TIPS Procedure: Everything You Need to Know

Transjugular intrahepatic portosystemic shunt, also known as TIPS, is a procedure in which a stent, a small wire-mesh coil, is placed into a liver vein to form a channel, or shunt, that bypasses the liver. The goal of TIPS is to reduce blood backed up in the liver and other complications of severe liver disease, such as hepatitis and cirrhosis.

It's a minimally invasive procedure (not a surgery) that allows an interventional radiologist to place a stent into the liver under image guidance through a small access point in the neck.

What Is TIPS?

TIPS is a connection created between a vein in the liver (hepatic vein) and a branch of the portal vein to reduce pressure in the portal vein. A portal vein transports blood to the liver from the spleen, stomach, pancreas, and intestines.

A TIPS procedure is performed under image guidance. Dye is injected at different points to allow the radiologist to effectively see the veins.

There are several steps to the procedure:

• A small incision is made in the neck to access the jugular vein. A small tube (catheter) is inserted into the vein and is guided down to the liver veins using X-ray imaging. The catheter contains a small balloon and a stent that will be left behind to create the shunt.
• A needle is used to create a passage between the hepatic vein and a branch of the portal vein.
• The catheter balloon is then inflated with a small amount of saline to expand the metal stent (which creates the shunt).
• Then the balloon is deflated.
• Vein pressures are measured throughout the procedure to ensure that the shunt is effective.
• The radiologist will treat any areas of bleeding.
• The catheter is removed, and the stent remains behind to create the shunt.
• A small dressing is placed over the tiny incision made for the catheter.

Contraindications

There are some conditions that may make someone not a suitable candidate for TIPS, although this is not absolute and is decided by the radiologist. The following conditions can lead to complications following a TIPS procedure:

• Elevated right or left heart pressures
• Heart failure or severe deficiency of cardiac valves
• Rapidly deteriorating liver failure
• Severe or uncontrolled liver disease that affects brain function (hepatic encephalopathy) 
• Uncontrolled sepsis or systemic infection
• Unrelieved clogged duct that transports bile from the liver to the intestines through the gallbladder (biliary obstruction)
• Polycystic liver disease
• Liver cancer (hepatic malignancy or metastatic liver malignancy)
• Severe, uncorrectable bleeding or clotting disorders (coagulopathy) 

Potential Risks

Every procedure comes with a certain level of risks, and some are more likely than others. Potential risks of TIPS include:

• Damage to blood vessels
• Hepatic encephalopathy
• Infection, bruising, or bleeding
• Allergic reactions to medications or the dye used for the procedure
• Stiffness, bruising, or neck soreness
• Bleeding in the belly
• Blockage of the TIPS stent
• Blood clots in liver blood vessels
• Heart problems or abnormal heart rhythms
• Infection of the TIPS stent

Purpose of a TIPS Procedure

There are several conditions that a person might have that would indicate a need for the TIPS procedure:

• Increased pressure in the portal veins connecting the intestines to the liver (portal hypertension) created by scarring of the liver from alcohol abuse (liver cirrhosis), blood clots in the vein from the liver to the heart, increased iron levels in the liver (hemochromatosis), and hepatitis B or C
• Uncontrollable bleeding of the veins throughout the esophagus and stomach (variceal bleeding)
• Recurrent excessive variceal bleeding (variceal hemorrhage) despite therapy
• Excessive fluid buildup in the tissues between the abdomen and organs in the abdominal cavity (ascites)
• Fluid in the chest cavity due to severe liver disease (hepatic hydrothorax)

A TIPS procedure is not the first line of treatment for many of these conditions that stem from severe liver disease. There are other options to treat the symptoms prior to pursuing this option. Your doctor may decide to try this approach to prevent excessive bleeding.

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One of the guidelines for deciding when to pursue a TIPS procedure is persistent bleeding and severe rebleeding within five days of treatment. In this scenario, the rebleeding should be managed with a TIPS procedure. The procedure, if successful, is likely to lower mortality and improve control of ascites.

