Semin intervent Radiol 2006; 23(2): 165-176
DOI: 10.1055/s-2006-941447
Copyright © 2006 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Transjugular Intrahepatic Portosystemic Shunt-Related Complications and Practical Solutions

Renato Ripamonti1 , Hector Ferral1 , Marc Alonzo1 , Nilesh H. Patel1
  • 1Department of Diagnostic Radiology, Section of Interventional Radiology, Rush University Medical Center, Chicago Illinois
Further Information

Publication History

Publication Date:
16 May 2006 (online)

ABSTRACT

Despite the clinical complexity of patients with severe liver disease and the technical demands associated with the creation of a transjugular intrahepatic portosystemic shunt (TIPS), the major complication rate of this procedure is less than 5%. Delayed recognition and treatment of complications related to TIPS can have life-threatening consequences. This article provides an overview of the spectrum of periprocedural and delayed complications related to the performance of TIPS and offers the reader pearls for both avoiding and managing those complications.

REFERENCES

  • 1 Haskal Z J, Rees C R, Ring E J, Saxon R, Sacks D. Reporting standards for transjugular intrahepatic portosystemic shunts. Technology Assessment Committee of the SCVIR.  J Vasc Interv Radiol. 1997;  8 289-297
  • 2 Freedman A M, Sanyal A J, Tisnado J et al.. Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review.  Radiographics. 1993;  13 1185-1210
  • 3 Coldwell D M, Ring E J, Rees C R et al.. Multicenter investigation of the role of transjugular intrahepatic portosystemic shunt in management of portal hypertension.  Radiology. 1995;  196 335-340
  • 4 Encarnacion C E, Palmaz J C, Rivera F J et al.. Transjugular intrahepatic portosystemic shunt placement for variceal bleeding: predictors of mortality.  J Vasc Interv Radiol. 1995;  6 687-694
  • 5 Tyburski J G, Noorily M J, Wilson R F. Prognostic factors with the use of the transjugular intrahepatic portosystemic shunt for bleeding varices.  Arch Surg. 1997;  132 626-630; , discussion 630-622
  • 6 Patch D, Nikolopoulou V, McCormick A et al.. Factors related to early mortality after transjugular intrahepatic portosystemic shunt for failed endoscopic therapy in acute variceal bleeding.  J Hepatol. 1998;  28 454-460
  • 7 Rajan D K, Haskal Z J, Clark T WI. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of a multivariate analysis.  J Vasc Interv Radiol. 2002;  13 155-161
  • 8 Helton W S, Belshaw A, Althaus S, Park S, Coldwell D, Johansen K. Critical appraisal of the angiographic portacaval shunt (TIPS).  Am J Surg. 1993;  165 566-571
  • 9 Banares R, Casado M, Rodriguez-Laiz J M et al.. Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding.  Am J Gastroenterol. 1998;  93 75-79
  • 10 Rubin R A, Haskal Z J, O'Brien C, Cope C, Brass C. Transjugular intrahepatic portosystemic shunting: decreased survival for patients with high APACHE II scores.  Am J Gastroenterol. 1995;  90 556-563
  • 11 Chalasani N, Clark W S, Martin L G et al.. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting.  Gastroenterology. 2000;  118 138-144
  • 12 Malinchoc M, Kamath P S, Gordon F D, Peine C J, Rank J, ter Borg P C. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.  Hepatology. 2000;  31 864-871
  • 13 Kamath P S, Wiesner R H, Malinchoc M et al.. A model to predict survival in patients with end-stage liver disease [see comments].  Hepatology. 2001;  33 464-470
  • 14 Angermayr B, Cejna M, Karnel F et al.. Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt.  Gut. 2003;  52 879-885
  • 15 Salerno F, Merli M, Cazzaniga M et al.. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt.  J Hepatol. 2002;  36 494-500
