Background Information:

What are the other Names for the Procedure?

• TIPS (Transjugular Intrahepatic Portosystemic Shunt)
• TIPSS (Transjugular Intrahepatic Porto-Systemic Shunt)

What is Transjugular Intrahepatic Portosystemic Shunt radiology procedure? (General Explanation)

• Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure involves creating a tract between the portal vein and hepatic vein within the liver
• The portal vein is a vein that carries blood from the digestive organs to the liver. The hepatic veins consist of three veins carrying blood from the liver to the heart
• X-ray guidance is used to perform this procedure and a stent is placed, in order to keep the shunt open. The TIPS procedure is performed to reduce the pressure in the portal vein system, due to a condition known as portal hypertension
• The TIPS procedure is performed in patients with chronic liver disease, which may lead to liver cirrhosis and cause portal hypertension
• In patients with portal hypertension, the pressure is increased, which causes blood to flow backward from the liver into the veins of stomach, spleen, esophagus, and intestines. This causes enlarged vessels which eventually bleed. It also causes accumulation of fluid in the chest or abdomen, known as ascites

What part of the Body does the Procedure involve?

Transjugular Intrahepatic Portosystemic Shunt procedure involves treating complications related to portal hypertension, thus it involves the liver.

Why is the Transjugular Intrahepatic Portosystemic Shunt radiology procedure Performed?

Transjugular Intrahepatic Portosystemic Shunt procedure is used treat complications of portal hypertension, such as ascites, variceal bleeding, portal gastropathy, and Budd-Chiari syndrome

• Budd-Chiari syndrome: It is caused by a blockage in one of the hepatic veins that carries blood from the liver to the heart
• Portal gastropathy is another complication of portal hypertension which involves dilated veins in the wall of stomach that could lead to severe bleeding
• Variceal bleeding is also a complication of portal hypertension; it is usually seen in the esophagus, but can also cause bleeding in the stomach and intestine

What is the Equipment used? (Description of Equipment)

The following equipment is used in Transjugular Intrahepatic Portosystemic Shunt procedure:

• Ultrasound - the equipment for ultrasound imaging consists of:
  • An ultrasound transducer
  • A computer monitor
  • A central processing unit
  • A printer          

A transducer is used to send high-frequency sound waves in the body and the computer creates the image based on the echoes of that sound returning from the patient’s body. 

• X-ray machine:
  • An X-ray machine consists of an examination table, an x-ray tube, and a television monitor
  • Fluoroscopy uses X-rays and converts them into real-time images       
• Catheter: It is a long, thin plastic tube, which is used to place the stent in the tunnel
• Metal stent: It is basically a metal tube covered with fabric and it is placed in the tunnel formed, to stop it from getting closed

What are the Recent Advances in the Procedure?

There have been no recent advances in the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure. 

What is the Cost of performing the Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

The cost of Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.ncbi.nlm.nih.gov/pubmed/25714299 (assessed on 3/9/2015)

http://www.ncbi.nlm.nih.gov/pubmed/25709851 (assessed on 3/9/15)

http://www.ncbi.nlm.nih.gov/pubmed/25673803 (assessed on 3/9/15)

Prior to Transjugular Intrahepatic Portosystemic Shunt radiology procedure:

How does the Transjugular Intrahepatic Portosystemic Shunt radiology procedure work?

• Transjugular Intrahepatic Portosystemic Shunt procedure is performed to treat complications of portal hypertension, which usually causes enlarged veins in the digestive system and eventually leads to bleeding
• Portal hypertension involves high blood pressure in the portal veins, which backs up in the digestive system and causes enlarged veins
• The TIPS procedure involves creating a tunnel between the portal vein and the hepatic vein so that blood from the digestive system to portal vein bypasses the liver and directly goes to the hepatic vein. This helps decrease the pressure in the portal vein and avoids the backup of blood in the digestive system

How is the Transjugular Intrahepatic Portosystemic Shunt radiology procedure Performed?

