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Transjugular Intrahepatic Portosystemic Shunt (TIPS)


KEY FACTS

Terminology

  • Shunt between main portal vein and hepatic vein created with balloon-expandable metallic stent

Imaging

  • US is primary imaging tool following t ransjugular intrahepatic portocaval shunt (TIPS)

    • Goal of US: Detect stenosis before shunt occludes or symptoms recur

    • Echogenic stent easily seen on US but does not block sound transmission

    • Color Doppler shows patency and flow direction within TIPS, portal vein, hepatic veins, and their branches

  • Shunt malfunction

    • Hepatofugal or bidirectional flow within TIPS

    • Continuous flow (no pulsatility or respiratory change) within TIPS

    • TIPS velocity < 90 or > 250 cm/s at any point

    • Flow away from shunt (hepatopetal) in right and left portal branches

    • Focal severe turbulence (post stenosis)

    • Absence of flow: Occlusion

  • CT and MR angiography

    • Indicated if US is technically compromised or equivocal

    • Offers global view; including depiction of neoplastic occlusion of TIPS

  • Portal venography via jugular vein catheterization

    • Definitive test for TIPS stenosis or occlusion

    • May allow balloon dilation of TIPS lumen or placement of new shunt within stenotic TIPS

Clinical Issues

  • Candidates for TIPS

    • Cirrhosis with intractable ascites or variceal bleeding

    • Budd-Chiari syndrome

    • Temporizing measure, preliver transplantation

Graphic of transjugular intrahepatic portocaval shunt (TIPS) creation shows the hepatic vein punctured within 2 cm of the inferior vena cava (IVC). The metallic wire TIPS
extends to the right portal vein, adjacent to its junction with the main portal vein.

Image from a TIPS procedure shows the IV catheter
proceeding down the IVC then penetrating the liver parenchyma to enter the portal vein
. The intraparenchymal tract is dilated with a balloon
. Incidentally noted is a plastic biliary stent
.

Film from the same procedure shows the TIPS itself
deployed with its distal end in the hepatic vein
and its proximal end in the main portal vein
.

Longitudinal color Doppler ultrasound shows the mid portion of a normally patent TIPS
. Although the stent is highly echogenic, it does not obstruct sonographic visualization. Color Doppler indicates brisk flow toward the heart, the expected finding.

TERMINOLOGY

Abbreviations

  • Transjugular intrahepatic portocaval shunt (TIPS)

Definitions

  • Shunt between main portal vein (PV) and hepatic vein (HV) created with balloon-expandable metallic stent

  • Hepatopetal blood flow: Toward liver

  • Hepatofugal blood flow: Away from liver

IMAGING

General Features

  • Location

    • Most common route: Right HV → right PV → main PV

  • Size

    • 10-12 mm in diameter

  • Morphology

    • Typically follows curved course through hepatic parenchyma

    • Portal end slightly proximal to main PV bifurcation

    • Hepatic end located at, or slightly cephalad to, junction of HV and inferior vena cava (IVC)

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