Cirrhosis – What is a TIPS procedure?

​TIPS—T-I-P-S—is a procedure that lowers pressure in the portal vein.

That's the vein that moves blood to your liver.

The medical name for this procedure is transjugular intrahepatic portosystemic shunt.

But most people just call it TIPS.

Before we talk about TIPS, let's go over some reasons your healthcare team may recommend it for you.

In a healthy liver, blood flows in through the portal vein, like water from a hose into a sponge.

But imagine the sponge is hard like a rock.

Then water can't flow through the hose as easily, and pressure builds. 

Just like with the hose and the rock, pressure in the portal vein builds when the liver gets scarred and hard.

This is called portal hypertension.

When the pressure gets too high, it can back up and make the veins around your stomach and esophagus, or food pipe, swell.

These swollen veins are called varices.

If they swell too much, they break open and bleed.

This is called variceal bleeding. 

High pressure can also cause fluid to leak out and build up in your belly or around your lungs.

Doctors might use a TIPS procedure to treat variceal bleeding or fluid buildup in the belly or around the lungs when other treatments aren't working.  

Before the procedure, you'll get a general anesthetic that puts you to sleep.

The doctor will insert a thin, flexible tube, called a catheter, into a blood vessel in your neck.

They'll use an imaging test, usually an x-ray with contrast dye, to guide the catheter until it gets to your liver.

Then the doctor will create a channel from the hepatic vein, which is the vein that takes blood out of the liver, to the portal vein.

This channel allows blood to bypass your liver.

The TIPS stent, which is a wire mesh tube, will be placed to keep the channel open.

Then, the doctor can measure the blood flow in your veins to make sure the pressure drops.

If it's still too high, they might use a balloon on the catheter to open the stent wider.

The procedure usually takes 2 to 4 hours.

After the procedure, you'll stay in the hospital, but most people can go home after a day or 2.

It can take weeks or months for the TIPS to work.

So if you have fluid buildup in your belly (called ascites), it may take time to go away.

After you go home, rest and drink lots of water.

For at least 10 days, don't do heavy exercise like running and don't lift more than 10 pounds, or about 4.5 kilograms.

You can still do gentle activity, like walking, each day.

It's really important to watch for symptoms like memory trouble, feeling sleepy, and balance problems.

Also watch for yellow skin and swollen legs.

Call your doctor or nurse right away if you have any of these symptoms.

The TIPS stent can get narrower over time.

If this happens, you may need another procedure to make it wider.

You'll do follow-up tests to help your healthcare team check your progress.

A TIPS procedure can help you feel better and lower your chances of varices and fluid buildup in your belly or around your lungs.

But just like any procedure, there are risks and side effects you should know about.

You'll do tests before the procedure to check your risk of side effects.

Because it's the liver's job to filter toxins out of your blood, sending some blood through the TIPS means less of it goes through the liver to get filtered.

This can cause toxins to build up in your body.

Toxin buildup is called hepatic encephalopathy.

It can cause you to feel confused, have balance problems, and feel sleepy.

About 3 out of 10 people will get hepatic encephalopathy after a TIPS.

It can usually be treated with medicine.

Some people might have more liver problems because less blood goes to the liver.

Or they might have heart problems because more blood flows into the heart through the TIPS.

If you get major problems that can't be managed with medicine, your doctor may block off the TIPS stent.

Other side effects are rare.

This procedure could cause bleeding, infection, or damage to your kidneys or lungs.

We understand you may have many thoughts and feelings about having a TIPS procedure.

Remember, your healthcare team is there to support you.

Reach out to them if you have questions.

To learn more, visit cirrhosiscare.ca or MyHealth.Alberta.ca.

A transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure for treating portal vein hypertension and other complications of liver disease. A surgeon inserts a stent to relieve blood pressure in the portal vein by rerouting blood flow past the liver.

As well as being less invasive than traditional bypass surgery, the TIPS procedure carries fewer risks.

While a TIPS procedure can help reduce the risk of further complications, it cannot correct existing liver damage, and some people may require additional treatments.

In this article, we discuss the uses of a TIPS procedure, its effect on life expectancy, how the procedure works, and what to expect during recovery. We also cover the side effects, risks, and complications.

Uses

Liver diseases, such as cirrhosis, can increase the blood pressure inside the vessels that connect the hepatic and portal veins. This increase in blood pressure may lead to a serious condition called portal hypertension.

A doctor may use a TIPS procedure to relieve blood pressure in the portal vein by rerouting the blood flow from the other digestive organs past the liver.

The liver plays a vital role in circulation. In addition to the arteries, the liver has two types of veins with different functions. The portal vein carries nutrient-rich blood from the organs in the digestive system to the liver, while the hepatic veins carry deoxygenated blood from the liver back to the heart.

A TIPS procedure creates a channel between these two types of veins.

