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• W1525534239 abstract "In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)–covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver. In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)–covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver. In 1969 already, Joseph Rösch et al. first described an interventional technique to establish a transjugular intrahepatic portosystemic shunt in dogs by implanting a silicone-coated spring coil to achieve patency for as long as 2 weeks [1Rösch J. Hanafee W. Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study.Radiology. 1969; 92: 1112-1114Crossref PubMed Google Scholar, 2Rösch J. The creation of TIPS: a brief history.in: Conn H.O. Palmaz J.C. Rösch J. Rössle M. TIPS-transjugular intrahepatic portosystemic shunts. Igaku-Shoin, New York1996: 55-63Google Scholar]. These early experiments were continued by creation of a TIPS in cirrhotic livers and in cadavers [[3]Rösch J. Hanafee W. Snow H. Barenfus M. Gray R. Transjugular intrahepatic portacaval shunt.Am J Surg. 1971; 121: 588-592Abstract Full Text PDF PubMed Scopus (75) Google Scholar]. In the late ‘70s, Burgener and Gutierrez [[4]Gutierrez O.H. Burgener F.A. Production of non-surgical portosystemic venous shunts in dogs by transjugular approach.Radiology. 1979; 130: 507-509Crossref PubMed Google Scholar] constructed shunt tracts in dogs with portal hypertension by balloon dilatation of the parenchymal track that normalized the elevated portal pressure, but occluded within 1 week. In 1982, Colapinto and Gordon were the first to apply this technique clinically in more than 20 patients [5Colapinto R.F. Stronell R.D. Birch S.J. Langer B. Blendis L.M. Greig P.D. et al.Creation of an intrahepatic portosystemic shunt with a Grüntzig balloon catheter.Can Med Assoc J. 1982; 126: 267-268PubMed Google Scholar, 6Gordon J.D. Colapinto R.F. Abecassis M. Makowka L. Langer B. Blendis L.M. et al.Transjugular intrahepatic portosystemic shunt: a nonoperative approach to life-threatening variceal bleeding.Can J Surg. 1987; 30: 45-49PubMed Google Scholar]. The long-term results were, however, not encouraging and most patients rebled and 9 died within a month. With the introduction of expandable metallic stents in the mid-1980s by Palmaz, high long-term patency rates were achieved by implanting such stents in cirrhotic livers of dogs [7Palmaz J.C. Sibbitt R.R. Reuter S.R. Garcia F. Tio F.O. Expandable intrahepatic portocaval shunts: early experience in the dog.Am J Radiol. 1985; 145: 821-825Google Scholar, 8Palmaz J.C. Garcia F. Sibbitt R.R. Tio F.O. Kopp D.T. Schwesinger W. et al.Expandable intrahepatic portacaval shunt stents in dogs with chronic portal hypertension.Am J Radiol. 1986; 147: 1251-1254Google Scholar]. Based on own experiences in hepatic vein catheterization and transjugular liver biopsies, the Freiburg TIPS project was started in 1987 after its approval by the local ethics committee. With the help of J. Palmaz, the first TIPS procedure with implantation of a metallic Palmaz-stent was performed in Freiburg in 1988 and 9 more procedures followed in the same year [9Rössle M. Richter G.M. Nöldge G. Haag K. Wenz W. Gerok W. et al.Performance of an intrahepatic portacaval shunt (PCS) using a catheter technique – a case report.Hepatology. 1988; 8: 1348AGoogle Scholar, 10Rössle M. Richter G.M. Noldge G. Palmaz J.C. Wenz W. Gerok W. New non-operative treatment for variceal haemorrhage.Lancet. 1989; 2: 153Abstract PubMed Scopus (36) Google Scholar, 11Richter G.M. Palmaz J.C. Nöldge G. Rössle M. Siegerstetter V. Wenz. Der transjugulare intrahepatische portosystemische Stent-Shunt (TIPSS). Eine neue nichtoperative, perkutane Methode.Radiologe. 1989; 29: 406-411PubMed Google Scholar, 12Rössle M. Richter G.M. Noeldge G. Siegerstetter V. Palmaz J.V. Wenz W. et al.The intrahepatic portosystemic shunt. Initial clinical experiences with patients with liver cirrhosis.Dtsch Med Wochenschr. 