatly influenced by the introduction of the model for end-stage liver disease (MELD) scoring system for risk assessment of short-term mortality in patients undergoing TIPS and also by the introduction of polytetrafluoroethylene-covered endografts, which achieve durable long-term patency. These endografts and their effect on producing long-term shunt patency are redefining the role of TIPS for treating complications of portal hypertension. In this review article, we describe the common indications of TIPS procedure, the pathophysiology of portal hypertension, and anatomic aspects relevant to the safe creation of a TIPS. We describe the preprocedure evaluation of patients undergoing a TIPS procedure and techniques for step-wise placement of a TIPS as well as monitoring for and management of shunt dysfunction. We also look at newer techniques, such as direct intrahepatic portocaval shunting