TIPS Procedure: Treatment for Portal Hypertension

What Is the TIPS Procedure and When Is It Needed?

TIPS (Transjugular Intrahepatic Portosystemic Shunt) is a minimally invasive procedure that creates an artificial channel within the liver to redirect blood flow and reduce dangerously high pressure in the portal vein system. It is primarily used for patients with liver cirrhosis who experience variceal bleeding or severe fluid accumulation (ascites) that doesn't respond to medication.

Portal hypertension occurs when blood flow through the liver becomes obstructed, typically due to cirrhosis (scarring of the liver). When the liver is damaged, blood backs up in the portal vein system, creating dangerously high pressure. This pressure can cause the blood to find alternative routes, leading to the development of varices (enlarged veins) in the esophagus and stomach that can rupture and bleed, as well as ascites (fluid accumulation in the abdomen).

The TIPS procedure addresses these complications by creating a shortcut for blood flow. An interventional radiologist inserts a metal stent through the liver tissue, connecting the portal vein (which carries blood from the intestines to the liver) directly to a hepatic vein (which carries blood from the liver back to the heart). This bypass reduces the pressure in the portal system by allowing blood to flow around the diseased liver tissue rather than through it.

The name TIPS stands for Transjugular Intrahepatic Portosystemic Shunt:

• Transjugular: The procedure is performed through the jugular vein in the neck
• Intrahepatic: The shunt is created within the liver
• Portosystemic: It connects the portal venous system to the systemic venous system
• Shunt: An artificial pathway that redirects blood flow

Who Needs TIPS?

TIPS is not a first-line treatment for portal hypertension. It is typically reserved for patients who have not responded adequately to other therapies. The most common indications for TIPS include:

Variceal bleeding: When varices in the esophagus or stomach rupture and bleed, initial treatment usually involves endoscopic procedures (banding or sclerotherapy) combined with medications to reduce portal pressure. However, if bleeding recurs despite these treatments, TIPS may be recommended. In some cases of severe acute variceal bleeding, early TIPS (within 72 hours) may be performed as a life-saving measure.

Refractory ascites: Ascites is the accumulation of fluid in the abdominal cavity, a common complication of cirrhosis. While most cases respond to dietary sodium restriction and diuretic medications, some patients develop "refractory ascites" that doesn't respond to maximum medical therapy. These patients may require frequent paracentesis (drainage of fluid with a needle) for symptom relief, and TIPS can provide a more permanent solution by reducing the pressure that causes fluid accumulation.

Budd-Chiari syndrome: This condition involves blockage of the hepatic veins that drain blood from the liver. TIPS can be used to decompress the liver and restore blood flow in certain patients with this syndrome.

Hepatorenal syndrome: In selected cases, TIPS may be considered for patients with hepatorenal syndrome (kidney failure due to advanced liver disease) who are awaiting liver transplantation, as it can improve kidney function by reducing portal pressure.

How Do You Prepare for a TIPS Procedure?

Preparation for TIPS involves comprehensive medical evaluation including liver and heart imaging, blood tests, and sometimes drainage of ascites. You'll need to fast before the procedure, stop certain medications, and shower with antiseptic soap. Some patients may not be candidates for TIPS if they have severe heart disease, active infection, or extremely poor liver function.

Before undergoing TIPS, you will need thorough evaluation to ensure you are a suitable candidate for the procedure and to minimize the risk of complications. This evaluation process typically involves multiple tests and consultations over several days or weeks before the scheduled procedure.

Medical Evaluation

Your healthcare team will conduct several tests to assess your liver function, heart health, and overall condition:

Liver imaging: A CT scan (computed tomography) or MRI (magnetic resonance imaging) of the abdomen is performed to visualize the liver's anatomy, including the portal and hepatic veins. Doppler ultrasound may also be used to assess blood flow patterns. These images help the interventional radiologist plan the procedure and identify any anatomical variations that might affect the approach.

