Teaching Case

TIPS procedure

Patient suffers from ethanol-induced liver cirrhosis (Child C) for a couple of years. He had developed hepatorenal syndrome and untreatable ascites. Conservative treatment including paracentesis failed to reduce ascites. Sonography revealed a very small liver but patent hepatic veins and portal vein. As a last option, it was decided to perform a TIPS procedure. After a right jugular puncture, the TIPS needle was inserted into the patent right hepatic vein, which is the usual route to perform a TIPS procedure (Fig. 1 a). After puncturing the liver parenchyma from the central third of the right hepatic vein in an anterior and medial direction, the portal vein was hit intrahepatically at its right main branch (Fig. 1 b). After exchanging the puncture needle for a coated guide wire, a 5 F catheter was inserted into the main portal vein and a stiff guide wire inserted exchanging the coated guidewire. After dilating the intrahepatic tract with an 8 mm balloon, a 12 mm wide self-expanding nitinol stent (Smart, Cordis Inc.) was inserted into the tract and redliated by an 8 mm balloon (Fig. 1 c) Portosystemic pressure gradient fell from 25 mm Hg to 8 mm Hg indicating a sufficient shunt function and the procedure was terminated.

TIPS is a relatively new percutaneous technique to reduce portal hypertension. The acute results concerning variceal bleeding are excellent, however, restenosis within the TIPS tract is frequent. Main indications are bleeding from varices, gastric varices, ascites and Budd-Chiari syndrome. Main acute complications are bleeding, failed puncture and hepatic rupture. Late complications are TIPS thrombosis and hepatic encephalopathy. There are pros and cons for self-expanding and balloon-expandable stents. Balloon-expandable stents have an advantage in a controlled adaptation of the TIPS diameter for gradual reduction of portal pressure; self-expanding stents can be used even in curved TIPS tracts and mostly only one stent is requested.