Overview of Transjugular Intrahepatic Portosystemic Shunt
A transjugular intrahepatic portosystemic shunt (TIPS) is a procedure done through the skin to reduce high blood pressure in the veins of your liver. The procedure is usually recommended for conditions like variceal hemorrhage (bleeding from abnormal veins) and ascites (fluid buildup in the abdomen); all are symptoms of severe liver disease. During a TIPS, a tube (stent) is placed between the portal vein (the vein that carries blood from the digestive organs to the liver) and the hepatic vein (one of the veins that take blood out of the liver) to redirect blood flow in the liver. Through this shift in blood flow, the pressure is reduced. It helps to stop bleeding and fluid build-up without any major changes to the body’s structure outside the liver.
The TIPS procedure first came into practice in 1969. It started with creating a path between the portal and hepatic veins using a balloon. The main hurdle to its widespread use at the time was the short lifespan of the path created. With the introduction of flexible metal stents, the lifespan of these paths improved significantly. However, there were still issues with the formation of tissue within the stent that needed additional procedures like balloon dilation and re-stenting. The procedure has since evolved with advances in stent technology. Now polytetrafluoroethylene-covered stents (a type of stent covered in a synthetic fluoropolymer) are used, which have significantly improved the lifespan and long-term results of TIPS.
Anatomy and Physiology of Transjugular Intrahepatic Portosystemic Shunt
Understanding the structure and working conditions of blood vessels is crucial, particularly when it comes to a condition called portal hypertension. This involves looking at the anatomy of the portal vein (the major vein supplying the liver), the hepatic veins (the veins that drain blood from the liver), and the ways in which collateral veins bypass blocked veins. All of these aspects need to be looked at before initiating a procedure called ‘transjugular intrahepatic portosystemic shunt’. This procedure helps to reduce high blood pressure in the liver by creating a new pathway for blood flow.
This procedure could be influenced greatly by the presence or absence of shunts – basically detours for blood flow – like the splenorenal shunt (which connects the spleen and the kidney). Therefore, any available shunts should also be checked before starting a transjugular intrahepatic portosystemic shunt.
Why do People Need Transjugular Intrahepatic Portosystemic Shunt
The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure is recommended for several liver conditions. The procedure involves creating a new pathway between two blood vessels in your liver. Here are a few situations when you might need the TIPS procedure:
Firstly, this could be used to prevent bleeding from swollen veins in your esophagus or stomach, known as varices. This is a high priority treatment with strong evidence supporting its effectiveness.
Secondly, the procedure can help with ascites, which is when you have a build-up of fluid in the abdomen that is not responding to medication. Ascites can be very uncomfortable. This use of the TIPS procedure is also strongly supported by evidence.
Thirdly, TIPS can help with a condition called hepatic hydrothorax which is when fluid builds up in your lungs as a result of liver disease, and typical treatments are not working.
Fourthly, it’s also used for Budd-Chiari syndrome, a rare condition where the veins that carry blood out of your liver get blocked.
Furthermore, TIPS can be used for hepatorenal syndrome, which is when kidney function decreases because of severe liver disease. It’s typically used when standard treatments aren’t working well.
Finally, it is a treatment option for hepatopulmonary syndrome. In this condition, the lungs aren’t properly oxygenating the blood due to liver disease.
When a Person Should Avoid Transjugular Intrahepatic Portosystemic Shunt
If an individual has certain health conditions, it may not be safe for them to undergo certain procedures. These conditions are referred to as ‘contraindications’. Here are some situations where specific treatments are not recommended:
There are a few reasons a person might not be able to receive treatment to prevent the bleeding of swollen veins in their food pipe, a condition referred to as ‘variceal hemorrhage’. This is also true if someone has congestive heart failure (a condition where the heart doesn’t pump blood as well as it should), pulmonary hypertension (high blood pressure in the arteries to your lungs), severe sepsis (a life-threatening complication of an infection), a blocked bile duct (biliary obstruction) or many cysts (sac-like pockets of fluid) in their liver.
Situations where treatment might be risky, but could still be considered depending on the person’s overall health, include having liver cancer, a blood clot in the liver’s veins (portal vein thrombosis) or hepatic vein occlusion, a severe problem with blood clotting and/or a low platelet count (severe coagulopathy and thrombocytopenia), and advanced hepatic encephalopathy (which is the loss of brain function that occurs when the liver is unable to remove toxins from the blood).
