1
Indications / Contraindications
Indications for Revision
- TIPS stenosis on Duplex US: intrastent velocity >200 cm/s OR velocity change >50 cm/s between segments suggests stenosis; also mVPmax <28 cm/s (hepatofugal) or <39 cm/s (hepatopetal) per AASLD; loss of phasic waveform; or PPG >12 mmHg on catheter measurement. Normal post-TIPS intrastent flow is hepatofugal, typically 90–190 cm/s.
- Recurrent variceal hemorrhage with known TIPS — strongly suggests shunt dysfunction; proceed directly to catheter lab
- Recurrent or refractory ascites post-TIPS — may indicate inadequate shunt function
- TIPS thrombosis (complete occlusion) — requires mechanical and/or thrombolytic recanalization
Indication for TIPS Reducer
- Refractory post-TIPS hepatic encephalopathy not controlled with lactulose and rifaximin
- Goal: reduce shunt diameter (e.g., 8 mm → 6 mm) without full occlusion to preserve partial portal decompression while reducing ammonia shunting
Contraindications
- Active uncontrolled sepsis or bacteremia (relative; treat infection first)
- Complete TIPS occlusion with no residual lumen and inaccessible portal vein (requires fresh portal vein puncture)
- Worsening liver failure prohibiting further intervention (clinical judgment)
- INR >2.5 uncorrectable — correct with FFP/PCC before revision
2
Pre-Procedure Checklist
Review original TIPS procedure report — stent type (covered vs bare metal), stent size, date of placement, original PPG, and access route
Labs: CBC, CMP, INR — same targets as primary TIPS (platelets >50K, INR <2.5)
If thrombolysis anticipated: baseline fibrinogen level; have FFP available
Informed consent: stent thrombosis, bleeding, encephalopathy worsening after re-dilatation, incomplete revision requiring repeat procedure
Note stent manufacturer — bare metal Wallstents (pre-2003 era) require covered stent extension; Viatorr stents may need only angioplasty or focal extension
3
Relevant Anatomy
Common Stenosis Locations
- Outflow at hepatic vein–IVC junction: most common stenosis site; intimal hyperplasia at stent flare; responds to angioplasty ± stent extension into IVC
- Intrastent pseudointimal hyperplasia: diffuse throughout bare metal stent; requires covered stent extension for durable treatment
- Inflow at portal vein end: fibrous ingrowth at uncovered segment; balloon angioplasty ± covered stent extension into portal vein
Stent-Specific Anatomy
- Bare metal stents (legacy TIPS): pseudointimal ingrowth throughout stent lumen; angioplasty alone has 40–60% restenosis rate; always require covered stent extension
- Viatorr (covered): ePTFE-covered central segment with bare metal portal end; stenosis typically at uncovered portal segment or at hepatic vein flare
- Portal vein thrombosis: may extend from TIPS inflow into main portal vein; requires thrombolysis ± mechanical thrombectomy before stent revision
4
Technique
Default RadCall approach · share your own below
Supplies
Right IJV access sheath (9–10 Fr)
Angled catheter (Kumpe or Cobra)
Stiff Amplatz guidewire
Hydrophilic angled wire (Glidewire)
Pressure transducer
Angioplasty balloons (8 mm and 10 mm)
Viatorr TIPS extender or Wallstent
Aspiration catheter (thrombectomy if needed)
rtPA (for thrombosed TIPS)
Multi-sidehole infusion catheter
TIPS reducer device (encephalopathy cases)
Steps — Standard Revision
1
Right IJV Access
Ultrasound-guided right IJV access, same approach as primary TIPS. Upsize to 9 Fr sheath.
2
Catheterize Existing TIPS Stent
Advance angled catheter through IVC into the right hepatic vein orifice and enter the existing stent lumen. Use a hydrophilic wire if lumen is narrowed.
3
Traverse Stent to Portal Vein
Advance wire through the full length of the stent into the main portal vein. Exchange for stiff Amplatz wire for stable platform.
4
Pressure Measurement
Measure portal vein pressure and right atrial pressure. Calculate current PPG. Compare to original post-TIPS PPG from procedure report.
