Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Published on 19/07/2015 by admin

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Last modified 22/04/2025

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 Controversial whether CTA/MRA is superior to US for TIPS surveillance

image US is primary TIPS surveillance tool
image CTA or MRA indicated if US is technically compromised or equivocal

TOP DIFFERENTIAL DIAGNOSES

• Portal vein occlusion
• Hepatic vein occlusion
• Inferior vena cava occlusion

PATHOLOGY

• Stenosis is usually secondary to intimal fibroplasia within hepatic vein or TIPS itself
• Associated abnormalities

image Hepatic encephalopathy as portal flow bypasses liver

CLINICAL ISSUES

• Maintaining TIPS patency is the major problem

DIAGNOSTIC CHECKLIST

• Consider TIPS malfunction if shunt velocity is < 90 cm/s or portal vein velocity is < 35 cm/s
• Image interpretation pearls

image Low flow is difficult to detect with US
image Confirm occlusion angiographically (CTA, MRA, DSA)
image
(Left) Graphic of TIPS shunt creation shows the hepatic vein punctured within 2 cm of the IVC. The metallic wire TIPS image extends to the right portal vein, adjacent to its junction with the main portal vein.

image
(Right) Image from a TIPS procedure shows the IV catheter image proceeding down the IVC, then penetrating the liver parenchyma to enter the portal vein image. The intraparenchymal tract is dilated with a balloon image. Incidentally noted is a plastic biliary stent image.
image
(Left) Film from the same procedure shows the TIPS itself image deployed with its distal end in the hepatic vein image and its proximal end in the main portal vein image.

image
(Right) Longitudinal color Doppler ultrasound shows the mid portion of a normally patent TIPS image. Although the stent is highly echogenic, it does not obstruct sonographic visualization. Color Doppler indicates brisk flow toward the heart, the expected finding.

TERMINOLOGY

Abbreviations

• Transjugular intrahepatic portocaval shunt (TIPS)

Definitions

• Shunt between main portal vein (PV) and hepatic vein (HV) created with balloon-expandable metallic stent
• Hepatopetal blood flow: Toward liver
• Hepatofugal blood flow: Away from liver

IMAGING

General Features

• Location

image Most common route: Right HV → right PV → main PV
• Size

image 10-12 mm in diameter
• Morphology

image Typically follows curved course through hepatic parenchyma
image Portal end slightly proximal to main PV bifurcation
image Hepatic end located at, or slightly cephalad to, junction of HV and inferior vena cava (IVC)

Ultrasonographic Findings

• Grayscale ultrasound

image Echogenic stent easily seen on grayscale images but does not block sound transmission

– Fabric-covered stent may cause acoustic shadowing soon after placement

image Probably due to gas bubbles trapped in fabric
image May preclude US evaluation of TIPS patency for a few days
image Usually resolves, allowing subsequent US surveillance for TIPS stenosis
image Stent is typically curved but not kinked
image Normally uniform stent caliber
image Hepatic and portal ends “squarely” within veins (best seen on grayscale US)
• Pulsed Doppler

image Portal vein, satisfactory function

– Hepatopetal flow toward heart
– Flow toward shunt in right and left portal branches (occasionally away in left branch)
image Shunt malfunction

– Hepatofugal or bidirectional flow within TIPS
– Peak velocity in portal vein < 35 cm/s
– Flow away from shunt (hepatopetal) in right and left portal branches
image Within shunt, satisfactory function

– Flow slightly turbulent, slight pulsatility, possible slight respiratory variation
– Peak velocity at any location, at least 90 cm/s
– Similar velocity throughout shunt; not > 50 cm/s point-to-point variation
– Similar velocity temporally; not > 50 cm/s change, study-to-study
image Within shunt, malfunction

– Continuous flow (no pulsatility or respiratory change)
– Shunt velocity < 90 or > 250 cm/s at any point
– Temporal drop in velocity ≥ 50 cm/s
– Point-to-point increase in velocity ≥ 50 cm/s indicates focal stenosis
– Focal severe turbulence (post stenosis)
– Absence of flow: Occlusion

image Always confirm angiographically
• Color Doppler

image PV/splenic vein (SV), satisfactory function

– Widely patent, with hepatopetal flow
– Flow toward shunt in right and left portal branches (occasionally away in left branch)
image Within shunt, satisfactory function

– Color flow extends to stent margins
– Uniform, velocity (color scale) throughout shunt
– Mild turbulence
image Within shunt, malfunction

– Visible stenosis, focal or diffuse
– Focal color change indicates high velocity
– Focal severe flow disturbance (post stenosis)
– Absence of flow: Occlusion

image Check with spectral Doppler (more sensitive); always confirm angiographically

Other Modality Findings

• CTA, MRA

image Anatomic depiction of stenosis, occlusion, or collateralization
image Less technically dependent
image Multiplanar reconstruction possible
image More expensive than US
image IV contrast administration is essential for CTA; generally required for MRA

Imaging Recommendations

• Best imaging tool

image Controversial whether CTA or MRA is superior to US for TIPS surveillance
image US is primary TIPS surveillance tool
image CTA/MRA

