Procedure completion and hemodynamic control
The final stage of portosystemic shunt creation is the placement of a special covered stent (e.g., Viatorr; Gore Medical). After positioning, the stent-graft is expanded using balloon dilation (e.g., up to 8 mm).
A mandatory condition for completing the procedure is strict hemodynamic control — measuring pressure to assess the portosystemic gradient. A successful result is considered to be a gradient of <12 mmHg or at least a 50% reduction from its baseline value.
At the very end of the intervention, a control venography is performed. If contrast opacification of varices persists on the portogram (e.g., left gastric/coronary vein) and the patient has a history of significant bleeding, mandatory endovascular embolization of these branches using coils (coils) is indicated.
Postoperative management and complications
Abrupt hemodynamic changes following shunt opening and blood diversion into the systemic circulation can trigger right-sided heart failure. Diuretics are prescribed to lower central venous pressure.
Another frequent consequence is hepatic encephalopathy, with a risk ranging from 5% to 35%. For its prevention in the perioperative period, lactulose and rifaximin are prescribed, which reduce the activity of the intestinal microflora.
Procedure complications: Although direct mortality is <2%, severe and specific complications are possible:
- Vascular and organ injuries: perforation of the liver capsule, hepatic artery injury, direct puncture of the extrahepatic portal vein (leading to intraperitoneal hemorrhage), bile duct injury with the development of hemobilia.
- Cardiac: right atrial perforation due to improper stent positioning, heart failure.
- Structural: intraparenchymal hematoma, stent occlusion followed by sepsis (the frequency of this complication has significantly decreased due to the introduction of covered stents, but monitoring and timely balloon dilation of restenoses remain relevant).
TIPS in Budd-Chiari syndrome
Shunting is actively used in the treatment of Budd-Chiari syndrome — a pathology caused by partial or complete obstruction of hepatic venous outflow (at the level of the hepatic veins, inferior vena cava, or right atrium). This disease is not a primary parenchymal lesion, but it triggers a severe cascade: obstruction $\rightarrow$ progressive sinusoidal congestion $\rightarrow$ centrilobular necrosis $\rightarrow$ fibrosis $\rightarrow$ nodular regeneration.
Clinically, the syndrome manifests as painful hepatomegaly, ascites, or fulminant liver failure. Ultrasound diagnostics with duplex Doppler ultrasonography show absent blood flow or hepatic vein thrombosis, intrahepatic collaterals, flow reversal in distal segments, or the presence of a membrane in the vena cava.
If direct catheter-directed thrombolysis with tissue plasminogen activator (tPA) and venoplasty do not provide a sustained result (restenosis frequently occurs), TIPS is used as an effective alternative to maintain venous outflow, helping to improve liver function.
Related interventions: Portal vein embolization
In addition to shunting, percutaneous portal vein embolization (Portal Vein Embolisation) is widely used in interventional radiology. It is indicated as preoperative preparation before extensive liver resection for hepatocellular carcinoma or metastases.
The goal of the procedure is to redirect portal blood flow into the remaining part of the liver (FLR, usually the left lobe) to stimulate its compensatory hypertrophy. The required volume is calculated using CT volumetry.
Criteria for embolization:
- FLR <25% in patients with healthy parenchyma.
- FLR <40% in patients with cirrhosis.
The procedure is performed 4–6 weeks before surgery under ultrasound guidance using micro-access (e.g., Neff Set), coils, occluders, and liquid embolic agents. The effectiveness of hypertrophy may be reduced in patients with diabetes mellitus and systemic diseases.
Briefly: answers to topical questions
What are the main indications for the TIPS procedure?
The main indications for the procedure are complications of portal hypertension and impaired venous outflow. These include:
- Variceal bleeding — acute and refractory to endoscopic therapy.
- Refractory ascites — unresponsive to medical management.
- Hepatic hydrothorax — fluid accumulation in the pleural cavity.
- Budd-Chiari syndrome (Budd-Chiari syndrome) — the procedure is used as an alternative to maintain venous outflow from the liver.
Which veins are subject to additional embolization if they continue to show contrast opacification after TIPS stent placement?
Varices are subject to additional embolization if their opacification persists at the end of the procedure in patients with a history of significant bleeding. In particular, the following may require embolization:
- Left gastric vein (v. coronaria sinistra / left gastric vein) — if it participates in the blood supply to large esophageal varices.
Embolization coils are used for vascular occlusion. Control venography after the intervention must confirm the complete absence of variceal blood flow.
To remember the pathogenesis of Budd-Chiari syndrome, use the mnemonic: Congestion (sinusoidal) → Necrosis (centrilobular) → Fibrosis → Nodular regeneration.
Class and exam questions
What is the main hemodynamic goal of the TIPS procedure?
The main goal is to reduce the portosystemic gradient to less than 12 mmHg, or to decrease the baseline gradient by at least half.
How to prevent the development of hepatic encephalopathy after shunting?
Lactulose and rifaximin are prescribed for prevention. These drugs reduce the activity of the intestinal microflora in the perioperative period.
What to do if contrast opacification of varices persists after stent placement?
If the patient has a history of significant bleeding, additional embolization of varices (e.g., with coils) is indicated during the same procedure.
What complications are directly related to puncture and stent positioning?
Perforation of the liver capsule, injury to the hepatic artery or bile ducts (hemobilia), as well as right atrial perforation due to excessively high stent positioning are possible.
What else to study on this topic
- Calculation of the future remnant liver (FRL) using CT volumetry
- Ultrasound-guided micro-access techniques to the portal vein
- Embolization of a hepatic artery pseudoaneurysm: front door and back door techniques
- Catheter-directed thrombolysis and venoplasty in acute hepatic vein thrombosis
- Choosing between covered and bare stents in interventional hepatology
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