Transjugular Intrahepatic Portosystemic Shunt procedure is performed in the following manner:

• The patient is positioned in a supine position on the examination table. The vital signs, such as heart rate, blood pressure, and pulse, are monitored throughout the procedure
• An IV line is inserted into the patient’s arm vein which is used for giving fluids and sedation medication
• This procedure is performed under conscious sedation. Sometimes, a general anesthetic is used, when the patient is sedated completely
• The catheter insertion site is shaved and sterilized. The area just above the right collarbone is numbed using a local anesthetic and a small skin incision is made at the site
• Ultrasound guidance is used to find the internal jugular vein. The catheter is inserted into the jugular vein and using x-ray fluoroscopy, it is guided into one of the hepatic veins
• Once the catheter reaches the hepatic vein, pressure is measured in the hepatic vein and the right heart to confirm the diagnosis of portal hypertension and the severity of the condition
• A contrast material is injected into the hepatic veins to identify the portal vein
• The TIPS needle is advanced from the hepatic vein into the portal system. Once the needle tip is in the portal vein, a stent is placed extending from the portal vein to the hepatic vein
• The pressure is measured again to confirm reduction in portal hypertension. A portal venogram is also performed to check the blood flow to the TIPS
• The catheter is removed and pressure applied at the insertion point to prevent bleeding
• The patient is admitted following the procedure to observe for any kind of bleeding

Where is the Procedure Performed?

The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure is performed as an outpatient procedure, at a hospital.

Who Performs the Procedure?

Interventional radiologists perform the Transjugular Intrahepatic Portosystemic Shunt procedure.

How long will the Procedure take?

The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure usually takes about two hours to perform. But, it may take several hours, if the vascular anatomy is complex

Who interprets the Result?

An interventional radiologist interprets the results of the Transjugular Intrahepatic Portosystemic Shunt procedure.

What Preparations are needed, prior to the Procedure?

Following preparations are needed prior to Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure.

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient, including information related to the medications that are currently being taken
• Do inform the medical professional if you have a history of any medical conditions such as a heart disease, asthma, diabetes, or kidney disease
• Patient may be asked to stop taking any blood thinner medications such as NSAIDs, aspirin, warfarin, or heparin
• Do inform the medical professional about any allergies, especially related to barium or iodinated contrast material, which may be used in the procedure
• It is advisable to wear comfortable and loose clothes. Avoid wearing any metal objects or jewelry, as it may interfere with the x-ray
• Women should notify the physician if they are pregnant or breastfeeding their child, as many such procedures may not be performed on pregnant women
• Depending on the procedure adopted, the patient may be asked for certain bowel or bladder preparations before the preparation sessions
• The patient may be asked to avoid eating or drinking several hours before the procedure
• Patients are admitted after the procedure, and so they should make plans of staying in the hospital for 1-2 days

What is the Consent Process before the Procedure?

A physician will request your consent for the Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent. 

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What are the Benefits versus Risks, for this Procedure?

Following are the benefits of the Transjugular Intrahepatic Portosystemic Shunt procedure:

• It is a minimally invasive procedure that provides the same benefits as a surgical shunt or bypass, which is more invasive and has more complications
• This procedure has a very high success rate and it has a very short recovery time, compared to a surgical shunt
• The TIPS procedure involves placing a stent that is inside the liver; thus, when going through the transplantation, it could be removed with the liver

Following are the risks of the Transjugular Intrahepatic Portosystemic Shunt procedure:

• Contrast material used during the procedure may cause a severe allergic reaction in certain patients
• Since a skin incision is made to insert the catheter, there is a chance of infection at the catheter insertion site
• Since a catheter is placed in the vein for stent placement, there is a risk of damaging or rupturing the blood vessel
• The tunnel created between portal vein and hepatic vein may get narrowed in future due to stenosis, which may require that the procedure be repeated
• Catheter insertion in the neck area may cause stiffness and pain after the procedure

Serious complications of TIPS may include infection of the stent, heart arrhythmias, congestive heart failure, damage to hepatic artery, severe liver injury, complete occlusion of the stent, the need for blood transfusion, and even death. However, these complications are very rare.

