I’ve taken care of a few patients following a transjugular intrahepatic portosystemic shunt (TIPS) procedure, but I didn’t really know what it involved. If you are a nurse who cares for patients following TIPS insertion, here’s what you need to know.
Anatomy of the Liver
Let’s start with a review of basic liver anatomy. The portal vein carries blood from the stomach, intestines, spleen, gallbladder, and the pancreas to the liver. In the liver, blood flows through capillaries where old red blood cells, bacteria and other toxins are filtered out and nutrients are added. Blood then exits the liver back to circulation via the hepatic veins. This system of vessels is known as the portal venous system.
Disorders such as hepatitis, fatty liver disease and excessive alcohol use damage the liver, leading to scarring or cirrhosis which can block vessels in the liver, preventing blood from flowing properly. When blood cannot properly leave the liver, it backs up, increasing pressure within the entire network; this is known as portal hypertension. The high pressure can cause ascites and varices within the esophagus, duodenum, rectum, or umbilical area. Other causes of portal hypertension include blood clots in the portal vein, parasitic infection (schistosomiasis), and focal nodular hyperplasia. The TIPS procedure decreases portal pressure by creating a channel between the hepatic vein and intrahepatic branch of the portal vein.
TIPS Indications (Bajaj, Sanyal & Collares, 2023)
The TIPS procedure is indicated in the following conditions:
- Esophageal varices:
- Control active bleeding varices that fail first line hemostasis or rebleeding within 120 hours of initial hemorrhage
- Prevent recurrent bleeding
- Gastric varices
- Ectopic varices (duodenal, rectal, peristomal)
- Portal hypertensive gastropathy (lesions on the stomach mucosa)
- Refractory ascites: (ascites that is unresponsive to medical therapy)
- Budd-Chiari syndrome (hepatic veins blocked or narrowed by a clot)
- Hepatic hydrothorax: (pleural effusion (>500 mL) in a patient with cirrhosis)
- Bridge to liver transplant
TIPS Contraindications (Bajaj, Sanyal & Collares, 2023)
|Congestive heart failure
|Severe tricuspid regurgitation
||Obstruction of all hepatic veins
|Severe pulmonary hypertension
|Polycystic liver disease
||Portal vein thrombosis
|Active systemic infection or sepsis
|Unrelieved biliary obstruction
||Moderate pulmonary hypertension
Pre-TIPS Procedure Testing (Bajaj, Sanyal & Collares, 2023)
Prior to TIPS placement, the following tests are obtained:
- Complete blood count
- Total bilirubin
- International normalized ratio (INR)
- Serum creatinine
- Model for End-stage Liver Disease (MELD) score
- Liver imaging, such as contrast-enhanced computed tomography (CT scan), magnetic resonance imaging (MRI), or non-contrast abdominal ultrasound with Doppler study
- Chest radiography to evaluate for fluid overload and cardiomegaly
- Complete cardiac evaluation in select patients with signs, symptoms, or history of heart failure, tricuspid regurgitation, cardiomyopathy, or pulmonary hypertension
TIPS Procedure (Bajaj, Sanyal & Collares, 2023; Lippincott Procedures, 2023)
TIPS is a minimally invasive procedure performed in the interventional radiology suite by specially trained staff, but an understanding of the procedure is good for anyone educating patients or providing pre- or post-procedure care. Sedation and/or pain medication will be administered. Under fluoroscopy, a catheter is typically inserted into the right jugular vein and advanced down the superior vena cava into the right or middle hepatic vein. There, contrast is used to identify the internal liver circulation. A TIPS needle is then advanced through the catheter into the hepatic vein to the portal vein. A stent is deployed connecting the two veins forming a shunt resulting in a decrease in portal pressures.
If esophageal or gastric varices require embolization, coils, plugs or sclerosing agents may be utilized. The patient is monitored for cardiac arrythmias throughout the procedure.
Post-procedure (Lippincott Procedures, 2023)
Follow your facility protocols and postprocedure orders which may include:
- Admit to intensive care unit overnight.
- Place patient on bedrest for 4 hours with head of bed elevated 30 to 45 degrees.
- Monitor vital signs, mental status, and access site (for bleeding or hematoma) every 15 minutes for the first hour, every 30 minutes for 2 hours, then hourly for 2 hours.
- Perform strict intake and output, as well as daily patient weight.
- Obtain lab tests: complete blood count, coagulation panel, and liver and kidney function tests.
- Monitor for signs of gastric bleeding.
- Monitor for signs of encephalopathy.
- Measure abdominal circumference.
- Restrict fluid and protein intake.