  • 16 Ferral H, Gamboa P, Postoak D W et al.. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score.  Radiology. 2004;  231 231-236
  • 17 Fitt G, Thomson K, Hennessy O. Delayed fatal cardiac perforation by an indwelling long introducer sheath following transjugular intrahepatic portocaval stents (TIPS).  Cardiovasc Intervent Radiol. 1993;  16 109-110
  • 18 Richter G M, Noeldge G, Palmaz J C et al.. Transjugular intrahepatic portacaval stent shunt: preliminary clinical results.  Radiology. 1990;  174 1027-1030
  • 19 Uflacker R, Reichert P, D'Albuquerque L C, de Oliveira e Silva A. Liver anatomy applied to the placement of transjugular intrahepatic portosystemic shunts.  Radiology. 1994;  191 705-712
  • 20 Saxon R R, Keller F S. Technical aspects of accessing the portal vein during the TIPS procedure.  J Vasc Interv Radiol. 1997;  8 733-744
  • 21 Rose S C, Behling C, Roberts A C et al.. Main portal vein access in transjugular intrahepatic portosystemic shunt procedures: use of three-dimensional ultrasound to ensure safety.  J Vasc Interv Radiol. 2002;  13 267-273
  • 22 Richter G M, Noeldge G, Palmaz J C, Roessle M. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study.  Cardiovasc Intervent Radiol. 1990;  13 200-207
  • 23 Semba C P, Saperstein L, Nyman U, Dake M D. Hepatic laceration from wedged venography performed before transjugular intrahepatic portosystemic shunt placement.  J Vasc Interv Radiol. 1996;  7 143-146
  • 24 Petersen B. Intravascular ultrasound-guided direct intrahepatic portacaval shunt: description of technique and technical refinements.  J Vasc Interv Radiol. 2003;  14 21-32
  • 25 Haskal Z J, Martin L, Cardella J F et al.. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts.  J Vasc Interv Radiol. 2001;  12 131-136
  • 26 Kim J K, Yun W, Kim J W, Joo Y U, Park J G. Extrahepatic portal vein tear with intraperitoneal hemorrhage during TIPS.  Cardiovasc Intervent Radiol. 2001;  24 436-437
  • 27 Davis A G, Haskal Z J. Extrahepatic portal vein puncture and intra-abdominal hemorrhage during transjugular intrahepatic portosystemic shunt creation.  J Vasc Interv Radiol. 1996;  7 863-866
  • 28 Owen R J, Rose J D. Endovascular treatment of a portal vein tear during TIPSS.  Cardiovasc Intervent Radiol. 2000;  23 230-232
  • 29 Schultz S R, LaBerge J M, Gordon R L, Warren R S. Anatomy of the portal vein bifurcation: intra- versus extrahepatic location: implications for transjugular intrahepatic portosystemic shunts.  J Vasc Interv Radiol. 1994;  5 457-459
  • 30 Saxon R S, Ross P L, Mendel-Hartvig J et al.. Transjugular intrahepatic portosystemic shunt patency and the importance of stenosis location in the development of recurrent symptoms.  Radiology. 1998;  207 683-693
  • 31 Peltzer M Y, Ring E J, LaBerge J M, Haskal Z J, Radosevich P M, Gordon R L. Treatment of Budd-Chiari syndrome with a transjugular intrahepatic portosystemic shunt.  J Vasc Interv Radiol. 1993;  4 263-267
  • 32 Soares G M, Murphy T P. Transcaval TIPS: indications and anatomic considerations.  J Vasc Interv Radiol. 1999;  10 1233-1238
  • 33 Haskal Z J, Duszak Jr R, Furth E E. Transjugular intrahepatic transcaval portosystemic shunt: the gun-sight approach.  J Vasc Interv Radiol. 1996;  7 139-142
  • 34 Rozenblit G, DelGuercio L R, Savino J A et al.. Transmesenteric-transfemoral method of intrahepatic portosystemic shunt placement with minilaparotomy.  J Vasc Interv Radiol. 1996;  7 499-506
  • 35 Haskal Z J, Pentecost M J, Rubin R A. Hepatic arterial injury after transjugular intrahepatic portosystemic shunt placement: report of two cases.  Radiology. 1993;  188 85-88
