Diagnostic Ultrasound - Abdomen and Pelvis

Transjugular Intrahepatic Portosystemic Shunt (TIPS)
262
Diagnoses: Liver
HV Occlusion
• Predisposing factors
○ Hypercoagulable states, Budd-Chiari syndrome,
myeloproliferative states, birth control pills, tumor
invasion (especially hepatocellular carcinoma)
• CECT
○ Arterial phase: Normal enhancing caudate lobe, mottled
and reticular enhancement in liver periphery
– Due to congestion and centrilobular necrosis
○ Venous phase: "Flip-flop" with lower attenuation of
caudate lobe and increased density in liver periphery
○ Visualization of thrombi in HV and peridiaphragmatic
collateral veins
IVC Occlusion
• Etiologies
○ Tumor infiltration, hepatocellular carcinoma most
common; rarely metastases
○ Congenital web or band
○ Angiosarcoma of IVC
PATHOLOGY
General Features
• Etiology
○ Stenosis usually secondary to intimal fibroplasia within
HV
– Biliary leak or contamination of shunt may induce
intimal hyperplasia
• Associated abnormalities
○ Hepatic encephalopathy as portal venous flow bypasses
liver
Microscopic Features
• Intimal hyperplasia within areas of TIPS stenosis
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ TIPS malfunction
– Signs of worsening portal hypertension with
increasing ascites
– Variceal hemorrhage
Demographics
• Epidemiology
○ Maintaining TIPS shunt patency is major problem
– Primary patency (no intervention): 1 year = 38-84%
– Secondary (assisted) patency: 1 year = 96-100%
Natural History & Prognosis
• Causes of TIPS failure
○ Technical problems: Malposition, kinks, incomplete
deployment, hepatic perforation with hemoperitoneum,
or bile leak
○ Venous trauma during stent insertion: Usually HV
progresses to fibrosis/stenosis, may result in acute
occlusion of PV
○ Neointimal hyperplasia (ameliorated by covered stents)
○ Thrombosis: Coagulopathy, intercurrent illness due to
above problems
○ Hepatic arterial injury and arteriovenous fistula
http://radiologyebook.com/
○ Gallbladder injury
• Guarded prognosis
○ Maintaining shunt patency
○ Inevitable liver disease progression
○ High risk of cirrhosis-related hepatocellular carcinoma
○ 7-45% 30-day mortality
Indications for TIPS
• Variceal bleeding refractory to sclerosis/banding
• Refractory ascites
• Hepatic hydrothorax
• Budd-Chiari syndrome
• Bridge to liver transplantation
Relative Contraindications for TIPS
• Hepatobiliary or pancreatic malignancy
• Portal venous system thrombosis
• Polycystic liver disease
• Biliary obstruction
• Infectious cholangitis
DIAGNOSTIC CHECKLIST
Consider
• TIPS malfunction on Doppler US
○ If shunt velocity < 90 cm/sec or > 200 cm/sec or PV
velocity < 35 cm/sec
• Low flow difficult to detect with US
○ Confirm occlusion angiographically (CTA, MRA, shunt
venography)
SELECTED REFERENCES
1. Engstrom BI et al: Covered transjugular intrahepatic portosystemic shunts:
accuracy of ultrasound in detecting shunt malfunction. AJR Am J
Roentgenol. 200(4):904-8, 2013
2. Sajja KC et al: Long-term follow-up of TIPS created with expanded polytetrafluoroethylene
covered stents. Dig Dis Sci. 58(7):2100-6, 2013
3. Wu Q et al: Transjugular intrahepatic portosystemic shunt using the
FLUENCY expanded polytetrafluoroethylene-covered stent. Exp Ther Med.
5(1):263-266, 2013
4. Gazzera C et al: Fifteen years' experience with transjugular intrahepatic
portosystemic shunt (TIPS) using bare stents: retrospective review of clinical
and technical aspects. Radiol Med. 114(1):83-94, 2009
5. Kim MJ et al: Technical essentials of hepatic Doppler sonography. Curr Probl
Diagn Radiol. 38(2):53-60, 2009
6. Bauer J et al: The role of TIPS for portal vein patency in liver transplant
patients with portal vein thrombosis. Liver Transpl. 12(10):1544-51, 2006
7. Harrod-Kim P et al: Predictors of early mortality after transjugular
intrahepatic portosystemic shunt creation for the treatment of refractory
ascites. J Vasc Interv Radiol. 17(10):1605-10, 2006
8. Benito A et al: Doppler ultrasound for TIPS: does it work? Abdom Imaging.
29(1):45-52, 2004
9. Middleton WD et al: Doppler evaluation of transjugular intrahepatic
portosystemic shunts. Ultrasound Q. 19(2):56-70; quiz 108 - 10, 2003
10. Bodner G et al: Color and pulsed Doppler ultrasound findings in normally
functioning transjugular intrahepatic portosystemic shunts. Eur J
Ultrasound. 12(2):131-6, 2000
11. Zizka J et al: Value of Doppler sonography in revealing transjugular
intrahepatic portosystemic shunt malfunction: a 5-year experience in 216
patients. AJR Am J Roentgenol. 175(1):141-8, 2000