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Indications / Contraindications
Indications
- Refractory variceal hemorrhage (esophageal or gastric) — failed endoscopic/medical management; acute hemorrhage or secondary prophylaxis
- Refractory ascites — ≥2 large-volume paracenteses in 4 weeks despite maximum medical therapy; not a first-line treatment
- Budd-Chiari syndrome — acute/subacute with clinical decompensation; bridging to transplant
- Hepatic hydrothorax — refractory, failed thoracentesis and medical therapy
- Portal hypertensive gastropathy — refractory bleeding
- Ectopic varices — stomal, rectal, mesenteric
MELD / Child-Pugh Guidance
- MELD ≤15 — optimal candidate
- MELD 15–24 — benefit likely outweighs risk; case-by-case
- MELD ≥24 — ~50% 30-day mortality in acute setting; consider palliative intent vs bridging to transplant
Absolute Contraindications
- Right heart failure (EF <20% or right heart dysfunction) — absolute contraindication due to inability to tolerate sudden preload increase; for borderline dysfunction (EF 20–35%), consider TAPSI (constrained-diameter shunt using balloon-expandable covered stent, e.g., VBX/iCAST 6–7 mm) with formal echo and cardiology co-management; can be gradually dilated if cardiac function improves
- Severe pulmonary hypertension (PASP >45 mmHg)
- Hepatic encephalopathy — uncontrolled, grade 3–4
- Polycystic liver disease
- Active systemic infection / sepsis
- Severe coagulopathy (INR >5) without correction
- Complete portal vein thrombosis (relative — see below)
Relative Contraindications
- Child-Pugh C (≥12) without bridging-to-transplant intent
- Bilirubin >3–5 mg/dL
- MELD >24
- Hepatic neoplasm in planned shunt tract
- Biliary obstruction
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Pre-Procedure Checklist
Cross-sectional imaging (CT/MRI with contrast) within 3 months — hepatic vein anatomy, portal vein patency, hepatic parenchyma, liver size, ascites volume, varices
Labs: CBC, CMP, INR/PT, type & screen. Target: platelets >50K (transfuse if needed), INR <2.5 (FFP/PCC if needed)
Echo/cardiac evaluation — rule out right heart failure and pulmonary hypertension; EF check essential. If suspected right heart failure: formal echo required before proceeding.
Hepatic encephalopathy assessment — baseline neurologic exam; optimize lactulose and rifaximin pre-procedure
IV access: 2 large-bore PIVs + arterial line if general anesthesia
Informed consent: encephalopathy (new or worsening, 20–30%), shunt dysfunction/thrombosis, hepatic failure, intra-abdominal bleeding, biliary injury, contrast nephropathy
Consider ICE (intracardiac echocardiography) capability — increasingly used for real-time visualization of portal vein access; improves first-pass success
NPO: 8h for general anesthesia; 4h for liquids with moderate sedation
Cefazolin 1g IV at induction
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Relevant Anatomy
Hepatic Vein – Portal Vein Relationships
- Right hepatic vein → right portal vein tract: most common approach; direct path; shorter stent required
- Middle hepatic vein → left portal vein: alternative if right hepatic vein unsuitable; used for left-sided (gastric) varices
- Portal vein target: right main portal vein, bifurcation used as fluoroscopic landmark
- Right hepatic vein → right portal vein distance: ~3–5 cm in most patients
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Technique
Default RadCall approach · share your own below
Supplies
Access & Imaging
Ultrasound (IJ access)
ICE catheter
10 Fr × 40 cm sheath × 2
Catheters & Wires
MPA catheter
Glidewire 0.035”
Nitrex wire 0.018”
Navicross catheter 4 Fr, 90 cm
Lunderquist wire
Straight marking catheter
TIPS Kit
TLAB set
21G × 61 cm Chiba needle
Stent & Balloon
Viatorr stent graft
Conquest balloon 8 mm × 4 cm
Completion
Trialysis catheter 15.5 Fr × 15 cm
Contrast + power injector
Pressure transducer & manifold
Steps
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Access & Setup
Ultrasound-guided right IJV access. Place two 10 Fr × 40 cm sheaths: one for hepatic vein access, one dedicated for the ICE catheter.