Heart evaluation: Because TIPS increases blood flow returning to the heart, cardiac function must be assessed. An echocardiogram (ultrasound of the heart) is performed to evaluate heart muscle function and valve health. An electrocardiogram (ECG) checks for heart rhythm abnormalities. Patients with significant heart failure may not be candidates for TIPS because the increased blood flow could worsen their cardiac condition.

Blood tests: Comprehensive blood work includes liver function tests, kidney function tests, complete blood count, and coagulation studies. These tests help assess the severity of liver disease and identify any factors that might increase bleeding risk during the procedure. The MELD score (Model for End-Stage Liver Disease), calculated from bilirubin, creatinine, and INR values, helps predict outcomes and may influence the decision to proceed with TIPS.

Who Cannot Have TIPS?

Several conditions may make TIPS too risky or ineffective:

• Severe congestive heart failure: The increased blood return to the heart can worsen heart failure
• Active systemic infection or sepsis: Infection must be controlled before an elective procedure
• Very advanced liver disease: Patients with extremely poor liver function (very high MELD scores) have high mortality risk
• Severe hepatic encephalopathy: TIPS worsens encephalopathy, so patients with severe baseline symptoms may not tolerate it
• Primary prevention of bleeding: TIPS is not recommended to prevent first-time bleeding in patients who have never bled
• Polycystic liver disease: The cysts make the procedure technically difficult and risky
• Severe pulmonary hypertension: Can worsen with increased blood flow

Home Preparation Before the Procedure

In the days leading up to your TIPS procedure, you will receive specific instructions from your medical team:

Fasting: You will typically need to fast (no food or drink) for at least 6-8 hours before the procedure to ensure a safe anesthesia.

Medication adjustments: Some medications may need to be stopped or adjusted. Blood thinners such as warfarin, aspirin, or direct oral anticoagulants are usually stopped several days before the procedure to reduce bleeding risk. Your doctor will provide specific instructions about which medications to stop and when.

Antibiotics: You may be prescribed antibiotics to take before the procedure to prevent infection, particularly if you have had previous episodes of spontaneous bacterial peritonitis (infection of the ascites fluid).

Ascites drainage: If you have significant ascites, your doctor may drain the fluid (paracentesis) a few days before the TIPS procedure to make the procedure technically easier and reduce the risk of complications.

Hygiene preparation: You will be asked to shower with antiseptic soap (such as chlorhexidine) the evening before and the morning of the procedure to reduce skin bacteria and infection risk.

How Is the TIPS Procedure Performed?

The TIPS procedure is performed under general anesthesia and typically takes 1-3 hours. An interventional radiologist inserts a catheter through the jugular vein in your neck, guides it to the liver using imaging, and places a metal stent between the portal vein and hepatic vein. Contrast dye and X-ray imaging verify correct placement and pressure reduction.

The TIPS procedure is performed by a specially trained interventional radiologist in a sterile procedure room equipped with advanced imaging technology. Understanding what happens during the procedure can help reduce anxiety and prepare you for what to expect.

Anesthesia and Positioning

Before the procedure begins, you will receive general anesthesia, which means you will be completely asleep throughout the procedure. This ensures you feel no pain and remain still during the delicate work of placing the stent. The anesthesiologist will monitor your vital signs continuously throughout the procedure.

Once you are asleep, you will be positioned lying flat on your back on the procedure table. The area of your neck where the catheter will be inserted will be cleaned with antiseptic solution and covered with sterile drapes.

Step-by-Step Procedure

Step 1 - Accessing the jugular vein: Using ultrasound guidance, the interventional radiologist locates the internal jugular vein in your neck. A small incision (only a few millimeters) is made, and a needle is inserted into the vein. Through this needle, a guidewire is threaded, which serves as a track for the catheter to follow.

Step 2 - Navigating to the liver: Over the guidewire, a special catheter is advanced down through the superior vena cava (the large vein entering the heart) and into the hepatic vein (one of the veins draining the liver). The radiologist uses fluoroscopy (real-time X-ray imaging) to visualize the catheter's path and ensure proper positioning.