  • 36 Pattynama P M, van Hoek B, Kool L J. Inadvertent arteriovenous stenting during transjugular intrahepatic portosystemic shunt procedure and the importance of hepatic artery perfusion.  Cardiovasc Intervent Radiol. 1995;  18 192-195
  • 37 Kerlan Jr R K, LaBerge J M, Gordon R L, Ring E J. Inadvertent catheterization of the hepatic artery during placement of transjugular intrahepatic portosystemic shunts.  Radiology. 1994;  193 273-276
  • 38 Mallery S, Freeman M L, Peine C J, Miller R P, Stanchfield W R. Biliary-shunt fistula following transjugular intrahepatic portosystemic shunt placement.  Gastroenterology. 1996;  111 1353-1357
  • 39 Jawaid Q, Saeed Z A, Di Bisceglie A M et al.. Biliary-venous fistula complicating transjugular intrahepatic portosystemic shunt presenting with recurrent bacteremia, jaundice, anemia and fever.  Am J Transplant. 2003;  3 1604-1607
  • 40 Saxon R R, Mendel-Hartvig J, Corless C L et al.. Bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic portosystemic shunts: comparative histopathologic analysis in humans and swine.  J Vasc Interv Radiol. 1996;  7 487-497
  • 41 Cohen G S, Young H Y, Ball D S. Stent-graft as treatment for TIPS-biliary fistula.  J Vasc Interv Radiol. 1996;  7 665-668
  • 42 Boyvat F, Cekirge S, Balkanci F, Besim A. Treatment of a TIPS-biliary fistula by stent-graft in a 9-year-old boy.  Cardiovasc Intervent Radiol. 1999;  22 67-68
  • 43 Saxon R R. A new era for transjugular intrahepatic portosystemic shunts?.  J Vasc Interv Radiol. 2004;  15 217-219
  • 44 Darcy M D, Vesely T M, Picus D, Middleton W D, Hicks M E. Percutaneous revision of an acutely thrombosed transjugular intrahepatic portosystemic shunt.  J Vasc Interv Radiol. 1992;  3 77-80 , discussion 81-72
  • 45 Hausegger K A, Sternthal H M, Klein G E, Karaic R, Stauber R, Zenker G. Transjugular intrahepatic portosystemic shunt: angiographic follow-up and secondary interventions.  Radiology. 1994;  191 177-181
  • 46 Clark T W, Agarwal R, Haskal Z J, Stavropoulos S W. The effect of initial shunt outflow position on patency of transjugular intrahepatic portosystemic shunts.  J Vasc Interv Radiol. 2004;  15 147-152
  • 47 Sehgal M, Brown D B, Picus D. Aortoatrial fistula complicating transjugular intrahepatic portosystemic shunt by protrusion of a stent into the right atrium: radiologic/pathologic correlation.  J Vasc Interv Radiol. 2002;  13 409-412
  • 48 Slonim S M, Dake M D, Razavi M K et al.. Management of misplaced or migrated endovascular stents.  J Vasc Interv Radiol. 1999;  10 851-859
  • 49 Ferral H, Banks B, Wholey M, Nazarian G K, Bjarnason H, Castaneda-Zuniga W R. Techniques for transjugular intrahepatic portosystemic shunt revision.  AJR Am J Roentgenol. 1998;  171 1041-1047
  • 50 Sterling K M, Darcy M D. Stenosis of transjugular intrahepatic portosystemic shunts: presentation and management.  AJR Am J Roentgenol. 1997;  168 239-244
  • 51 Cekirge S, Foster R G, Weiss J P, McLean G K. Percutaneous removal of an embolized Wallstent during a transjugular intrahepatic portosystemic shunt procedure.  J Vasc Interv Radiol. 1993;  4 559-560
  • 52 Linka A Z, Jenni R. Migration of intrahepatic portosystemic stent into right ventricle: an unusual cause of tricuspid regurgitation.  Circulation. 2001;  103 161-162
  • 53 Rumi M N, Schumann R, Freeman R B, Rohrer R J, Fairchild R B. Acute transjugular intrahepatic portosystemic shunt migration into pulmonary artery during liver transplantation.  Transplantation. 1999;  67 1492-1494
  • 54 Cohen G S, Ball D S. Delayed Wallstent migration after a transjugular intrahepatic portosystemic shunt procedure: relocation with a loop snare.  J Vasc Interv Radiol. 1993;  4 561-563
