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Transjugular intrahepatic portosystemic shunts: Indications and contraindications

INTRODUCTION

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). 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 [1]. 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 "Treatment of diuretic-resistant ascites in patients with cirrhosis", section on 'Transjugular intrahepatic portosystemic stent-shunt' and "Transjugular intrahepatic portosystemic shunts: Complications".)

A guideline issued by the American Association for the Study of Liver Diseases (AASLD; updated in 2009) is also available [2]. The AASLD guideline can be accessed through the AASLD web site at www.aasld.org.

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 "Treatment of diuretic-resistant ascites in patients with cirrhosis".)

HEPATORENAL SYNDROME

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 µmol/L) at baseline, was unchanged at one week, and fell to 0.9 mg/dL (80 µmol/L) by six months [4].

              

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Literature review current through: Apr 2013. | This topic last updated: Apr 5, 2013.
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References
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