Step 3 - Accessing the portal vein: This is the most technically challenging part of the procedure. From within the hepatic vein, the radiologist must pass a needle through the liver tissue to reach the portal vein. This is done using ultrasound and fluoroscopic guidance, often combined with special imaging techniques to visualize the portal vein's location. Once the needle is in the portal vein, pressure measurements are taken to confirm the diagnosis of portal hypertension and to serve as a baseline for comparison after stent placement.

Step 4 - Creating the shunt: A balloon catheter is passed through the tract between the hepatic vein and portal vein to dilate (widen) the pathway. Then, a metal mesh stent is deployed across this tract. Modern TIPS procedures typically use covered stents (polytetrafluoroethylene-covered stent grafts), which have better long-term patency rates than bare metal stents.

Step 5 - Verifying success: Contrast dye is injected, and additional X-ray images (portography) are obtained to confirm that the stent is properly positioned and that blood is flowing through it correctly. Pressure measurements are repeated to confirm that portal pressure has decreased to the target range. The goal is typically to reduce the portal pressure gradient to below 12 mmHg or to reduce it by at least 50% from the baseline.

Step 6 - Completing the procedure: Once satisfactory results are confirmed, the catheters and wires are removed. The small incision in the neck usually doesn't require stitches and is simply covered with a bandage. The entire procedure typically takes between 1 and 3 hours, depending on the complexity of the case and any technical difficulties encountered.

What Is the Recovery Like After TIPS?

After TIPS, you'll spend 2-4 hours in a recovery area before being transferred to a hospital ward. Most patients stay 2-5 days in the hospital. You may be able to walk the same day. Before discharge, you'll have an ultrasound to confirm the stent is working. Symptoms like ascites and bleeding risk should improve within days to weeks.

The recovery period after TIPS begins immediately after the procedure ends. Understanding what to expect during this time can help you prepare and recognize any signs of complications that need medical attention.

Immediate Post-Procedure Period

After the procedure is completed, you will be taken to a recovery area where you will gradually wake from anesthesia. This process typically takes 1-2 hours. During this time, nurses will closely monitor your vital signs (blood pressure, heart rate, breathing, oxygen levels) and check the small wound on your neck where the catheter was inserted.

You may feel groggy or drowsy for several hours after waking. Some patients experience mild throat discomfort from the breathing tube used during anesthesia, but this typically resolves within a day. You will not be allowed to eat or drink initially, but can usually start with clear liquids a few hours after the procedure once you are fully awake.

Hospital Stay

Most patients stay in the hospital for 2-5 days after TIPS, though this varies depending on individual circumstances and the underlying condition being treated. During this time, your medical team will:

• Monitor for signs of bleeding from the procedure site
• Watch for symptoms of hepatic encephalopathy (confusion, drowsiness, personality changes)
• Check liver and kidney function with daily blood tests
• Assess whether ascites or other symptoms are improving
• Perform an ultrasound before discharge to confirm the stent is open and blood is flowing properly

Many patients are surprised to find they can get up and walk around the same day as the procedure. Early mobilization is encouraged to prevent complications like blood clots. However, you should avoid strenuous activity for about a week.

Managing Hepatic Encephalopathy

One of the most common complications after TIPS is hepatic encephalopathy, which occurs in 20-30% of patients. This condition develops because the shunt allows some toxins (particularly ammonia) from the intestines to bypass the liver and reach the brain. Symptoms can range from mild (subtle personality changes, difficulty concentrating, sleep disturbances) to severe (confusion, disorientation, unconsciousness).

To prevent and treat hepatic encephalopathy, your doctor will likely prescribe:

• Lactulose: A medication that reduces ammonia absorption in the gut by causing loose bowel movements
• Rifaximin: An antibiotic that reduces ammonia-producing bacteria in the intestines
• Dietary modifications: Your protein intake may be adjusted; contrary to old recommendations, moderate protein intake is now encouraged rather than severe restriction

Regular bowel movements (2-3 per day) are important to prevent encephalopathy. You should contact your healthcare provider if you experience increasing confusion, drowsiness, or other neurological symptoms.

What Are the Risks and Complications of TIPS?