1989; 114: 1511-1516Crossref PubMed Google Scholar, 13Richter G.M. Nöldge G. Palmaz J.C. Rössle M. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study.Cardiovasc Intervent Radiol. 1990; 13: 200-207Crossref PubMed Scopus (95) Google Scholar]. Of the 10 patients who were intended to treat, TIPS could be implanted successfully in 7. Two of these 7 patients died early. Interventions lasted an average of 8 hours and consisted of a transjugular as well as a percutaneous transcostal approach to place a metallic target (Dormia bascet) in the right branch of the portal vein. Due to complications and technical difficulties in establishing the TIPS, the project was discontinued until spring 1990 when Jean Marc Perarnau from Metz, France, joined our group. With his improved puncture technique including sonographic targeting of the portal vein, we were able to perform the procedure in its present form within 1 to 2 hours with a considerably reduced complication rate [[14]Perarnau J.M. Noeldge G. Rössle M. Intrahepatic portacaval anastomosis by the transjugular approach. Use of Palmaz endoprosthesis.Presse Med. 1991; 20: 1770-1772PubMed Google Scholar]. This was the start of a series of about 50 patients treated within 1990 and 500 patients treated until 1995 in Freiburg. A summary of the early results of the 2 leading centers at this time, Freiburg and San Francisco, was published in 1993 [[15]Conn H.O. Transjugular intrahepatic portal-systemic shunts: the state of the art.Hepatology. 1993; 17: 148-158Crossref PubMed Google Scholar]. The last decade of the millennium was devoted to technical problems solving and to performing numerous randomized clinical studies [[16]Rössle M. Siegerstetter V. Huber M. Ochs A. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art.Liver. 1998; 18: 73-89Crossref PubMed Google Scholar]. Finally, patients’ selection and the definition of the best indications have been worked out and discussed in consensus conferences [17Boyer T.D. Haskal Z.J. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009.Hepatology. 2010; 51: 1-16Crossref PubMed Scopus (0) Google Scholar, 18Bari Khurram Garcia-Tsao Guadalupe Treatment of portal hypertension.World J Gastroenterol. 2012; 18: 1166-1175Crossref PubMed Scopus (45) Google Scholar]. Steady adaptation of this process is necessary to include new results obtained with increasing experience and new technical facilities such as covered stents. The present review concentrates on specific technical aspects and clinical implications based on former and actual study results. Before TIPS implantation, hepatic functional insufficiency and clinically overt hepatic encephalopathy should be excluded. A duplex examination should exclude portal and hepatic arterial abnormalities. Road mapping by CT or MRI is not routinely necessary but may help facilitate the anatomical orientation. In patients with suspected or known cardiac disease, an echocardiography should be performed to exclude significant diastolic or systolic cardiac failure. In patients with refractory ascites or hydrothorax, paracentesis and/or thoracentesis should be performed. This may reposition the liver from a more transversal into a more frontal posture, facilitating the portal puncture. It also improves the quality of the fluoroscopic picture and reduces the radiogenic exposure of the patient and physician. In addition, the respiratory function improves and facilitates sedation. The technical performance of the TIPS procedure may be somewhat different in the US and Europe where not only Radiologists but also Gastroenterologists have given their input. Thus, many centers in Europe use sedation with midazolam, piritamide, and propofol while in the US general anesthesia with endotracheal intubation is preferred [[19]Fidelman N. Kwan S.W. LaBerge J.M. et al.The transjugular intrahepatic portosystemic shunt: an update.AJR Am J Roentgenol. 