5
Venography
Inject contrast to visualize stent, identify stenosis location and length, assess portal vein anatomy, and evaluate for collateral variceal filling.
6
Stenosis Treatment
Pseudointimal hyperplasia (bare metal stent): balloon angioplasty 8–10 mm followed by covered stent extension (Viatorr extender or parallel covered stent). Outflow stenosis at hepatic vein: balloon angioplasty ± stent extension flared into IVC. Inflow stenosis at portal vein end: balloon angioplasty ± extension of covered stent segment into portal vein.
7
Thrombosed TIPS (if applicable)
Mechanical thrombectomy with aspiration catheter (AngioJet or Penumbra Indigo) followed by local rtPA infusion through multi-sidehole catheter if residual thrombus. After thrombus clearance: balloon angioplasty and covered stent placement to bridge the underlying stenosis responsible for occlusion.
8
Post-Revision Pressure & Venogram
Re-measure PPG. Confirm reduction to target (<12 mmHg for variceal hemorrhage, <8 mmHg for ascites). Completion venography confirms shunt patency, flow direction, and elimination of variceal filling.
Constrained TIPS Technique — Controlled Diameter Reduction
Used when a smaller shunt diameter is desired from the outset (e.g., high-risk encephalopathy patient, Child-Pugh B/C) without committing to a full 10 mm shunt. The "waist" technique limits shunt diameter and can reduce early encephalopathy while still achieving adequate portal decompression.
1
Device Selection
Balloon-expandable covered stent with precise deployment control is preferred. Recommended options: VBX stent (W.L. Gore) or iCAST stent (Atrium) — balloon-expandable, covered, accurate to ±1 mm in diameter.
2
Method A — Balloon Under-Expansion
Deploy the stent, then expand with a smaller balloon than nominal stent diameter. Example: 10 mm stent deployed, then expanded with 6–7 mm balloon → creates a controlled waist. Check PPG after partial expansion. Expand in 1 mm increments until target PPG achieved (variceal hemorrhage: <12 mmHg; ascites: <8 mmHg).
3
Method B — Sheath-Constrained Deployment
Deploy the stent partially inside the delivery sheath, then gradually withdraw the sheath as the stent opens. This limits the final diameter at the sheath-constrained zone, creating a reliable "waist" at the mid-TIPS position. Preferred by some operators for reproducibility.
4
Pressure-Guided Titration
Position across mid-TIPS. Inflate balloon partially — check gradient. If PPG remains above target: re-dilate in 1 mm increments and repeat pressure measurement until target achieved. Document final effective diameter and PPG.
Steps — TIPS Reducer (Refractory Encephalopathy)
1
Catheterize Existing TIPS via Right IJV
Standard right IJV access, traverse stent to portal vein as above.
2
Baseline PPG Measurement
Measure and document current PPG to confirm adequate shunt function before reducing diameter.
3
Deploy TIPS Reducer Device
Position a balloon-expandable covered stent (reducer) within the existing TIPS stent to reduce internal diameter from 8 mm to 6 mm (or 10 mm to 8 mm). Confirm positioning fluoroscopically before full deployment.
4
Confirm Pressure Response
Post-reducer PPG should increase (accepting some return of portal hypertension). Goal: reduce encephalopathy while maintaining PPG below the variceal hemorrhage threshold (~12 mmHg). If PPG rises above 12 mmHg: accept the tradeoff or perform partial expansion.
Sign in to view and create community cards
5
Troubleshooting
Problem
Cannot enter original TIPS stent lumen
Likely cause: Complete thrombosis, stent migration, or severe kinking preventing wire passage
Next step: CO2 venography to opacify stent. Try angled hydrophilic wire (Glidewire). If truly occluded: fresh portal vein puncture under ICE guidance (parallel TIPS). Do not force wire through a fully occluded stent.
Problem
Cannot cross intrastent stenosis with wire
Likely cause: Dense fibrous pseudointimal tissue in old bare metal stents
Next step: Try hydrophilic angled wire (Glidewire Advantage). Pre-dilate with small 4 mm balloon to crack fibrous tissue. Exchange for stiff wire once across for definitive balloon dilation.