  • 55 Hartnell G G, Crenshaw W B, Burger A J, Hamer A W. Percutaneous removal of a fully expanded Wallstent from the right ventricle with transesophageal echocardiography guidance.  J Vasc Interv Radiol. 1996;  7 371-374
  • 56 Lipton M, Cynamon J, Bakal C W, Sprayregen S. Percutaneous retrieval of two Wallstent endoprostheses from the heart through a single jugular sheath.  J Vasc Interv Radiol. 1995;  6 469-472
  • 57 Prahlow J A, O'Bryant T J, Barnard J J. Cardiac perforation due to Wallstent embolization: a fatal complication of the transjugular intrahepatic portosystemic shunt procedure.  Radiology. 1997;  205 170-172
  • 58 Azoulay D, Castaing D, Dennison A, Martino W, Eyraud D, Bismuth H. Transjugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: preliminary report of a prospective study.  Hepatology. 1994;  19 129-132
  • 59 Van der Linden P, Le Moine O, Ghysels M, Ortinez M, Deviere J. Pulmonary hypertension after transjugular intrahepatic portosystemic shunt: effects on right ventricular function.  Hepatology. 1996;  23 982-987
  • 60 Kerlan Jr R K, LaBerge J M, Gordon R L, Ring E J. Transjugular intrahepatic portosystemic shunts: current status.  AJR Am J Roentgenol. 1995;  164 1059-1066
  • 61 Walser E, Ozkan O S, Raza S, Soloway R, Gajula L. Hepatic perfusion as a predictor of mortality after transjugular intrahepatic portosystemic shunt creation in patients with refractory ascites.  J Vasc Interv Radiol. 2003;  14 1251-1257
  • 62 Walser E M, DeLa Pena R, Villanueva-Meyer J, Ozkan O, Soloway R. Hepatic perfusion before and after the transjugular intrahepatic portosystemic shunt procedure: impact on survival.  J Vasc Interv Radiol. 2000;  11 913-918
  • 63 Zipprich A, Steudel N, Behrmann C et al.. Functional significance of hepatic arterial flow reserve in patients with cirrhosis.  Hepatology. 2003;  37 385-392
  • 64 Madoff D C, Wallace M J, Ahrar K, Saxon R R. TIPS-related hepatic encephalopathy: management options with novel endovascular techniques.  Radiographics. 2004;  24 21-36 , discussion 36-37
  • 65 Forauer A R, McLean G K. Transjugular intrahepatic portosystemic shunt constraining stent for the treatment of refractory postprocedural encephalopathy: a simple design utilizing a Palmaz stent and Wallstent.  J Vasc Interv Radiol. 1998;  9 443-446
  • 66 Paz-Fumagalli R, Crain M R, Mewissen M W, Varma R R. Fatal hemodynamic consequences of therapeutic closure of a transjugular intrahepatic portosystemic shunt.  J Vasc Interv Radiol. 1994;  5 831-834
  • 67 Kerlan Jr R K, LaBerge J M, Baker E L et al.. Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts.  J Vasc Interv Radiol. 1995;  6 917-921
  • 68 Haskal Z J, Middlebrook M R. Creation of a stenotic stent to reduce flow through a transjugular intrahepatic portosystemic shunt.  J Vasc Interv Radiol. 1994;  5 827-829 , discussion 829-830
  • 69 Hauenstein K H, Haag K, Ochs A, Langer M, Rossle M. The reducing stent: treatment for transjugular intrahepatic portosystemic shunt-induced refractory hepatic encephalopathy and liver failure.  Radiology. 1995;  194 175-179
  • 70 Madoff D C, Perez-Young I V, Wallace M J, Skolkin M D, Toombs B D. Management of TIPS-related refractory hepatic encephalopathy with reduced Wallgraft endoprostheses.  J Vasc Interv Radiol. 2003;  14 369-374
  • 71 Knautz M A, Abele D C, Reynolds T L. Radiodermatitis after transjugular intrahepatic portosystemic shunt.  South Med J. 1997;  90 352-356

Hector FerralM.D. 

Department of Diagnostic Radiology, Section of Interventional Radiology, Rush University Medical Center

1653 W. Congress Parkway, Chicago, IL 60612