2012; 199: 46-55Crossref Scopus (18) Google Scholar]. In addition, sonographic targeting is commonly performed by Gastroenterologists while Radiologists often trust preinterventional imaging [[17]Boyer T.D. Haskal Z.J. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009.Hepatology. 2010; 51: 1-16Crossref PubMed Scopus (0) Google Scholar]. For the creation of the TIPS procedure, two puncture sets are presently in use: the modified open Colapinto or Ross needle with an adapted multipurpose catheter and a closed coaxial system where a stylette is advanced through a canula. The open needle is relatively inexpensive and allows rapid execution of the puncture. With its use, complete TIPS procedures have been performed in less than 20 min. The closed coaxial needle set is more expensive, more complex, and time consuming, but may be less invasive. Studies comparing the two equipments have not been performed so far. After an appropriate branch of the intrahepatic portal vein has been punctured, a guidewire followed by a pigtail catheter is introduced into the splenic vein and portal venography and pressure measurements are performed. If present and indicated, collaterals are now occluded using bucrylate, coils or Amplatzer plug. The parenchymal track is then dilated and a stent is placed. To avoid shunt related complications, stents with a nominal diameter of 10 mm should be employed but dilated only to 8 mm. This may result in a more limited pressure reduction, not always achieving the recommended threshold of 12 mmHg [19Fidelman N. Kwan S.W. LaBerge J.M. et al.The transjugular intrahepatic portosystemic shunt: an update.AJR Am J Roentgenol. 2012; 199: 46-55Crossref Scopus (18) Google Scholar, 20Boyer T.D. Haskal Z.J. American Association for the Study of Liver Disease Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension.J Vasc Interv Radiol. 2005; 16: 615-629Abstract Full Text Full Text PDF PubMed Google Scholar, 21Garcia-Tsao G. Groszmann R.J. Fisher R.L. Conn H.O. Atterbury C.E. Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding.Hepatology. 1985; 5: 419-424Crossref PubMed Scopus (516) Google Scholar, 22Casado M. Bosch J. García-Pagán J.C. Bru C. Banares R. Bandi J.C. et al.Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings.Gastroenterology. 1998; 114: 1296-1303Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar], but possibly reducing the rate of TIPS-induced hepatic encephalopathy [22Casado M. Bosch J. García-Pagán J.C. Bru C. Banares R. Bandi J.C. et al.Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings.Gastroenterology. 1998; 114: 1296-1303Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar, 23Rössle M. Siegerstetter V. Olschewski M. Ochs A. Berger E. Haag K. How much reduction in portal pressure is necessary to prevent variceal rebleeding? A longitudinal study in 225 patients with a transjugular intrahepatic portosystemic shunt.Am J Gastroenterol. 2001; 96: 3379-3383Crossref PubMed Scopus (57) Google Scholar]. In case of insufficient response, further pressure reduction can be achieved by a second intervention. However, no studies are available showing that the presently preferred self-expandable stents with a nominal diameter of 10 mm keep the reduced diameter over time. This certainly depends on the radial forces of the stent and compliance of the cirrhotic liver, both may differ to a great extent. Stents with low radial forces (e.g., Viatorr) may be preferred. A final portography and pressure measurement in the main portal vein and the right atrium are performed. In contrast to the measurements of the pressure gradients performed and published in studies investigating the effect of drugs, the free hepatic vein pressure measurement is usually replaced by the measurement in the right atrium. Measurement in the hepatic vein after TIPS is compromised by the stent and the high flow in the hepatic vein. Instead, measurement in the inferior caval vein at the level of the hepatic veins has been suggested [[24]Groszmann R.J. Wongcharatrawee S. The hepatic venous pressure gradient: anything worth doing should be done right.Hepatology. 