Techniques in Vascular & Interventional Radiology
Volume 11, Issue 4 , Pages 201-202, December 2008

Introduction

Article Outline

 

The transjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical, minimally invasive method of portal decompression initially used in patients with refractory esophagogastric variceal bleeding.1, 2, 3 Created using catheters, balloons, and stents inserted under radiologic guidance through the jugular vein, TIPS intrinsically functions as a side-to-side portocaval shunt. Since its inception as a method for preventing variceal bleeding, indications for TIPS have expanded to include other complications of liver disease, including refractory ascites,4, 5, 6, 7, 8 Budd–Chiari syndrome,9, 10, 11 hepatic hydrothorax,12, 13, 14 and hepatorenal syndrome.15 Although multiple randomized trials to date have established the efficacy of TIPS in preventing variceal rebleeding,16, 17, 18, 19, 20, 21, 22, 23 a significant drawback of TIPS created with bare stents is that the shunt is prone to stenosis or occlusion. This drawback has been successfully overcome through the widespread use of expanded polytetrafluoroethylene-covered endografts for TIPS creation, which achieve durable long-term patency and are redefining the role of TIPS for treating complications of portal hypertension.11, 24, 25, 26, 27, 28, 29, 30, 31, 32

A growth in the demand for portal decompression therapy, such as TIPS, is expected in the face of the rising prevalence of complications from hepatitis C (HCV). An estimated 3.9 million (1.8%) Americans have been infected with HCV.33 Most HCV-infected persons are aged 30-49 years; over the next 2 decades, this population of infected persons will reach an age at which variceal bleeding and ascites from chronic liver disease typically occurs.34

In this issue of Techniques in Vascular and Interventional Radiology, Dr Wael Saad describes portal venous anatomy and common variants that are relevant to planning and performing TIPS. Drs Robert Ryu and Robert Scallon describe current techniques of portal vein imaging and targeting during TIPS and offer insight into future directions in portal imaging technology. I discuss the stepwise procedure of TIPS creation using endografts, outlining the differences of shunt creation compared to conventional bare stent TIPS. I also provide an overview of the patterns of shunt dysfunction which can occur in a subset of patients with TIPS endografts. Balloon occlusion through retrograde variceal access has largely replaced TIPS in Japan for treating patients with refractory variceal bleeding; Dr Hector Ferral describes this procedure and the role it plays in contemporary endovascular therapy for complications of portal hypertension. Dr Bryan Petersen describes the direct intrahepatic portocaval shunt, which uses a novel method for portal access with intravascular ultrasound to create a side-to-side inferior vena cava to portal vein shunt, and extends the spectrum of patients for whom endovascular shunting can be performed. Last, TIPS is an effective therapy for children with refractory variceal bleeding and ascites; Dr Jonathan Lorenz describes TIPS placement in the pediatric population.

We hope you find this issue of Techniques in Vascular and Interventional Radiology relevant to your daily practice in the care of patients with portal hypertension.

