Steps of the TIPS procedure
- • A hepatic vein, most commonly the right hepatic vein, is accessed via a right internal jugular vein approach. A wedged hepatic venogram may be obtained to opacify the portal vein and map its location.
- • A stiff metal cannula is placed, and a needle is passed from the right hepatic vein into the right portal vein under fluoroscopic guidance. Often, several needle passes are required to obtain portal access. The portosystemic pressure gradient measurement is obtained.
- • A stiff wire is placed into the portal vein, and dilation of the intrahepatic parenchymal tract is performed with an angioplasty balloon.
- • A flexible, self-expanding stent graft (usually 8 or 10 mm in diameter) is placed from the portal vein to the confluence of the hepatic vein with the inferior vena cava. Stent grafts have been shown to significantly improve long-term patency in TIPS and to reduce the incidence of shunt dysfunction and are therefore preferred over bare metal stents.
- • A venogram and repeat portosystemic pressure gradient measurements are obtained.
- • If there is a history of bleeding varices, and if varices are still seen on venography after the TIPS is created, then variceal embolization is performed.