Transjugular intrahepatic portosystemic shunt (TIPS)

Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal system in patients with decompensated portal hypertension. It is a less invasive technique that may replace open portocaval and splenorenal shunts. Patients may have advanced liver disease, actively bleeding esophageal varices, massive recurrent ascites, severely compromised liver function, or hypoxemia. Oliguria from hepatorenal syndrome is common.

1. After cannulation of the right internal jugular, a trochar is directed into a hepatic vein and passed through liver parenchyma to enter a portal vein and create a connection for egress of portal blood into systemic circulation; the conduit is dilated, and patency is maintained with a stent. Portal vein may be visualized fluoroscopically with retrograde insufflation of carbon dioxide gas via the hepatic vein.
2. Sedation under MAC with standard monitors may be sufficient in some patients, but general anesthesia is common because of the procedure length and discomfort.
3. Patients with bleeding or ascites should be considered to have full stomachs and receive a rapid sequence induction. It is preferable to perform paracentesis to drain ascites before induction of general anesthesia to avoid consequences of sympathectomy on rapid decompression of the portal system.
4. Liver failure patients are often hyperdynamic with low systemic vascular resistance due to arteriovenous fistulas in the liver and lung. Preprocedural hypoxemia may be multifactorial from
   
   mismatch or hepatopulmonary syndrome with associated intrapulmonary vascular dilations.
5. Patients with actively bleeding varices may be treated with continuous infusion of octreotide to reduce mesenteric blood flow.