2004; 39: 280-282Crossref PubMed Scopus (242) Google Scholar]. However, the location of the tip of the catheter straight below the right atrium is often difficult and distinction between the upper part of the caval vein and the right atrium is not always possible. Therefore, in the setting of TIPS, most investigators measure the porto-atrial gradient which is slightly higher than the gradients obtained between the portal vein and the hepatic or inferior caval veins. Should anticoagulation or antibiotics be provided during or after the TIPS procedure? This is an open question which has often been discussed. The advantage of platelet aggregation inhibitors has been demonstrated for bare stents [16Rössle M. Siegerstetter V. Huber M. Ochs A. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art.Liver. 1998; 18: 73-89Crossref PubMed Google Scholar, 25Siegerstetter V. Huber M. Ochs A. Blum H.E. Rössle M. Platelet aggregation and platelet-derived growth factor inhibition for prevention of insufficiency of the transjugular intrahepatic portosystemic shunt: a randomized study comparing trapidil plus ticlopidine with heparin treatment.Hepatology. 1999; 29: 33-38Crossref PubMed Scopus (39) Google Scholar]. Our present approach is to treat patients with bare stents and with higher platelet count (e.g., >100000/μl) with acetylic salicylic acid (100 mg/day). Whether this strategy can also be recommended for covered stents is not investigated so far. Their introduction led to marked decrease in shunt dysfunction [15% vs. 44%], and a lower rate of clinical relapse [10% vs. 29%] [26Bureau C. García-Pagán J.C. Layrargues G.P. Metivier S. Bellot P. Perreault P. et al.Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicenter study.Liver Int. 2007; 27: 742-747Crossref PubMed Scopus (116) Google Scholar, 27Eesa M. Clark T. Transjugular intrahepatic portosystemic shunt: state of the art.Semin Roentgenol. 2011; 46: 125-132Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. However, it should be noticed that the advantage diminishes with time to require shunt revision of about 50% after a 5-year follow-up [[28]Rössle M. Siegerstetter V. Euringer W. Olschewski M. Kromeier J. Kurz K. et al.The use of a polytetrafluoroethylene-covered stent graft for transjugular intrahepatic portosystemic shunt (TIPS): Long-term follow-up of 100 patients.Acta Radiol. 2006; 47: 660-666Crossref PubMed Scopus (44) Google Scholar]. Post-interventional infection has been observed in up to 20% of patients and prophylactic antibiosis with Ceftriaxone [[29]Gülberg V. Deibert P. Ochs A. Rössle M. Gerbes A.L. Prevention of infectious complications after transjugular intrahepatic portosystemic shunt in cirrhotic patients with a single dose of ceftrtiaxone.Hepatogastroenterology. 1999; 46: 1126-1130PubMed Google Scholar], but not with Cefotiam [[30]Deibert P. Schwarz S. Olschewski M. Siegerstetter V. Blum H.E. Rössle M. Risk factors and prevention of early infection after implantation or revision of transjugular portosystemic shunts: results of a randomised study.Dig Dis Sci. 1998; 43: 1708-1713Crossref PubMed Google Scholar], has been suggested. In addition, infection of the stent lumen, named “endotipsitis”, has been described with a calculated incidence of 1.3% [31Brown R.S. Brumage L. Yee H.F. Lake J.R. Roberts J.P. Somberg K.A. Enterococcal bacteremia after transjugular intrahepatic portosystemic shunts (TIPS).Am J Gastroenterol. 