The main complications of TIPS include hepatic encephalopathy (20-30%), temporary heart failure symptoms, stent dysfunction requiring revision, and rarely bleeding or infection. The 30-day mortality rate is 3-15% depending on liver function. Most complications are manageable, and modern covered stents have significantly improved long-term outcomes.

Like any medical procedure, TIPS carries certain risks. However, for appropriately selected patients, the benefits typically outweigh these risks. Understanding potential complications helps you make an informed decision and recognize warning signs early.

Hepatic Encephalopathy

Hepatic encephalopathy is the most common complication, affecting 20-30% of patients after TIPS. As explained earlier, this occurs because the shunt allows toxins to bypass the liver's filtering function. While this can be concerning, it's important to know that most cases are mild to moderate and can be effectively managed with medications like lactulose and rifaximin.

Severe encephalopathy that doesn't respond to medical treatment is uncommon but may require reducing the diameter of the shunt (shunt reduction or occlusion) to restore some liver filtering function. This is typically done only as a last resort when other treatments fail.

Cardiac Complications

TIPS increases the amount of blood returning to the heart because blood that was being held back by the portal hypertension now flows freely through the shunt. In patients with normal heart function, this is well tolerated. However, in patients with pre-existing heart problems, this increased blood flow can cause or worsen heart failure symptoms, including shortness of breath, leg swelling, and fatigue.

This is why careful cardiac evaluation is performed before TIPS. Patients with significant heart failure may not be candidates for the procedure. For those who develop mild heart failure symptoms after TIPS, diuretics (water pills) can often control the symptoms.

Stent Dysfunction

Over time, the TIPS stent can become narrowed (stenosis) or completely blocked (occlusion). This was a more significant problem with older bare-metal stents, occurring in 50-80% of patients within two years. Modern covered stent grafts (ePTFE-covered stents) have dramatically improved outcomes, with primary patency rates of 80-90% at one year.

When stent dysfunction occurs, symptoms of portal hypertension (bleeding, ascites) may return. This is why regular ultrasound monitoring is essential. If the stent becomes narrowed or blocked, it can usually be reopened or revised with another minimally invasive procedure.

Other Complications

Less common complications include:

• Bleeding: During the procedure, passing the needle through liver tissue can cause bleeding. This is usually minor and self-limiting, but occasionally may require blood transfusion.
• Infection: Any procedure involving catheters carries some infection risk. Antibiotics and sterile technique minimize this risk.
• Injury to bile ducts: The needle may pass through bile ducts during the procedure, potentially causing bile leakage. This is usually minor and resolves on its own.
• Worsening liver function: By diverting blood away from the liver, TIPS can sometimes worsen liver function. This is more likely in patients with already severely impaired liver function.
• Contrast-induced kidney injury: The contrast dye used during the procedure can affect kidney function, particularly in patients with pre-existing kidney disease.

Mortality Risk

The 30-day mortality rate after TIPS ranges from approximately 3% in patients with relatively preserved liver function to 15% or higher in patients with advanced liver disease. The main predictors of poor outcome include high MELD score (>18-20), emergency TIPS for acute bleeding, renal failure, and severe hepatic encephalopathy before the procedure. These factors are carefully considered when deciding whether TIPS is appropriate for each individual patient.

What Follow-Up Care Is Needed After TIPS?

After TIPS, you need regular follow-up including ultrasound monitoring at 1 month, 6 months, and annually to check stent patency. Blood tests monitor liver function. Lifestyle modifications include taking medications to prevent encephalopathy, eating regular healthy meals, and avoiding alcohol completely. Contact your doctor immediately if symptoms return.

Long-term success after TIPS requires ongoing medical monitoring and certain lifestyle adjustments. Your commitment to follow-up care plays a crucial role in achieving the best possible outcomes.

