An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm

Transjugular intrahepatic portosystemic shunts (TIPS) have evolved as an effective and durable nonsurgical option in the treatment of portal hypertension (PH). It has been shown to improve survival in decompensated cirrhosis and may also serve as a bridge to liver transplantation. In spite of the technical improvements in the procedure, problems occur with the shunt which jeopardizes effective treatment of the PH. Appropriate management is vital to ensure the longevity of the conduit. Shunt revision techniques include endovascular revision techniques and new shunt creation or, in the appropriate patients, alternative/rescue therapies. The ability of interventional radiologists to restore adequate TIPS function has enormous implications for quality of life with palliation, morbidity/mortality related to variceal bleeding and survival if transplant candidates can live long enough to receive a new liver. As such, it is imperative that these treatment strategies are understood and employed when these patients are encountered. In this review, the restoration of appropriate shunt function using various techniques will be discussed as they apply to a variety of clinical scenarios, based on literature. In addition, illustrative case examples highlighting our experience at an academic tertiary medical center will be included. It is the intent to have this document serve as a concise and informative reference to be used by those who may encounter patients with suboptimal functioning TIPS.