TIPS (transjugular intrahepatic portosystemic shunt)

Blood from your stomach and intestines flows to the liver through a large vein called the portal vein. When the liver is scarred, a condition called cirrhosis, blood cannot pass through easily. Pressure builds up in the portal vein. This is called portal hypertension.

The high pressure pushes blood into smaller veins in the esophagus and stomach, which swell into varices. Varices can burst and bleed heavily. The pressure also pushes fluid out into the belly, called ascites, or into the chest, called hepatic hydrothorax. Common causes of cirrhosis include alcohol, hepatitis B and C, and fatty liver disease.

A TIPS creates a new path inside the liver that connects the portal vein to a hepatic vein, one of the veins that carries blood out of the liver to the heart. A metal stent lined with fabric holds the path open. Some blood now bypasses the scarred liver, and the pressure falls.

On the X-ray, the TIPS stent looks like a short, curved mesh tube inside the liver. When contrast dye is injected, it flows smoothly from the portal vein through the stent toward the heart, and the swollen varices stop filling.

A TIPS treats the pressure, not the liver disease itself. Many people who need a TIPS should also be evaluated for a liver transplant. The TIPS stent sits entirely inside the liver and is removed with it during a transplant.

First-line care for varices is medicines called beta blockers and banding, where rubber bands are placed on varices through a camera. For ascites, the first steps are a low-salt diet and water pills, then drainage with paracentesis. A tunneled belly drain is another option for some people. Surgical shunts are rarely done today. A TIPS is usually the next step when these do not work well enough.

In an emergency bleed, a TIPS may be done urgently in the hospital, sometimes after a stay in intensive care. See before your procedure and sedation.

1. 1
   Anesthesia and access

   Most people have general anesthesia. We numb the right side of the neck and, with ultrasound, place a thin tube into the jugular vein.

2. 2
   Reaching the liver

   Using live X-ray, we guide a catheter down through the heart's large vein into a hepatic vein. We measure pressures and inject dye to map the veins.

3. 3
   Creating the shunt

   A long, thin needle passes through the liver from the hepatic vein into the portal vein. A balloon widens the path, and a fabric-lined metal stent is placed to hold it open.

4. 4
   Checking the result

   We measure pressures again to confirm they have dropped to the target. If needed, we block large varices with coils or glue. The neck tube comes out and the tiny nick is closed with glue or a small bandage.

The procedure usually takes 1 to 3 hours, depending on your anatomy.

1. First day
   You recover in the hospital. The neck may be sore or bruised. Mild belly discomfort is common.
2. 1–2 days
   Most people with a planned TIPS go home. People treated for heavy bleeding may stay longer.
3. 7–10 days
   Most normal activities are fine. Avoid heavy lifting until we say otherwise.
4. Weeks to months
   Belly fluid usually shrinks gradually. You may still need a drainage or two at first.
5. Ongoing
   Doppler ultrasound checks the stent, usually within a few weeks and then at regular visits.

Keep taking your liver medicines as your liver doctor directs. Many people are started on lactulose or rifaximin to help prevent confusion. Keep avoiding alcohol completely and follow a low-salt diet if you have ascites.

A TIPS stops variceal bleeding in more than 9 out of 10 people. The chance of bleeding again is much lower than with banding alone. For ascites, about 2 out of 3 people have much less fluid, though it can take weeks to months. Modern fabric-lined stents stay open well, and most narrowing can be fixed with a short procedure through the neck.

Before I recommend a TIPS, I look closely at three things: how well your liver works, how strong your heart is, and whether you have had confusion from your liver before. I tell every patient and family plainly that TIPS trades one problem for a possible other, confusion, and that we plan for it together. When the patient is well chosen, it can change their life, from monthly drainages or emergency bleeds to living normally.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

The most important side effect is hepatic encephalopathy. Because some blood now skips the liver, toxins that the liver normally clears reach the brain. This can cause sleepiness, forgetfulness, confusion or personality changes. New or worse encephalopathy happens in about 1 in 3 people after a TIPS. Most cases are mild and improve with lactulose and rifaximin. In a small number, the stent needs to be narrowed or closed.