Back to Article Outline

References 

  1. Colapinto RF, Stronell RD, Gildiner M, et al. Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: Preliminary clinical experience. AJR Am J Roentgenol. 1983;140:709–714
  2. Coldwell DM, Ring EJ, Rees CR, et al. Multicenter investigation of the role of transjugular intrahepatic portosystemic shunt in management of portal hypertension. Radiology. 1995;196:335–340
  3. Barange K, Peron JM, Imani K, et al. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. J Hepatol. 1999;30:1139–1143
  4. Somberg KA, Lake JR, Tomlanovich SJ, et al. Transjugular intrahepatic portosystemic shunts for refractory ascites: Assessment of clinical and hormonal response and renal function. J Hepatol. 1995;21:709–716
  5. Lebrec D, Giuily N, Hadengue A, et al. Transjugular intrahepatic portosystemic shunts: Comparison with paracentesis in patients with cirrhosis and refractory ascites: A randomized trial (French Group of Clinicians and a group of biologists). J Hepatol. 1996;25:135–144
  6. Rossle M, Ochs A, Gulberg V, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med. 2000;342:1701–1707
  7. Gines P, Uriz J, Calahorra B, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology. 2002;123:1839–1847
  8. Salerno F, Merli M, Riggio O, et al. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. J Hepatol. 2004;40:629–635
  9. Ryu RK, Durham JD, Krysl J, et al. Role of TIPS as a bridge to hepatic transplantation in Budd–Chiari syndrome. J Vasc Interv Radiol. 1999;10:799–805
  10. Slakey DP, Klein AS, Venbrux AC, et al. Budd–Chiari syndrome: Current management options. Ann Surg. 2001;233:522–527
  11. Hernandez-Guerra M, Turnes J, Rubinstein P, et al. PTFE-covered stents improve TIPS patency in Budd–Chiari syndrome. J Hepatol. 2004;40:1197–1202
  12. Haskal ZJ, Zuckerman J. Resolution of hepatic hydrothorax after transjugular intrahepatic portosystemic shunt (TIPS) placement. Chest. 1994;106:1293–1295
  13. Strauss RM, Martin LG, Kaufman SL, et al. Transjugular intrahepatic portal systemic shunt for the management of symptomatic cirrhotic hydrothorax. Am J Gastroenterol. 1994;89:1520–1522
  14. Siegerstetter V, Deibert P, Ochs A, et al. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: Long-term results in 40 patients. Eur J Gastroenterol Hepatol. 2001;13:529–534
  15. Brensing KA, Textor J, Perz J, et al. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: A phase II study. Gut. 2000;47:288–295
  16. Cabrera J, Maynar M, Granados R, et al. Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology. 1996;110:832–839
  17. Sauer P, Theilmann L, Stremmel W, et al. Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding. Gastroenterology. 1997;113:1623–1631
  18. Sanyal AJ, Freedman AM, Luketic VA, et al. Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage (A randomized, controlled trial). Ann Intern Med. 1997;126:849–857
  19. Rossle M, Deibert P, Haag K, et al. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding. Lancet. 1997;349:1043–1049
  20. Cello JP, Ring EJ, Olcott EW, et al. Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage (A randomized, controlled trial). Ann Intern Med. 1997;126:858–865
  21. Jalan R, Forrest EH, Stanley AJ, et al. A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices. J Hepatol. 1997;26:1115–1122
  22. Merli M, Salerno F, Riggio O, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: A randomized multicenter trial (Gruppo Italiano studio TIPS (G.I.S.T.)). J Hepatol. 1998;27:48–53
  23. Pomier-Layrargues G, Villeneuve JP, Deschenes M, et al. Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: A randomised trial. Gut. 2001;48:390–396
  24. Andrews RT, Saxon RR, Bloch RD, et al. Stent-grafts for de novo TIPS: Technique and early results. J Vasc Interv Radiol. 1999;10:1371–1378
  25. Sze DY, Vestring T, Liddell RP, et al. Recurrent TIPS failure associated with biliary fistulae: Treatment with PTFE-covered stents. Cardiovasc Interv Radiol. 1999;22:298–304
  26. Cejna M, Peck-Radosavljevic M, Thurnher S, et al. ePTFE-covered stent-grafts for revision of obstructed transjugular intrahepatic portosystemic shunt. Cardiovasc Interv Radiol. 2002;25:365–372
  27. Haskal ZJ, Weintraub JL, Susman J. Recurrent TIPS thrombosis after polyethylene stent-graft use and salvage with polytetrafluoroethylene stent-grafts. J Vasc Interv Radiol. 2002;13:1255–1259
  28. Angermayr B, Cejna M, Koenig F, et al. Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stent grafts versus bare stents. J Hepatol. 2003;38:1043–1050
  29. Hausegger KA, Karnel F, Georgieva B, et al. Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft. J Vasc Interv Radiol. 2004;15:239–248
  30. Maleux G, Nevens F, Wilmer A, et al. Early and long-term clinical and radiological follow-up results of expanded-polytetrafluoroethylene-covered stent-grafts for transjugular intrahepatic portosystemic shunt procedures. Eur Radiol. 2004;14:1842–1850
  31. Rossi P, Salvatori FM, Fanelli F, et al. Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience. Radiology. 2004;231:820–830
  32. Bureau C, Pagan JC, Layrargues GP, et al. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: Long-term results of a randomized multicenter study. Liver Int. 2007;27:742–747
  33. Williams I. Epidemiology of hepatitis C in the United States. Am J Med. 1999;107:2S–9S
  34. Wong JB, McQuillan GM, McHutchison JG, et al. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Pub Health. 2000;90:1562–1569

PII: S1089-2516(09)00002-X

doi:10.1053/j.tvir.2009.04.001

Techniques in Vascular & Interventional Radiology
Volume 11, Issue 4 , Pages 201-202, December 2008

Article Tools