2
Hepatic Vein Selection (with ICE)
Insert ICE catheter via the second sheath. Use the ICE image to identify the optimal hepatic vein target. Advance MPA catheter + Glidewire through the primary sheath to select and access the hepatic vein.
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Baseline Pressures
Measure right atrial pressure and hepatic vein pressure. Document baseline portosystemic gradient before access.
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Portal Vein Access (Key Step)
Advance the TLAB set into the hepatic vein. Under real-time ICE guidance, use the 21G × 61 cm Chiba needle to puncture from hepatic vein into the portal vein. ICE provides direct visualization — confirm intraportal position with aspiration of blood and small contrast injection showing portal branching toward the liver.
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Wire Access Across Tract
Advance a 0.018” Nitrex wire into the portal system. Confirm intraportal position under fluoroscopy before proceeding.
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Upsize to Working Wire
Over the 0.018” wire, advance the 90 cm 4 Fr Navicross catheter into the portal vein. Exchange the Nitrex for a 0.035” Glidewire and advance into the main portal vein (MPV).
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Exchange for Stiff Wire & TIPS Sheath
Exchange the Glidewire for a Lunderquist wire. Advance the TIPS sheath over the Lunderquist wire into the main portal vein.
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Portal Venography & Pressures
Perform portal venogram through the TIPS sheath. Measure direct portal vein pressure and right atrial pressure. Calculate PPG = portal pressure − RA pressure. Targets: <12 mmHg for variceal hemorrhage, <8 mmHg for ascites.
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Tract Measurement
Advance a straight marking catheter. Measure the parenchymal tract length to select the correct Viatorr stent size.
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Stent Deployment (Viatorr)
Advance the Viatorr stent. Deploy technique: deploy ~2 cm within the sheath first, then pull the sheath back to the desired position while maintaining gentle back tension on the stent system to avoid pull-through. Fully deploy. The ePTFE-covered portion spans the liver parenchyma; uncovered portion extends 1–2 cm into the portal vein.
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Post-Dilation
Dilate the deployed stent with the 8 mm × 4 cm Conquest balloon. Inflate to nominal pressure for 3 minutes to expand the stent to the target diameter.
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Final Assessment
Repeat portal venogram and pressure measurements. Confirm adequate flow through the shunt and document PPG reduction. If PPG >12 mmHg (hemorrhage) or >8 mmHg (ascites): consider expanding to 10 mm or placing parallel stent. Embolize varices if indicated.
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Completion
Place 15.5 Fr × 15 cm Trialysis catheter if needed (e.g., for continued access or infusion). Remove all sheaths. Manual compression ± figure-of-8 suture at right IJV access site.
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Troubleshooting
Problem
Cannot find portal vein with needle
Likely cause: Unusual anatomy, hepatic atrophy, portal vein thrombosis, poor fluoroscopic visualization
Next step: Opacify portal vein via SMA arterial injection (indirect portography) through a separately placed arterial sheath. Use CO2 for better contrast. Add ICE guidance. Review pre-procedure CT for portal vein position relative to hepatic vein.
Problem
Inadequate PPG reduction after stent (PPG >12 mmHg)
Likely cause: Stent undersized, hepatic vein/portal vein not fully bridged, competitive inflow from collaterals
Next step: Balloon-expand Viatorr to 10 mm if initially deployed at 8 mm. Confirm hepatic vein end is positioned in IVC. Consider parallel TIPS for dominant left-sided varices. Embolize competing collaterals.
Problem
Arterial bleeding during parenchymal puncture
Likely cause: Inadvertent hepatic artery puncture during needle pass
Next step: Withdraw needle immediately. If arterial bleeding continues: coil embolization of arterial injury via selective hepatic artery catheterization. Monitor for hemobilia.
Problem
Bile in aspiration (biliary puncture)
Likely cause: Intrahepatic biliary duct puncture during needle pass
Next step: Withdraw needle and reposition. If stent already placed across biliary duct: evaluate with ERCP; associated with shunt infection and cholangitis. May require endoscopic or IR biliary drainage.