Similarly, there are some cases where a treatment called TIPS, which is used to lower blood pressure in the liver, might not be recommended. Some conditions that might make this treatment risky are: having high blood pressure in the lungs or in the heart’s blood vessels, a blocked bile duct that hasn’t been resolved, multiple liver cysts, a blood clot in the liver’s veins, liver brain disease, and central liver cancer.
Equipment used for Transjugular Intrahepatic Portosystemic Shunt
The procedure needs to be performed in a specific area that comes equipped with the right tools for visualizing the inside of your body, like fluoroscopy and ultrasound machines. Basic tools for carrying out vessel-related procedures, such as needles and guide wires for accessing your veins, catheters for transporting drugs or other treatments, and balloons for opening up blocked or narrowed vessels, need to be readily available.
The doctor will also need access to specially designed tools for a procedure called a transjugular intrahepatic portosystemic shunt, or TIPS for short. This is a procedure that helps to ease the flow of blood in your liver. As part of this procedure, they’ll need special types of covered stents, which are tube-like devices that help to keep your blood vessels open. They need to have these in a range of sizes to ensure the right fit.
Apart from these, they also need to have ready access to materials that can help to block off certain blood vessels. These can include small metal coils, plugs and materials that cause blood clots on purpose (called sclerosis agents), which they can use to seal off problematic vessels known as varices or other types of shunts.
Lastly, they need to ensure that they have the right tools and people on hand to monitor your health during the procedure. This includes machines to keep track of your vital signs, as well as trained individuals such as nurses and technologists.
Who is needed to perform Transjugular Intrahepatic Portosystemic Shunt?
A procedure known as a transjugular intrahepatic portosystemic shunt should be performed by highly skilled specialists in a well-equipped room. This room should have enough trained staff, including experienced technologists and nurses. Typically, a team from the anesthesiology department will be on standby to ensure you stay comfortable and pain-free during the procedure.
Managing this procedure is best done as a team, where different specialists work together. This team may include experts from different fields such as interventional radiology (doctors who use images to guide them during treatment), hepatology (liver specialists), and transplant surgeons. Each of these specialists brings their unique skills to ensure the procedure is performed safely and successfully.
Preparing for Transjugular Intrahepatic Portosystemic Shunt
The first step in preparing a patient for a medical imaging procedure is a thorough checkup. Sometimes, this has to be done quickly in case of emergencies like bleeding. Doctors carry out a range of blood tests to check liver and kidney function, as well as how well the blood is clotting. Any problems with blood clotting need to be fixed. If a patient’s kidney function is not optimal, doctors may give the patient fluids before the procedure and use certain types of contrast dyes that are safer for the kidneys.
Doctors also carry out imaging scans before the procedure to check the blood vessels in the liver and to make sure there’s no tumor in the liver. If the patient has build-up of fluid in the abdomen, it can be drained before the procedure. This is especially useful if a wire needs to be passed into the vein in the liver, which is required for some special techniques.
An important part of the patient’s evaluation is the MELD score. This score helps predict the risk of death after the procedure. It considers levels of creatinine and bilirubin, two substances that, when high, can indicate problems with the kidneys or the liver. It also considers the INR, a measurement of how quickly blood clots. A score greater than 18 hints at a higher risk of death within three months of the procedure.
Lastly, all the risks and benefits of the procedure should be carefully explained to the patient and the family. The doctor who referred the patient should also be included in the discussion. This ensures everyone understands what to expect and is able to make informed decisions about the procedure.
How is Transjugular Intrahepatic Portosystemic Shunt performed
When a doctor is treating some liver diseases, they might use a method called transjugular intrahepatic portosystemic shunt (TIPS). This procedure usually requires general anesthesia which means that you’ll be asleep and won’t feel anything. Before the procedure, you’ll also be given antibiotics to prevent infections.
The doctor starts the procedure by making a small hole in the vein on the right side of your neck to get access to the main blood vessel. Once inside, a special angled tube is used to get to the right vein in your liver. To make it easier to see what’s going on, they’ll inflate a small balloon and put some harmless gas inside. This will cause certain veins inside your liver to “light up” on the X-ray screen and help guide the doctor where to put the needle.