Testing such as blood work and imaging—computed tomography (CT) scan or magnetic resonance imaging (MRI)—will be done before the procedure to see the patient’s anatomy to assess for likelihood of a successful procedure. The blood work includes a complete blood count (CBC), liver function tests, and a coagulation profile (clotting status).

How to Prepare

Location

Typically, patients have a TIPS procedure done in a hospital setting, in interventional radiology by a radiologist who uses imaging to diagnose and treat diseases. When entering the procedure area, the team will ask the patient to move over to the bed for the procedure, lying on their back and exposing their neck. 

What to Wear

It’s important to arrive on the day of the procedure wearing comfortable clothes. Comfortable pants and shoes are a good choice, and potentially a sweater or jacket because the hospital can be cold. Patients will be asked to change into a procedure gown prior to entering the procedure room.

Food and Drink

Patients will be instructed not to eat or drink anything after midnight the night before the procedure. Certain medications can be taken with small sips of water, but nothing else should be consumed unless otherwise directed by your doctor.

Medications

Patients should provide a thorough list of current medications and alert the doctor to any changes in or skipped medications on the day of the procedure. The doctor will determine if medications or supplements that can cause increased bleeding should be continued or stopped depending on the medical situation of each patient.

What to Bring

It’s important to bring a photo ID and insurance cards on the day of the procedure. An overnight bag with any belongings (such as glasses or a phone charger) should be available for an overnight stay in the hospital.

What to Expect on the Day of the Procedure

Before the Procedure

In the preoperative area on the day of the procedure, a nurse will assess your vital signs, weight, pregnancy status (if applicable), and blood sugar levels (if applicable). Patients will remove their clothes and jewelry, and change into a surgical gown that allows the radiologist to easily access the procedure site.

During the Procedure

The procedure generally takes 60 to 90 minutes to complete. Numbing medication will be given to the neck, where the catheter is inserted into the jugular vein. Medication will be given to help the patient relax if they will be awake for the procedure. Some patients will be put totally to sleep under general anesthesia (this is determined by the anesthesia team prior to the procedure).

When the radiologist deploys the stent, there may be some pressure or pain in the abdominal area. This is expected and normal during this procedure.

After the Procedure

Following the procedure, the radiologist will check that the stent is wide open and functioning correctly with an ultrasound. TIPS is considered successful in about 80% to 90% of patients with portal hypertension.

Recovery

Patients undergoing TIPS should expect to wake up from general anesthesia in a recovery room and then be transferred to a hospital room to stay overnight to monitor for bleeding or other complications. The minimally invasive approach reduces the time it takes to recover from the procedure.

Healing

There is not usually pain following the procedure, although there may be some soreness. A small dressing will cover the incision in the neck. It may take about seven to 10 days to return to everyday activities. 

Long-Term Care

The radiologist will use ultrasound to confirm that the shunt is functioning and that it is open to allow blood flow about seven to 14 days after the procedure. The shunt will continue to be monitored at three months, six months, and then every six to 12 months following the procedure.

More detailed imaging, such as a CT scan, may be used periodically to check that the stent is wide open and flowing freely.

Summary

The TIPS procedure can help reduce high blood pressure in the portal veins, which filter blood from the intestines through the liver, and its complications, especially bleeding when these veins burst from the increased pressure. It's typically used to help with liver conditions like hepatitis and cirrhosis. It's not recommended for everyone with these conditions, and your doctor will help you determine whether this procedure is right for you.

A Word From Verywell

The TIPS procedure can be successful in treating serious symptoms resulting from portal hypertension in patients with severe liver disease. All procedures carry risks, but this procedure has reduced risks compared with undergoing liver surgery. While TIPS is not a cure for liver disease, it is a step in the treatment process to reduce symptoms and improve the quality of life for patients with liver diseases.