Transjugular intrahepatic portosystemic shunts: Indications and contraindications
- Arun J Sanyal, MD
Arun J Sanyal, MD
- Charles Caravati Professor of Medicine
- Virginia Commonwealth University School of Medicine
- Jasmohan S Bajaj, MD
Jasmohan S Bajaj, MD
- Associate Professor of Medicine
- Virginia Commonwealth University and McGuire VA Medical Center
Transjugular intrahepatic portosystemic shunts (TIPS) involve creation of a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein (usually the right branch) using angiographic techniques (figure 1 and image 1). The tract is kept patent by deployment of an expandable metal stent across it, thereby allowing blood to return to the systemic circulation. The ability of TIPS to function like a surgical side-to-side portacaval shunt without requiring general anesthesia and major surgery led to its rapid acceptance into clinical practice . However, the expanding use of TIPS has also led to its misuse in some instances.
This topic will review the indications for TIPS other than variceal bleeding and ascites. It will also review contraindications to TIPS placement and conditions for which TIPS should not be used. The use of TIPS for variceal bleeding and ascites, and the complications associated with this procedure are discussed separately. (See "Role of transjugular intrahepatic portosystemic shunts in the treatment of variceal bleeding" and "Ascites in adults with cirrhosis: Diuretic-resistant ascites", section on 'Transjugular intrahepatic portosystemic stent-shunt' and "Transjugular intrahepatic portosystemic shunts: Complications".)
VARICEAL BLEEDING AND ASCITES
TIPS has primarily been used to treat the major consequences of portal hypertension (ie, variceal hemorrhage and ascites) (table 1). These topics are discussed in detail elsewhere. (See "Role of transjugular intrahepatic portosystemic shunts in the treatment of variceal bleeding" and "Ascites in adults with cirrhosis: Diuretic-resistant ascites".)
When used in patients with refractory ascites, insertion of TIPS may lead to a delayed improvement in renal function [3,4]. In one study, the average plasma creatinine concentration was 1.5 mg/dL (132 micromol/L) at baseline, was unchanged at one week, and fell to 0.9 mg/dL (80 micromol/L) by six months .
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- VARICEAL BLEEDING AND ASCITES
- HEPATORENAL SYNDROME
- MISCELLANEOUS USES OF TIPS
- Budd-Chiari syndrome
- Hepatic sinusoidal obstruction syndrome (veno-occlusive disease)
- Hepatic hydrothorax
- Portal hypertensive gastropathy
- Prior to abdominal surgery
- CONTRAINDICATIONS TO TIPS PLACEMENT
- CONDITIONS FOR WHICH TIPS SHOULD NOT BE USED
- Primary prophylaxis of variceal hemorrhage
- Prehepatic portal hypertension
- Correction of hypersplenism and thrombocytopenia
- Pulmonary hypertension and hepatopulmonary syndrome
- Portal hypertension associated with polycystic liver disease or Caroli disease
- SUMMARY AND RECOMMENDATIONS