– Indicated if US is technically compromised or equivocal
– Offers global view

image May be important in cases of suspected tumor occlusion of TIPS
• Protocol advice

image Pre-TIPS assessment (grayscale, color Doppler, spectral Doppler), for

– Liver morphology
– Hepatic masses (very important)
– Presence and volume of ascites and pleural fluid
– Location, patency, and flow direction in PVs and splenic veins (SVs)

image PV bifurcation may lie outside of liver
image Puncture at this point may cause fatal exsanguination
– Measure PV flow velocity
– Patency and flow direction in right and left PV branches
– Patency and flow direction in 3 major HV trunks
– IVC patency
image Post-TIPS assessment (grayscale, color Doppler, spectral Doppler)

– Hepatic masses
– Presence and volume of ascites and pleural fluid
– Stent configuration/position
– Patency and flow direction in PV and its branches
– Measure velocity mid-PV (not adjacent to shunt)
– Assess shunt with color Doppler
– Doppler waveforms/peak velocities: Proximal, mid, distal shunt
– Compare findings with prior results before discharging patient (recheck if needed)
– Presence of stenosis

image If present, peak stenosis velocity/post-stenotic turbulence
– Patency, flow direction, Doppler waveforms in HV

Angiographic Findings

• Portal venography via jugular vein catheterization

image Definitive test for TIPS stenosis or occlusion
image May allow balloon dilation of TIPS lumen or placement of new shunt within stenotic TIPS

DIFFERENTIAL DIAGNOSIS

Portal Vein Occlusion

• May occur in patients ± TIPS

image Hypercoagulable states, pancreatitis, tumor invasion, dehydration, trauma, cirrhosis

Hepatic Vein Occlusion

• May occur ± TIPS

image e.g., Budd-Chiari syndrome, tumor invasion (especially by hepatocellular carcinoma [HCC])

IVC Occlusion

• Rarely caused by TIPS
• May occur in primary (IVC sarcoma) or invasion by adjacent tumor (e.g., HCC, renal cell carcinoma)

PATHOLOGY

General Features

• Etiology

image Stenosis usually secondary to intimal fibroplasia within TIPS

Staging, Grading, & Classification

• Occlusion, low- or high-grade stenosis

Gross Pathologic & Surgical Features

• Chronic occlusion or stenosis secondary to build-up of intimal fibroplasia

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Signs of failing TIPS

– Recurrence of ascites, variceal hemorrhage
• Clinical profile

image Candidates for TIPS

– Cirrhosis with intractable ascites or variceal bleeding
– Budd-Chiari syndrome
– Temporizing measure, pre liver transplantation

Demographics

• Age

image Generally adults, may be used in children
• Epidemiology

image Maintaining TIPS shunt patency is the major problem

– Primary patency (no intervention): 1 year = 25-66%; 2 year = 5-42%
– Secondary (intervention-assisted) patency: 1 year = 85%; 2 year = 61%; 5 year = 55%
– Covered stents may improve primary patency but insufficient data

Natural History & Prognosis

• Causes of TIPS shunts failure

image Technical problems: Malposition, kinks, incomplete deployment, hepatic perforation with hemoperitoneum, or bile leak
image Venous trauma during stent insertion: HV stenosis often precedes PV fibrosis or stenosis
image Neointimal hyperplasia (may be ameliorated by covered stents but insufficient data)
image Thrombosis
image Hepatic arterial injury and arteriovenous fistula
image Gallbladder injury
• Guarded prognosis

image Maintaining shunt patency is difficult
image Inevitable liver disease progression
image High risk of cirrhosis-related HCC
image 7-45% 30-day mortality

DIAGNOSTIC CHECKLIST

Consider

• TIPS malfunction if flow velocity within TIPS is < 90 or > 250 cm/s, or PV velocity < 35 cm/s

Image Interpretation Pearls

• Low flow difficult to detect with US; confirm occlusion angiographically (CTA, MRA, DSA)
image
(Left) Grayscale US in a 51-year-old man who underwent a TIPS 5 months ago, now with a recent increase in ascites, demonstrates highly reflective echoes typical of the TIPS shunt walls image.

image
(Right) Longitudinal color Doppler ultrasound in the same patient, scanned through the mid-shunt level, demonstrates low-velocity flow (45 cm/s) within the shunt image. A subsequent angiogram revealed a high-grade TIPS stenosis involving the hepatic venous side of the shunt.
image
(Left) Color Doppler US in a 47-year-old woman who underwent TIPS 7 months ago illustrates marked aliasing and turbulent flow within the distal shunt image.

image
(Right) Longitudinal spectral Doppler ultrasound in the same patient demonstrates markedly increased velocity of flow in the distal shunt (255 cm/s) image, findings consistent with mid-shunt stenosis.
image
(Left) Portal venography in a 66-year-old man with a suspected TIPS stenosis based on Doppler ultrasound reveals multiple areas of luminal narrowing image within the parenchymal portion of the shunt, usually due to intimal hyperplasia.

