TIPS – Transjugular Intrahepatic Portosystemic Shunt
When portal hypertension leads to ascites that will not respond to diuretics, or variceal bleeding that endoscopy cannot control, TIPS creates a direct internal bypass inside the liver – dramatically reducing portal pressure. It is one of the most powerful tools in portal hypertension management, but patient selection is critical: the wrong patient can decompensate rapidly after TIPS. I am Dr Chetan Kalal, DM Hepatologist at Gleneagles Hospital Mumbai. This page explains what TIPS does, when it is appropriate, and how patients are managed afterwards.
How TIPS Works
TIPS is a metal stent (a covered tubular mesh) placed through the liver, connecting a branch of the portal vein to a hepatic vein. Blood that would have backed up into the portal system under high pressure now has a low-resistance path directly into the hepatic vein, bypassing the diseased liver parenchyma. Portal pressure drops – often from >20 mmHg to below 12 mmHg.
Modern TIPS uses ePTFE-covered stents (brand name Viatorr), which have dramatically improved long-term patency compared to bare metal stents used in the 1990s. Shunt dysfunction (stenosis or occlusion) occurs in approximately 15-20% of covered-stent TIPS over 2 years, compared to >50% with bare metal stents.
When Is TIPS Recommended?
Refractory Ascites
Ascites that requires paracentesis more than 3 times over 3 months despite maximum-dose diuretics. TIPS significantly reduces ascitic re-accumulation and improves quality of life.
Variceal Bleeding – Early TIPS
High-risk variceal bleeders (HVPG >20 mmHg, Child-Pugh B >7 with active bleeding, or Child-Pugh C ?13) benefit from early pre-emptive TIPS within 72 hours of presentation – reducing re-bleeding mortality by ~50%.
Rescue TIPS
Acute variceal bleeding that fails endoscopic control (two sessions). Rescue TIPS controls bleeding in >90% of such cases.
Hepatic Hydrothorax
Refractory pleural effusion from portal hypertension (fluid tracking through the diaphragm). TIPS is the most effective long-term solution when repeated thoracentesis is needed.
Budd-Chiari Syndrome
For hepatic vein obstruction where anticoagulation alone is insufficient – TIPS decompresses the congested liver while awaiting transplant evaluation.
The Procedure
TIPS is performed by an interventional radiologist under local anaesthesia and IV sedation, occasionally under general anaesthesia. Access is obtained through the right internal jugular vein. A catheter is guided into the hepatic vein under fluoroscopic guidance. A hollow needle is then passed through the liver parenchyma from the hepatic vein to a branch of the portal vein – this is the only technically demanding step. The TIPS stent is then deployed across this track, maintaining the channel between the two venous systems.
Portal pressure is measured before and after stent placement. The target is an HVPG below 12 mmHg (or a reduction of >50% from baseline for acute bleeding). The procedure takes 1-3 hours. Most patients are admitted for 24-48 hours post-TIPS for monitoring.
Risks and Contraindications
The main complication of TIPS is hepatic encephalopathy (HE). Approximately 25-35% of patients develop new or worsening HE after TIPS, because ammonia and other gut-derived toxins that would have been partially cleared by hepatocytes now bypass the liver. Most cases respond to lactulose and rifaximin; in refractory cases, the stent diameter can be reduced (shunt reduction procedure).
Contraindications include: severe hepatic encephalopathy (grade ?3 before TIPS), significant right heart failure or pulmonary hypertension (the added venous return overwhelms a failing right heart), severe portal hypertensive coagulopathy unresponsive to correction, polycystic liver disease (no suitable liver parenchyma to pass the needle through), and MELD score >18-24 or Child-Pugh C >13 (high short-term mortality from liver failure outweighs the benefit).
Post-TIPS monitoring: Doppler ultrasound at 1, 3, 6, and 12 months after TIPS checks shunt velocity and patency. Dr Kalal’s team manages all post-TIPS care – titrating diuretics, managing HE, and coordinating liver transplant assessment where appropriate.
Consult on TIPS Candidacy
TIPS is not appropriate for every patient with refractory ascites or variceal bleeding – careful assessment of liver function, cardiac function, and encephalopathy risk is essential before proceeding. Schedule a consultation at Gleneagles Hospital, Mumbai.