People typically only need a TIPS procedure if they have advanced liver disease. Doctors use TIPS procedures to treat some of the complications of this condition, including:

• Variceal bleeding. Varices develop when scar tissue or a blood clot blocks blood flow through the portal vein. Without treatment, varices can burst and bleed. Variceal bleeding causes 15–30% of deaths among people with cirrhosis.
• Portal gastropathy. Reduced blood flow through the portal vein can cause swelling in the veins in the mucous membrane of the stomach.
• Ascites. Ascites occurs when fluid builds up in the space between the abdominal lining and the internal organs. Without treatment, ascites can lead to abdominal pain, hernias, and bacterial infections.
• Hepatorenal syndrome is a type of progressive kidney failure that occurs in people who have severe liver damage. Hepatorenal syndrome is a serious condition with a poor outlook. About 90% of people with advanced hepatorenal syndrome die within 10 weeks of their diagnosis.

Life expectancy

The effects of TIPS procedures vary depending on the underlying condition and the person’s overall health status.

TIPS can help treat variceal bleeding and lower the risk of recurring bleeds. According to an older randomized trial, 88% of people with cirrhosis and variceal bleeding who received TIPS survived for 2 years, and 61% survived for at least 5 years.

A more recent analysis of TIPS procedures in one hospital found that 78.2% of patients survived longer than 90 days after the procedure. Risk factors for dying soon after the TIPS procedure included being older and having high blood pressure.

Procedure

Radiologists perform TIPS procedures using either X-ray or ultrasound imaging, as well as a balloon-tipped catheter and a stent.

They use the stent to keep the channel between the portal and hepatic veins open. The balloon-tipped catheter helps the radiologist place this stent.

Before the procedure, a specially trained nurse or anesthesiologist will administer a general or local anesthetic. The individual should tell their doctor if they have an allergy to anesthesia or X-ray contrast dye.

During the procedure, the radiologist inserts the catheter with a small balloon and a metal stent on the end into the jugular vein in the neck. They then carefully guide the catheter into one of the hepatic veins. They can track the catheter’s position using an X-ray or ultrasound machine.

Once the catheter reaches a hepatic vein, the radiologist injects a contrast dye into the vein to get a better view of the blood vessels in the liver. They will then use a thin needle to access the portal vein, where they will guide the balloon and metal stent into position.

When the catheter reaches the correct location, the radiologist will inflate the balloon and position the stent.

Blood flow from the digestive system organs will flow through the stent and into the hepatic veins, reducing the pressure in the portal vein.

The radiologist will finish the procedure by deflating the balloon, removing the catheter, and covering the cut in the neck with a bandage.

Recovery

After the procedure, a nurse will take the person to a hospital room where they will stay for several hours. During this time, nurses will regularly monitor the person’s vital signs and check for bleeding.

A doctor may perform an ultrasound or X-ray to ensure that the stent is working and is in a good position. Depending on whether a person had a local or general anesthetic, they may feel groggy or unwell for a short time.

Generally, people can go home the day after their procedure, as long as they do not have any complications. Anyone who has had a general anesthetic should not drive and should arrange for someone to take them home from the hospital.

Risks and complications

While people with portal hypertension may benefit from a TIPS procedure, the surgery can lead to additional complications.

After the procedure, blood from the digestive organs still flows through the portal vein, but the new stent carries it past the liver and into the hepatic veins.

This diversion increases the risk that natural toxins, such as ammonia, may remain in the blood when it returns to the heart.

Ammonia can travel to the brain through the bloodstream, which may result in hepatic encephalopathy. Hepatic encephalopathy is a brain disorder that can cause confusion, personality changes, and memory loss.

According to a 2017 study involving 98 people with portal hypertension, about 36.7% of these participants developed hepatic encephalopathy after undergoing a TIPS procedure.

A TIPS procedure can also affect the heart and lungs. The sudden increase in blood flow may put excess stress on these vital organs. This complication is especially dangerous for people with congestive heart failure or high blood pressure.

Doctors may perform additional procedures if the stent becomes blocked or collapses.

Other risks associated with TIPS procedures include:

• bacterial infections
• damage to surrounding blood vessels
• internal bleeding

A person should always speak to a doctor if they are concerned about the possible risks of a TIPS procedure.

Summary

Doctors can treat portal vein hypertension with a TIPS procedure. To do this, a radiologist uses X-rays or ultrasound imaging to guide a catheter through the jugular vein and into the portal vein in the liver, where they will create a tunnel between the portal and hepatic veins.

This tunnel allows blood to pass by the liver and go directly into the hepatic veins, reducing dangerous blood pressure in the portal vein.

Most individuals have a relatively low risk of developing serious complications after a TIPS procedure. However, people still require careful monitoring during the recovery process.

A doctor will likely schedule a follow-up appointment a few weeks later to check whether the TIPS procedure was effective and address any complications.