1998; 93: 636-639Crossref PubMed Scopus (22) Google Scholar, 32Bouza E. Munoz P. Rodriguez C. Grill F. Rodriguez-Creixems M. Banares R. et al.Endotipsitis: an emerging prosthetic-related infection in patients with portal hypertension.Diagn Microbiol Infect Dis. 2004; 49: 77-82Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. It can be assumed that, in the meanwhile, the incidence of post-interventional infection decreased by better technical skills (fewer catheter exchanges), questioning the usefulness of prophylactic antibiosis. However, complicated procedures requiring many changes of catheters and sheaths may have a higher rate of infection, justifying prophylactic antibiotic treatment. The early post-procedural setting consists of monitoring of the blood pressure, haemoglobin/hematocrit and maybe urine volume during 24 hours. With few exceptions, intensive care is not necessary. In general, in patients with variceal bleeding, ß-blockers are withdrawn and in patients with refractory ascites, diuretic medication is reduced by half. A Duplex-sonographic examination is performed before patient’s discharge. In patients with a Budd-Chiari syndrome, the catheterization of a heptic vein may not be possible. In these as well as in the rare patients with unaccessible hepatic veins, a direct puncture through the inferior caval vein may be inevitable. A series of 40 patients with direct TIPS (DIPS) using intravascular ultrasound has been reported showing a high success and patency rate [33Petersen B. Binkert C. Intravascular ultrasound-guided direct intrahepatic portacaval shunt: midterm follow-up.J Vasc Interv Radiol. 2004; 15: 927-938Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 34Petersen B.D. Clark T.W.I. Direct intrahepatic portocaval shunt.Tech Vasc Interv Radiol. 2008; 11: 230-234Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. Another technique of a direct TIPS, which was applied to 11 patients with Budd-Chiari syndrome, used a percutaneous transabdominal approach to the left portal branch which was then extended to the inferior caval vein [[35]Boyvat F. Aytekin C. Harman A. Ozin Y. Transjugular intrahepatic portosystemic shunt creation in Budd-Chiari syndrome: percutaneous ultrasound-guided direct simultaneous puncture of the portal vein and vena cava.Cardiovasc Intervent Radiol. 2006; 29: 857-861Crossref PubMed Scopus (17) Google Scholar]. Unfortunately, prospective studies investigating the technical complications are not available. Perforation of the liver capsule without or with intraperitoneal hemorrhage has been described in 33 and 1–2% of the procedures, respectively [[19]Fidelman N. Kwan S.W. LaBerge J.M. et al.The transjugular intrahepatic portosystemic shunt: an update.AJR Am J Roentgenol. 2012; 199: 46-55Crossref Scopus (18) Google Scholar]. However, in centers using sonography during the puncture process, these complications are almost abolished. The same is true for clinically significant hemobilia or hemolysis, complications which have been seen more frequently at the beginning of the TIPS era [[16]Rössle M. Siegerstetter V. Huber M. Ochs A. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art.Liver. 1998; 18: 73-89Crossref PubMed Google Scholar]. With the use of modern stents, stent misplacement or migration is also very rare. Frequencies of 20% proximal or distal displacement given in a recent review [[20]Boyer T.D. Haskal Z.J. American Association for the Study of Liver Disease Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension.J Vasc Interv Radiol. 2005; 16: 615-629Abstract Full Text Full Text PDF PubMed Google Scholar] are, in our experience, unusual. In particular, the Viatorr stent is designed to be placed with great accuracy and misplacement is almost impossible (Fig. 1). Doppler ultrasound is the most valuable means to estimate shunt function. The parameters which should be evaluated before and after TIPS implantation are summarized in Table 1. In general, the pre-procedural low-flow velocity in the portal vein (Vmax: 10–20 cm/sec) increases by TIPS by a factor of 2–4 to 40–60 cm/sec [36Zizka J. Elias P. Krajina A. Michl A. Lojik M. Ryska P. et al.Value of Doppler sonography in revealing transjugular intrahepatic portosystemic shunt malfunction: a 5-year experience in 216 patients.Am J Radiol. 