Indications

• Variceal Hemorrhage (most common request in the acute setting)

  • • Uncontrollable (rescue therapy)

    • Bleeding refractory to endoscopic banding

    • Decompression to prevent recurrent bleeding

• Budd-Chiari: outflow obstruction of hepatic veins

  • • Can provide symptom relief by decompressing portal HTN

    • Higher risk of TIPS stenosis / thrombosis than other indications

• Recurrent Ascites / Hydrothorax: more commonly an outpt procedure

• Portal Hypertensive Gastropathy

Contraindications

• Absolute: None, but these pts often have a combination of relative contraindications, putting them at increasing risk

• Relative:

  • • High MELD score: 18 or greater is cause for concern. >24 predicts 30-day mortality of 60%.

    • Heart failure / pHTN (TIPS can overload right heart)

    • Hepatic encephalopathy / hepatic failure (exacerbated by TIPS)

    • Portal vein thrombosis

    • Sepsis

    • Hepatic tumors / polycystic liver disease

    • Dilated biliary ducts

    • Standard concerns with angiography (allergy, renal failure, coags)

Imaging Review

• CT / MR / US: Eval portal vein patency, anatomic relation b/w portal and hepatic veins, competing shunts, ascites

• Echo: evaluate for heart failure, right heart overload

Tips for Workup

• Almost always GA case in a biplane fluoro room with prophylactic abx

• Consent for paracentesis if ascites present (reduces risk a/w hemorrhage)

• Hepatology usually starts lactulose for HE and manages follow-up TIPS imaging

• Consent: Worsening of hepatic encephalopathy / heart failure, bile duct injury, TIPS stenosis / thrombosis, infection, contrast nephropathy, access site complications