image
(Right) Portal venography in a 41-year-old man presenting with a suspected TIPS malfunction, based on a recurrence of ascites, demonstrates stenosis at the hepatic vein image at the proximal end of the TIPS.
image
(Left) Longitudinal pulsed Doppler ultrasound shows markedly elevated flow velocity (314 cm/s) at the narrowed lumen of the TIPS, clearly indicating stent stenosis.

image
(Right) Longitudinal color Doppler US in the same case shows focal narrowing and high velocity (blue shades) image near the hepatic end of the TIPS.
image
(Left) This initial US was performed 1 day after placement of a fabric-lined or “covered” stent image. Note the acoustic shadow deep to the stent image, precluding optimal US evaluation for stent patency.

image
(Right) Repeat US several months later shows resolution of the acoustic shadow deep to the TIPS. Color Doppler US shows narrowing of the lumen image and turbulent flow, likely due to intimal fibroplasia.
image
(Left) Color Doppler US in a 64-year-old man with cirrhosis and a recurrent upper GI bleed 1 month after TIPS placement shows a TIPS shunt image with complete absence of flow, indicating TIPS occlusion.

image
(Right) Image from a portal venogram in the same patient shows opacification of the portal branches image, but no opacification of the TIPS image, confirming shunt occlusion.
image
(Left) A 55-year-old man had a TIPS placed 3 years previously and returned with increased ascites and liver failure. Color Doppler US shows no flow within the TIPS image, the proximal end of which terminates in a markedly distended main portal vein image.

image
(Right) US in the same patient shows marked dilation of the left portal vein, which seemed to be filled with vascularized tumor image. The liver was very heterogeneous, but no discrete mass was identified.
image
(Left) Arterial phase CECT performed the next day showed occlusion of the TIPS lumen, with the proximal (portal) end of the TIPS image lying within a massively dilated portal vein that was distended with contrast-enhancing tumor thrombus image.

image
(Right) Portal venous phase CECT in the same case shows the occluded TIPS image and contrast washout from the portal vein tumor thrombus image along with the primary HCC that fills the left lobe of the liver image.
image
(Left) CT section in the same case shows the TIPS image entering the portal vein, along with the primary HCC image and its extension into the left portal vein image.

image
(Right) CT section in the same case shows the proximal end of the TIPS image embedded within a tumor thrombus image that distends the main portal vein.
image
Anteroposterior later-phase portal venous angiogram in a 52-year-old patient with suspected TIPS stenosis due to increasing ascites shows the extensive filling defects within the TIPS image due to a combination of clot and intimal fibroplasia. The shunt was successfully revised with balloon dilation.

SELECTED REFERENCES

1. Orloff, MJ. Fifty-three years’ experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in Cirrhosis: 1958-2011. JAMA Surg. 2014; 149(2):155–169.

2. Kirby, JM, et al. Image-guided intervention in management of complications of portal hypertension: more than TIPS for success. Radiographics. 2013; 33(5):1473–1496.

3. Qin, JP, et al. Clinical effects and complications of TIPS for portal hypertension due to cirrhosis: a single center. World J Gastroenterol. 2013; 19(44):8085–8092.

4. Micol, C, et al. Contrast-enhanced ultrasound: a new method for TIPS follow-up. Abdom Imaging. 2012; 37(2):252–260.

5. Wu, X, et al. Favorable clinical outcome using a covered stent following transjugular intrahepatic portosystemic shunt in patients with portal hypertension. J Hepatobiliary Pancreat Sci. 2010; 17(5):701–708.

6. Kim, MJ, et al. Technical essentials of hepatic Doppler sonography. Curr Probl Diagn Radiol. 2009; 38(2):53–60.

7. Bureau, C, et al. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study. Liver Int. 2007; 27(6):742–747.

8. Maleux, G, et al. Dynamic MR perfusion measurements before and after TIPS in cirrhotic patients with refractory ascites. Acad Radiol. 2007; 14(11):1400–1408.

9. Bauer, J, et al. The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis. Liver Transpl. 2006; 12(10):1544–1551.

10. Carr, CE, et al. Role of ultrasound surveillance of transjugular intrahepatic portosystemic shunts in the covered stent era. J Vasc Interv Radiol. 2006; 17(8):1297–1305.

11. Harrod-Kim, P, et al. Predictors of early mortality after transjugular intrahepatic portosystemic shunt creation for the treatment of refractory ascites. J Vasc Interv Radiol. 2006; 17(10):1605–1610.

12. Barrio, J, et al. Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts versus bare stents. Eur J Radiol. 2005; 55(1):120–124.

13. Benito, A, et al. Doppler ultrasound for TIPS: does it work? Abdom Imaging. 2004; 29(1):45–52.

14. Middleton, WD, et al. Doppler evaluation of transjugular intrahepatic portosystemic shunts. Ultrasound Q. 2003; 19(2):56–70. [quiz 108 – 10].

15. Bodner, G, et al. Color and pulsed Doppler ultrasound findings in normally functioning transjugular intrahepatic portosystemic shunts. Eur J Ultrasound. 2000; 12(2):131–136.

16. Ong, JP, et al. Transjugular intrahepatic portosystemic shunts (TIPS): a decade later. J Clin Gastroenterol. 2000; 30(1):14–28.

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