Indications
- Acute variceal hemorrhage — salvage after endoscopic failure
- Secondary prophylaxis — recurrent variceal bleeding
- Refractory ascites — failed medical management
- Hepatic hydrothorax — refractory pleural effusion
- Hepatorenal syndrome (HRS) — bridge to transplant
- Budd-Chiari syndrome — hepatic venous outflow obstruction
- Portal hypertensive gastropathy — refractory bleeding
- Ectopic varices — stomal, duodenal, rectal
Key Technical Points
TIPS is created via a transjugular approach: right internal jugular vein → right hepatic vein → transhepatic puncture into the portal vein → balloon dilation → covered stent deployment. Target portosystemic gradient (PSG) is <12 mmHg for varices, <8 mmHg for refractory ascites. e-PTFE-covered stents (Viatorr) are standard — superior 1-year patency vs bare metal stents.
- Access — right IJ, 10 Fr sheath
- Hepatic vein wedge pressure — baseline PSG measurement
- Transhepatic puncture — RPHV to right portal vein
- Portal vein pressure — direct measurement post-access
- Covered stent — Viatorr 8–10 mm, 6–8 cm
- PSG target — <12 mmHg (varices), <8 mmHg (ascites)
- Variceal embolization — concurrent with TIPS if active bleed
- CO2 portography — identifies portal vein and varices
Full TIPS Procedure Playbook
Technique, troubleshooting, complications, post-procedure management, and critical pearls
Complications and Contraindications
- Hepatic encephalopathy — 25–35%, new or worsened
- Stent thrombosis — covered stents reduce to ~10% at 1 year
- Hepatic infarction — aberrant puncture, bile duct injury
- Absolute contraindication — right heart failure, severe TR
- Relative contraindication — Child-Pugh C, MELD >18
- Cavernous portal vein thrombosis — technical challenge
- Polycystic liver disease — limited parenchymal access
- Primary biliary cholangitis — relative contraindication