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TIPSS and Hepatic Vein Stenting

Transjugular Intrahepatic Portosystemic Shunt (TIPSS) and hepatic vein stenting for portal hypertension, variceal bleeding, refractory ascites, and Budd-Chiari syndrome performed by Dr. Gurucharan S Shetty at Sparsh Hospitals Bangalore.

Hepatobiliary Interventional Radiology

What is TIPSS and Hepatic Vein Stenting?

Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is an interventional radiology procedure that creates an artificial channel within the liver using a covered metallic stent to connect the portal venous system to the hepatic venous system. This effectively decompresses the portal circulation, reducing portal pressure and controlling life-threatening complications of portal hypertension: variceal haemorrhage, refractory ascites, and hepatic hydrothorax. Hepatic vein stenting addresses Budd-Chiari Syndrome obstruction of the hepatic veins by restoring hepatic venous outflow and preventing progressive liver failure.

Who is This Procedure For?

Transjugular intrahepatic portosystemic shunt (TIPSS) is recommended for patients with complications of portal hypertension that are not adequately controlled by endoscopic or medical therapy. It is commonly used in cases of acute variceal haemorrhage as a rescue procedure when bleeding cannot be controlled endoscopically, achieving haemostasis in over 90% of cases. TIPSS is also effective in preventing variceal rebleeding and is considered superior to endoscopic banding in selected patients, particularly those with Child-Pugh B disease or high portal pressures (HVPG >20 mmHg) after an initial bleed. It plays a significant role in managing refractory ascites that does not respond to maximum diuretic therapy, leading to substantial reduction in fluid accumulation and improved quality of life. Additionally, TIPSS is beneficial in hepatic hydrothorax, where pleural effusion due to portal hypertension persists despite medical therapy or surgical options like VATS. It is also indicated in Budd–Chiari syndrome, where hepatic vein thrombosis causes painful hepatomegaly and ascites, as the procedure helps restore hepatic venous outflow. In selected cases, TIPSS may be used for portal vein thrombosis associated with severe portal hypertension complications.

How is TIPSS Created?

  • Jugular Vein Access & Hepatic Vein Entry

    Right internal jugular vein is punctured under ultrasound guidance. A catheter is advanced into the right hepatic vein under fluoroscopic guidance.

  • HVPG Measurement & Portal Vein Targeting

    Baseline portal pressure is measured. Wedge venography or intravascular ultrasound (IVUS) maps the portal vein position for accurate needle targeting.

  • Transhepatic Needle Pass

    A TIPSS needle is passed from the hepatic vein through liver parenchyma into the portal vein the most technically demanding step.

  • Tract Dilation & Stent Deployment

    The transhepatic tract is dilated. A covered ePTFE stent (Viatorr) is deployed across the shunt tract and dilated to 8–10mm diameter.

  • Portal Pressure Reassessment

    Post-TIPSS portal pressure confirms adequate reduction (target HVPG <12 mmHg). Variceal embolisation may be added if indicated.

Benefits of This Procedure

Controls Variceal Bleeding

Achieves haemostasis in >90% of cases of acute variceal bleeding refractory to endoscopic therapy a life-saving intervention.

Reduces Ascites

Dramatically reduces ascites volume and diuretic requirements improving quality of life and reducing hospitalisation for ascites tapping.

Long-term Patency

Covered ePTFE stents (Viatorr) have excellent long-term shunt patency far superior to uncovered stents with routine Doppler ultrasound surveillance.

Bridge to Transplant

TIPSS can stabilise patients with decompensated cirrhosis, controlling complications while awaiting liver transplantation.

Frequently Asked Questions

TIPSS diverts portal blood (containing ammonia) away from the liver increasing the risk of hepatic encephalopathy (confusion, drowsiness) in 10–40% of patients. This risk is higher in older patients, those with prior encephalopathy, and those with very low albumin. Modern covered stents (Viatorr) allow a controlled shunt diameter minimising encephalopathy risk. If encephalopathy develops, it is often manageable with lactulose, rifaximin, and dietary protein adjustment. Shunt reduction is occasionally needed for refractory cases.
Most patients notice a significant reduction in ascites within 4–8 weeks of TIPSS. Diuretics can often be reduced or stopped. Large volume paracentesis requirements typically cease or dramatically reduce. The full ascites benefit of TIPSS takes 2–3 months to manifest. A small proportion of patients (15–20%) do not respond adequately and require further management.
Patient selection is critical. TIPSS is generally safe and beneficial for Child-Pugh A and B patients. In Child-Pugh C patients (very poor liver function, MELD >18), the risk of post-TIPSS liver failure is significantly higher, and TIPSS may actually accelerate liver decompensation. Dr. Shetty carefully evaluates every patient's liver function, MELD score, and comorbidities before recommending TIPSS. Liver transplantation should always be considered in appropriate candidates.
Budd-Chiari Syndrome (BCS) is caused by obstruction of the hepatic veins, usually from thrombosis. In patients with short-segment hepatic vein stenosis, balloon angioplasty and stenting of the hepatic vein restores outflow and dramatically improves symptoms. TIPSS is used when hepatic vein recanalization is not technically feasible. Early treatment of BCS prevents irreversible liver damage and the need for transplantation.
Doppler ultrasound at 1 month, 3 months, and then 6-monthly assesses shunt flow velocity detecting stenosis or occlusion early. Covered Viatorr stents have significantly better long-term patency than uncovered stents. Portal pressure can be reassessed by repeat HVPG measurement if shunt dysfunction is suspected. Liver function tests and clinical assessment at regular intervals monitor for encephalopathy and liver function changes.
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Managing Portal Hypertension Complications?

Consult Dr. Gurucharan S Shetty at Sparsh Hospitals, Bengaluru for expert evaluation and minimally invasive management of portal hypertension, variceal bleeding, and refractory ascites.

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