Problem
New hepatic encephalopathy post-TIPS
Likely cause: Excessive hepatic shunting — ammonia-producing gut products bypassing the liver
Next step: Start or optimize lactulose and rifaximin. If severe or refractory: shunt reduction with a balloon-expandable TIPS reducer device. As a last resort: shunt occlusion (accept risk of variceal re-bleeding).
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Complications
Immediate
- Intra-abdominal hemorrhage (<1%) — capsular perforation or hepatic artery injury
- Hemobilia — biliary puncture during tract creation
- Contrast-induced nephropathy — minimize contrast volume; pre-hydration protocol
- Right heart failure exacerbation — sudden increase in preload from shunt; monitor with continuous telemetry and CVP/wedge pressure; risk mitigated by TAPSI technique (constrained-diameter shunt) in at-risk patients; treat with aggressive diuresis; vasopressors if hemodynamically unstable; consider TAPSI reducer if persistent right heart strain post-procedure
Delayed
- Hepatic encephalopathy — 20–30%; new or worsening post-TIPS; peak in first months; medical management first; TIPS reducer if refractory
- Shunt stenosis/occlusion — 20–30% without covered stent; <10% with Viatorr at 1 year; requires Duplex surveillance
- Hepatic failure — acute decompensation from shunting; irreversible in high-MELD patients; liver transplant evaluation
- Stent infection — rare; typically biliary contamination; IV antibiotics ± TIPS removal
- Radiation-induced liver injury — rare at standard fluoroscopy doses; document and limit screening times
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Post-Procedure Care
Immediate Monitoring
- ICU or step-down unit for 24h (general anesthesia or complex cases)
- Vital signs q1h × 4h, then q4h
- Neurologic checks q4h (encephalopathy screening)
- Labs at 6h: CBC, CMP, LFTs
- NPO until fully awake from GA; advance diet as tolerated
Discharge & Outpatient Plan
- Duplex US at 1 month, then q6 months (standard TIPS surveillance protocol)
- MELD/Child-Pugh reassessment at 4–6 weeks
- If TIPS for ascites: continue diuretics at reduced dose; allow 4–6 weeks for TIPS remodeling before judging ascites response
- Encephalopathy prophylaxis: lactulose 30 mL TID (titrate to 2–3 soft stools/day) + rifaximin 550 mg BID in high-risk patients
- Anticoagulation: not routine; consider 3–6 months if portal vein thrombosis was present pre-procedure
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Critical Pearls
✶
PPG target matters: For variceal hemorrhage, target PPG <12 mmHg. For ascites, target PPG <8 mmHg. Start at 8 mm Viatorr in encephalopathy-prone patients (elderly, prior encephalopathy, muscle wasting) — can expand to 10 mm later if needed.
✶
ICE guidance: Intracardiac echo dramatically improves first-pass portal vein puncture rate, especially with small or scarred right hepatic veins or unusual anatomy. Insert via femoral vein to right atrium; rotate to visualize hepatic veins. Consider routine use.
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Always use a covered stent (Viatorr): Covered ePTFE stents achieve >90% patency at 2 years vs ~50% for bare metal. Never use an uncovered stent for primary TIPS creation.
✶
Right IJV is preferred: Never use the left IJV without specific indication — the more tortuous path makes hepatic vein alignment and needle positioning significantly more difficult.
✶
Know your variceal collateral anatomy: Embolize the coronary vein for esophageal varices. For gastric fundal varices with a gastrorenal shunt communicating with the left renal vein, consider BRTO in addition to or instead of TIPS.
✶
Pre-existing encephalopathy is a major risk factor: Any patient with prior grade 3–4 encephalopathy is at very high risk for post-TIPS encephalopathy. Discuss carefully with hepatology and the patient before proceeding.
✶
Early TIPS for acute variceal bleed: TIPS within 72h dramatically improves outcomes in high-risk variceal bleeding (Child-Pugh B with active bleeding or Child-Pugh C). Do not delay for “elective” timing in acute high-risk presentations.
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References & Resources
Key Guidelines
Primary References
- Garcia-Pagan JC, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370–2379.
- Boyer TD, Haskal ZJ; AASLD. Practice guidelines: the role of TIPS in the management of portal hypertension. Hepatology. 2010;51(1):306.
- Garcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management. Hepatology. 2017;65(1):310–335. PMID 27786365.