Problem
PPG remains elevated after stent revision
Likely cause: Competing collateral inflow, inadequate stent sizing, or second stenosis not yet addressed
Next step: Portal venogram to identify large collaterals. If present: coil embolize coronary or short gastric veins. Balloon-expand stent to maximum diameter. Measure PPG sequentially at each level to localize residual gradient.
6
Complications
Immediate
- Intra-abdominal hemorrhage (rare) — capsular puncture or hepatic vein/IVC perforation
- Hemobilia — biliary injury during wire manipulation
- Arterial injury — hepatic artery during aggressive wire maneuvers
- Pulmonary embolism if thrombolysis dislodges large portal clot
Delayed
- Re-stenosis — especially with bare metal stent extension; covered stent provides more durable patency
- Hepatic encephalopathy worsening — after shunt re-opening or diameter increase from revision
- Stent migration — rare with covered stents; more common with bare metal
- Coagulopathy post-thrombolysis — fibrinogen depletion; monitor fibrinogen level post-infusion; target >100 mg/dL
7
Post-Procedure Care
Immediate Monitoring
- Duplex US at 1 month post-revision — confirm shunt patency and re-established flow velocity; earlier Doppler if clinical concern (recurrent symptoms, deterioration)
- If thrombolysis performed: check fibrinogen at end of infusion; transfuse FFP if fibrinogen <100 mg/dL
- Neurologic checks post-procedure — especially if shunt diameter was increased
- CBC and CMP at 6h
Surveillance & Outpatient Plan
- Resume standard TIPS surveillance: Duplex US at 1 month post-revision, then q6 months
- Hepatic encephalopathy monitoring — increased vigilance in first 4–6 weeks if shunt diameter was increased
- Reassess clinical response (ascites, variceal bleed-free status) at 4–6 week clinic visit
- For TIPS reducer: reassess encephalopathy grade and PPG at 4–6 weeks; titrate medical management
8
Critical Pearls
✶
AASLD Doppler thresholds: mVPmax <28 cm/s (hepatofugal) or <39 cm/s (hepatopetal) per AASLD should prompt venography and pressure measurement to confirm dysfunction. Normal post-TIPS flow is hepatofugal 90–190 cm/s. Do not wait for recurrent hemorrhage before acting on Duplex abnormalities — but negative Doppler does not exclude dysfunction in symptomatic patients; proceed to direct shunt interrogation.
✶
Covered stent extension is definitive for pseudointimal hyperplasia: Balloon angioplasty alone of bare metal stents has a 40–60% restenosis rate. Always extend with a covered stent (Viatorr extender) for durable treatment.
✶
TIPS reducer before shunt occlusion: For refractory encephalopathy, always attempt a TIPS reducer before considering full shunt occlusion — occlusion will cause immediate return of portal hypertension and high risk of variceal re-hemorrhage.
✶
Old bare metal TIPS need covered stent extension: Any TIPS placed before approximately 2003 is likely a bare metal Wallstent. Angioplasty alone will fail rapidly. Always extend with a covered stent at revision.
✶
Catheter pressure measurement is the gold standard: Duplex US has approximately 70% sensitivity for hemodynamically significant stenosis. Always directly measure PPG during the revision procedure to confirm the gradient and guide endpoint assessment.
9
References & Resources
Key Guidelines
- SIR Standards of Practice: TIPS (2016)
- AASLD Portal Hypertension Guidelines (2021)
Primary References
- Haskal ZJ, et al. Stent-graft for revision of transjugular intrahepatic portosystemic shunts. N Engl J Med. 1997;336(4):233–239.
- Maleux G, et al. Endovascular management of transjugular intrahepatic portosystemic shunt dysfunction. Eur Radiol. 2004;14(5):827–836. PMID 15221261.
- Clark TWI, et al. Management of shunt dysfunction in the era of TIPS endografts. Tech Vasc Interv Radiol. 2008;11(4):212–216. PMID 19527847.