2000; 175: 141-148Google Scholar, 37Lafortune M. Martinet J.-P. Denys A. Patriquin H. Dauzat M. Dufresne M.-P. et al.Sstemic shunts: a Doppler/manometric correlative study.Am J Radiol. 1995; 164: 997-1002Google Scholar, 38Rössle M. Haag K. Ochs A. Sellinger M. Nöldge G. Perarneau J.-M. et al.The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding.N Engl J Med. 1994; 330: 165-171Crossref PubMed Scopus (550) Google Scholar, 39Nolte W. Münke H. Schindler C. Figulla H.R. Werner G. Leonhardt U. et al.Doppler-sonographische Kurz- und Langzeituntersuchungen der portalen Hämodynamik nach transjugulärem intrahepatischem portosystemischem Stent-Shunt (TIPS).Z Gastroenterol. 1998; 36: 491-499PubMed Google Scholar, 40Haag K. Rössle M. Ochs A. Huber M. Siegerstetter V. Olschewski M. et al.Correlation of duplex-sonography findings and portal pressure in 375 patients with portal, hypertension.AJR Am J Roentgenol. 1999; 172: 631-635Crossref PubMed Google Scholar, 41Haag K. Conn H.O. Palmaz J.C. Rösch J. Rössle M. TIPS: transjugular intrahepatic portosystemic shunts. Igaku-Shoin, New York, Tokio1996: 319-338Google Scholar]. A post-TIPS portal vein flow velocity of less than 30 cm/sec suggests shunt insufficiency. The flow velocity in the stent is expected to be between 80 and 160 cm/sec shortly after TIPS. Values below 60 or above 180 cm/sec indicate shunt insufficiency. In particular, any value lower than 40 or higher than 200 cm/sec clearly indicates shunt malfunction [[41]Haag K. Conn H.O. Palmaz J.C. Rösch J. Rössle M. TIPS: transjugular intrahepatic portosystemic shunts. Igaku-Shoin, New York, Tokio1996: 319-338Google Scholar]. It should be emphasized that measurements in the stent-shunt or in the draining hepatic vein are only reliable in cases of simple stenoses (Fig. 2, Fig. 3). In cases with a complex structure of the intimal proliferation in the stent or in the draining hepatic vein, the measurements are not reliable and normal values cannot exclude stenosis (Fig. 2, Fig. 4). Therefore, in case of normal values within the stent, the findings in the portal vein define whether shunt function is sufficient or not. In addition, a change in flow direction of the intrahepatic portal branches from retrograde shortly after TIPS to prograde may also be a good qualitative indicator of shunt malfunction [[37]Lafortune M. Martinet J.-P. Denys A. Patriquin H. Dauzat M. Dufresne M.-P. et al.Sstemic shunts: a Doppler/manometric correlative study.Am J Radiol. 1995; 164: 997-1002Google Scholar]. If simple stenosis is seen, the Bernoulli equation (Δp = 4 v2) can be applied to calculate the pressure gradient Δp (in mmHg) across the stenosis from the flow velocity measured in the stenosis (Vmax in m/sec). Accordingly, a flow velocity (Vmax) of 180 cm/sec (1.8 m/sec) indicates a pressure gradient across the stenosis of 13 mmHg. It could be demonstrated that calculated gradients using the Bernoulli equation closely correlate with gradients determined by catheter measurement (r = 0.84) [[41]Haag K. Conn H.O. Palmaz J.C. Rösch J. Rössle M. TIPS: transjugular intrahepatic portosystemic shunts. Igaku-Shoin, New York, Tokio1996: 319-338Google Scholar].Table 1Duplex-sonographic findings obtained from the literature 36Zizka J. Elias P. Krajina A. Michl A. Lojik M. Ryska P. et al.Value of Doppler sonography in revealing transjugular intrahepatic portosystemic shunt malfunction: a 5-year experience in 216 patients.Am J Radiol. 2000; 175: 141-148Google Scholar, 37Lafortune M. Martinet J.-P. Denys A. Patriquin H. Dauzat M. Dufresne M.-P. et al.Sstemic shunts: a Doppler/manometric correlative study.Am J Radiol. 1995; 164: 997-1002Google Scholar, 38Rössle M. Haag K. Ochs A. Sellinger M. Nöldge G. Perarneau J.