There are special TIPS kits available that contain the tools the doctor will need for the procedure. Using a combination of X-ray and ultrasound technology, the doctor will insert the needle into the right side of a main vein inside your liver. Depending on your unique body, the doctor might use different veins in your liver.
Once the needle is in, the doctor will draw some blood to make sure they are in the right place. Then, they’ll inject a dye that, like the gas from earlier, “lights up” on the X-ray screen to make certain that the needle is in a good spot within the vein. For the best results, the needle should enter about a half inch to an inch from the place where your portal vein splits into two smaller veins. If the doctor can’t get the needle in the right place, they might use a thin metal wire as a guide.
Once the needle is in the right place, the doctor will insert a special type of camera to check the area and make sure everything looks okay. They’ll also measure the pressure in your veins to see how well blood flows between your liver and heart.
After all of these steps are done, the doctor will make a small tunnel (about a third of an inch across) for a stent. A stent is a small tube made of metal wire that helps to keep your veins open. Ideally, a stent that’s partially covered is used, with the bare part placed inside your liver and the covered part extending to a large vein called the Inferior Vena Cava (IVC). It’s really important to make sure that the stent isn’t too long or too short to avoid problems in case you need a liver transplant in the future.
If after the stent is placed, there’s still blood flowing into the varices (enlarged veins), the doctor might need to block these veins with something like a metal coil or a special type of foam. They’ll also measure the pressure in your veins again at the end of the procedure.
After the procedure, you’ll need to stay in a closely monitored area, like an intensive care unit (ICU), so that the doctors can keep an eye on you. They’ll also regularly check your liver by measuring certain chemicals in your blood called liver enzymes.
Within two to three days after the procedure, the doctors will perform an ultrasound of your liver to make sure that the shunt is working properly. This ultrasound is very important because it will serve as a point of reference for future check-ups.
If the doctors see anything unusual on the ultrasound, like a significant change in blood flow speed, they might take you back to the procedure room to check the shunt directly and fix any problems. This might mean inflating a balloon inside the stent to widen it or even placing a new stent.
Possible Complications of Transjugular Intrahepatic Portosystemic Shunt
Complications from a procedure known as a transjugular intrahepatic portosystemic shunt (TIPS), which is a type of procedure done on your liver, can be split into two categories: problems that happen right away, and problems that occur over time.
Immediate Complications
Sometimes there can be bleeding due to the puncture made during the procedure. This can sometimes require more treatment or even surgery. The stent (a small tube that’s put into your blood vessels) can sometimes end up in the wrong place or move. There could also be problems, like early blockage of the shunt due to technical issues or injury to the bile duct, the tube that carries bile out of the liver.
Some people might experience shunt-related encephalopathy, which affects the brain, with 30% to 46% people experiencing this side-effect. There could also be a worsening of liver function, which might be treated by narrowing the shunt or, in severe cases, closing it. Another possible complication includes the narrowing of the shunt, which may need further treatment.
Long-term Complications
Long-term, people may experience intimal hyperplasia within the TIPS, excessive growth of cells in the lining of an artery. This can lead to reduced blood flow and recurrence of high blood pressure in the liver vessels known as portal hypertension. There could also be complete blockage of the TIPS, again resulting in recurrence of portal hypertension. Both these conditions can be treated by reopening and expanding the TIPS with balloon dilation and re-stenting.
What Else Should I Know About Transjugular Intrahepatic Portosystemic Shunt?
For patients who have undergone a procedure called a transjugular intrahepatic portosystemic shunt (TIPS), continual monitoring and care in the form of medical checkups are crucial. This follow-up care includes regular visits with both the doctor who performed their procedure and a liver specialist. Part of the follow-up generally includes having non-invasive imaging procedures, such as ultrasounds, which are essential for monitoring your health.
The decision to undergo a liver transplant often comes as part of the follow-up for patients with more severe cases. This is determined based on the status of the patient’s health.
So, what is TIPS procedure? It’s a non-surgical, minimally invasive treatment that’s done to manage severe complications from high blood pressure in the liver (also known as portal hypertension). This type of high blood pressure can cause serious health problems and TIPS is one way doctors help manage these conditions. The procedure is performed by making a new pathway through the liver so that the blood can bypass the liver.