What are the Limitations of Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

• Transjugular Intrahepatic Portosystemic Shunt procedure may not be performed in patients with severe or advanced liver disease. Performing this procedure in such individuals may worsen the liver condition and lead to liver failure
• TIPS is not preferred in patients with hepatic encephalopathy
  • Encephalopathy is caused due to the presence of toxic substances in the brain. It leads to change in normal brain function which leads to confusion
  • Normal liver usually removes the toxic substances from the blood stream
  • After the TIPS procedure, blood bypasses the liver and goes directly to the hepatic vein from the portal vein. Thus, the liver does not have a chance to remove the toxic substances that finally end up in the brain and worsen the encephalopathy     

What are some Questions for your Physician?

Some of the basic questions that you might ask your healthcare provider or physician are as follows:

• What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed?
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• What are the possible side effects from the procedure? How can I minimize these side effects?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required after the procedure?
• Is there any medication that needs to be taken for life after the procedure?
• What are the costs involved?

During the Transjugular Intrahepatic Portosystemic Shunt radiology procedure:

What is to be expected during the Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

• The patients’ vital signs, such as blood pressure, heart and pulse rate, are monitored during the Transjugular Intrahepatic Portosystemic Shunt procedure
• When the IV line is inserted, patient shall feel a slight pinprick
• Conscious sedation or general anesthetic is used during the procedure; hence, the patient feels sleepy and relaxed and may not be even awake during the procedure
• When the catheter is inserted through the neck and advanced to the liver, patient may feel some discomfort
• Patient may feel some warm sensation when the contrast material is injected

What kind of Anesthesia is given, during the Procedure?

Conscious sedation or general anesthetic is used during the Transjugular Intrahepatic Portosystemic Shunt procedure.

How much Blood will you lose, during the Procedure?

• Since Transjugular Intrahepatic Portosystemic Shunt is a minimally invasive procedure, the blood loss involved during the procedure is minimal. 
• Very rarely, severe bleeding may occur which may require blood transfusion.

What are the possible Risks and Complications during the Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

• Contrast material used during the TIPS procedure may cause severe allergic reaction in some patients
• Since catheter is placed in the vein for stent placement, there is a risk of damaging or rupturing the blood vessel
• The procedure can cause certain serious (but rare) complications that includes infection of the stent, heart arrhythmias, congestive heart failure, damage to hepatic artery, severe liver injury, complete occlusion of the stent, and the need for blood transfusion

What Post-Operative Care is needed at the Healthcare Facility after the Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

• Patients are admitted to the hospital for 1-2 days for close observation after the Transjugular Intrahepatic Portosystemic Shunt procedure
• A follow-up ultrasound is performed to check success of the procedure

After the Transjugular Intrahepatic Portosystemic Shunt radiology procedure:

What is to be expected after the Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

• Patients are admitted to the hospital for 1-2 days for close observation
• Patient may feel some stiffness in their neck since catheter is inserted near the collarbone
• Patients are recommended to avoid normal activities for about a week’s time

When do you need to call your Physician?

Patients may need to call their physician in the following situations after a Transjugular Intrahepatic Portosystemic Shunt procedure:

• If there any signs of infection at the catheter insertion site, such as redness and warmth accompanied by fever or chills
• If patient develops severe abdominal pain
• If there any indications of hepatic encephalopathy such as confusion

What Post-Operative Care is needed at Home after the Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

• No specific postoperative care is needed at home after a Transjugular Intrahepatic Portosystemic Shunt procedure
• Patients should avoid normal activities for about a week after the procedure

How long does it normally take to fully recover, from the Procedure?

• It takes about a week to recover fully from the Transjugular Intrahepatic Portosystemic Shunt procedure
• Patient may resume their normal activities after about a week of the procedure, as instructed by their healthcare provider

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure does not involve the removal of any body tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Transjugular Intrahepatic Portosystemic Shunt radiology procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital, where the procedure is performed
• Healthcare providers, physicians, and radiologists, who are involved in the process

The patient is advised to inquire and confirm the type of billing, before the Transjugular Intrahepatic Portosystemic Shunt procedure is performed.