-M. et al.The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding.N Engl J Med. 1994; 330: 165-171Crossref PubMed Scopus (550) Google Scholar, 39Nolte W. Münke H. Schindler C. Figulla H.R. Werner G. Leonhardt U. et al.Doppler-sonographische Kurz- und Langzeituntersuchungen der portalen Hämodynamik nach transjugulärem intrahepatischem portosystemischem Stent-Shunt (TIPS).Z Gastroenterol. 1998; 36: 491-499PubMed Google Scholar, 40Haag K. Rössle M. Ochs A. Huber M. Siegerstetter V. Olschewski M. et al.Correlation of duplex-sonography findings and portal pressure in 375 patients with portal, hypertension.AJR Am J Roentgenol. 1999; 172: 631-635Crossref PubMed Google Scholar, 41Haag K. Conn H.O. Palmaz J.C. Rösch J. Rössle M. TIPS: transjugular intrahepatic portosystemic shunts. Igaku-Shoin, New York, Tokio1996: 319-338Google Scholar before and after TIPS and values indicating shunt failure. The portal vein and stent flow are calculated according to flow = π × d2/4 × ½ Vmax. Open table in a new tab Fig. 3Example of a simple stenosis in the draining hepatic vein exhibiting Vmax of >2 m/sec.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 4Example of a complex stenosis with lining of the stent. Duplex sonography of the stent flow velocity is not reliable and shunt function must be assessed by portal flow parameters.View Large Image Figure ViewerDownload Hi-res image Download (PPT) When TIPS dysfunction is suspected, revision is not generally indicated in the absence of clinical symptoms. In patients with previous variceal bleeding, the decision should be based on the endoscopic verification of significant varices. Certainly, revision should not be performed in patients who developed severe liver failure or hepatic encephalopathy at the time of TIPS patency. If the original TIPS was created using a bare-metal stent, a covered stent should now be implanted [[42]Jirkovsky V. Fejfar T. Safka V. Hulek P. Krajina A. Chovanec V. et al.Influence of the secondary deployment of expanded polytetrafluoroethylene-covered stent grafts on maintenance of transjugular intrahepatic portosystemic shunt patency.J Vasc Interv Radiol. 2011; 22: 55-60Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Due to the diversion of portal venous flow, an increase in bilirubin concentration is frequent due to decreased liver perfusion while albumin or INR is not affected [43Rössle M. Ochs A. Gulberg V. Siegerstetter V. Holl J. Deibert P. et al.A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites.N Engl J Med. 2000; 342: 1701-1707Crossref PubMed Scopus (368) Google Scholar, 44Pomier-Layrargues G. Bouchard L. Lafortune M. Bissonette J. Guerette D. Perreault P. The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status.Int J Hepatol. 2012; 2012: 167868Crossref PubMed Google Scholar, 45Baron A. Gülberg V. Sauter G. Waggershauser T. Reiser M. Gerbes A.L. Effects of transjugular intzrahepatic portosystemic shunt (TIPS) on quantitative liver function tests.Hepatogastroenterology. 1998; 45: 2315-2321PubMed Google Scholar]. A small study including 15 patients investigated the effect of TIPS on aminopyrin breath test, monoethylglycinexylidide test (MEGX), bilirubin, albumin, and PT-time. Compared to values obtained before TIPS, no significant changes were seen 1, 3, and 6 months after TIPS [[45]Baron A. Gülberg V. Sauter G. Waggershauser T. Reiser M. Gerbes A.L. Effects of transjugular intzrahepatic portosystemic shunt (TIPS) on quantitative liver function tests.Hepatogastroenterology. 1998; 45: 2315-2321PubMed Google Scholar]. Nevertheless, few patients develop severe liver failure characterized by a rapid increase in bilirubin concentration. They require immediate TIPS occlusion to prevent death. Fortunately, the loss or reduction of the portal perfusion by TIPS induces an immediate rise in the" @default.
• W1525534239 created "2016-06-24" @default.
• W1525534239 creator A5016637736 @default.
• W1525534239 date "2013-11-01" @default.
• W1525534239 modified "2023-10-11" @default.
• W1525534239 title "TIPS: 25years later" @default.
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