Ultrasound Surveillance

Regular Doppler ultrasound examinations are essential to monitor the TIPS stent and ensure it remains open and functioning properly. The typical surveillance schedule includes:

• Before hospital discharge (to confirm initial patency)
• 1 month after the procedure
• 6 months after the procedure
• Annually thereafter

The ultrasound measures blood flow velocity through the stent. Abnormal velocities (either too high or too low) can indicate stent stenosis or dysfunction, even before symptoms return. If problems are detected early, they can often be corrected before complications occur.

Ongoing Medical Management

After TIPS, you will likely need to continue or start several medications:

Encephalopathy prevention: Most patients take lactulose (a laxative that reduces ammonia absorption) and often rifaximin (an antibiotic). The goal is to have 2-3 soft bowel movements daily.

Diuretics: While TIPS often reduces or eliminates ascites, some patients may still need diuretics to control fluid retention. Your doctor will adjust doses based on your response.

Treatment for underlying liver disease: If your liver disease has a treatable cause (such as viral hepatitis or alcohol-related liver disease), treating this underlying condition is essential for long-term outcomes.

Lifestyle Recommendations

Several lifestyle factors can influence your outcomes after TIPS:

Alcohol abstinence: If your liver disease was caused or worsened by alcohol, complete abstinence is absolutely essential. Continued alcohol use will cause further liver damage and negate the benefits of TIPS.

Nutrition: Contrary to older recommendations that severely restricted protein, current guidelines recommend adequate protein intake (1.0-1.5 g/kg body weight daily) to prevent muscle wasting. Eat regular meals and avoid long periods of fasting, as this can worsen encephalopathy. Work with a dietitian experienced in liver disease if possible.

Sodium restriction: Limiting salt intake to less than 2 grams per day helps control fluid retention and ascites.

Medication awareness: Avoid medications that can worsen liver function, including over-the-counter pain relievers (NSAIDs like ibuprofen) and some herbal supplements. Always check with your doctor before taking any new medication.

How Effective Is the TIPS Procedure?

TIPS is highly effective with technical success rates exceeding 95%. For variceal bleeding, it reduces rebleeding risk from 70% to approximately 20%. For refractory ascites, 70-80% of patients experience significant improvement. Modern covered stents maintain patency in 80-90% of patients at one year, a significant improvement over older bare-metal stents.

The effectiveness of TIPS has been well established through decades of clinical experience and numerous clinical trials. However, outcomes depend significantly on patient selection and the underlying condition being treated.

Technical Success

Technical success—meaning the successful creation of a functioning shunt—is achieved in over 95% of cases at experienced centers. Factors that can make the procedure technically challenging include unusual anatomy, extensive liver scarring, or portal vein thrombosis. In some cases, the procedure may need to be modified or abandoned if these challenges cannot be overcome.

Effectiveness for Variceal Bleeding

For patients who have experienced variceal bleeding, TIPS is highly effective at preventing rebleeding:

• Without TIPS, patients with a history of variceal bleeding have approximately a 70% chance of rebleeding within 1-2 years
• After TIPS, this risk is reduced to approximately 20%
• Randomized controlled trials have shown TIPS is superior to repeat endoscopic therapy for preventing rebleeding
• Early TIPS (within 72 hours) for high-risk patients with acute variceal bleeding improves survival compared to standard management

Effectiveness for Refractory Ascites

For patients with refractory ascites (fluid that doesn't respond to diuretics), TIPS provides significant benefit:

• 70-80% of patients have complete or significant resolution of ascites
• Quality of life improves significantly as patients no longer need frequent paracentesis
• Kidney function often improves as well
• Studies suggest TIPS may improve survival compared to repeated paracentesis, though this remains somewhat controversial

Long-Term Outcomes

Long-term outcomes after TIPS depend largely on the underlying liver disease and its progression. For patients who are candidates for liver transplantation, TIPS often serves as an effective bridge, controlling complications while awaiting a donor organ. For patients who are not transplant candidates, TIPS can provide years of improved quality of life by controlling bleeding and ascites.

It's important to understand that TIPS does not improve liver function or halt the progression of liver disease. Patients with very advanced liver disease (high MELD scores) have poorer outcomes after TIPS because their liver function may continue to deteriorate regardless of successful portal decompression.