TIPS (TIPSS) procedure for the liver: what it is, how it is done and the risks

In advanced liver disease, scarring makes it harder for blood to flow through the liver. Pressure rises in the portal vein, the large vessel that brings blood from the gut to the liver. This is portal hypertension. Blood looks for other ways back to the heart, which can produce fragile enlarged veins in the gullet and stomach (varices) and fluid in the abdomen (ascites).

A TIPS gives that blood an easier route. Chelsea and Westminster Hospital explains the name: trans-jugular means through the neck, intrahepatic means inside the liver, portosystemic means between the portal vein and the hepatic vein, and shunt refers to the metal stent that forms the channel. The shunt stays in place permanently.

It is carried out by an interventional radiologist, a doctor trained to use X-ray and imaging guidance to treat conditions from inside the blood vessels. Some trusts use the spelling TIPSS, with the extra S standing for shunt.

The two main reasons are bleeding from varices and ascites that keeps returning. Leeds says most patients will have had several other treatments first, such as injecting glue or placing elastic bands on varices through an endoscope for bleeding, and water tablets or repeated drainage of fluid (paracentesis) for ascites. If bleeding cannot be controlled by endoscopy, an emergency TIPSS may be needed.

The same leaflet says that on rare occasions a TIPSS may be considered for people with Budd-Chiari syndrome, or who have had a liver transplant, when portal pressure is raised. The decision rests with the liver team, who will go through the likely benefits and the risks with you.

Open surgical shunts exist, but Leeds describes them as comparatively riskier and more invasive than a TIPSS.

Leeds says a TIPSS is normally done under general anaesthetic, while Chelsea and Westminster says local anaesthetic with sedation is used when general anaesthetic is not, so the approach varies between hospitals and patients. In both cases the skin over the side of the neck is cleaned and a thin catheter is placed in the jugular vein.

Under X-ray guidance the catheter is guided into a hepatic vein. A needle then makes a track through liver tissue to the portal vein. The track is widened with a balloon and held open with a stent. Leeds describes this as a fabric tube with a metal scaffold, called a stent-graft, that is left permanently in the liver.

The leaflets give different durations: about 2 to 3 hours at Leeds, and about two hours but possibly longer at Chelsea and Westminster. Preparation includes blood tests, a period of fasting (Leeds says at least six hours, with clear fluids allowed until two hours before) and review of any blood-thinning medicines.

Both Leeds and Plymouth describe the overall chance of major complications as low, at 1 to 2%. The main risk named by Plymouth is bleeding, which may need a transfusion or, rarely, a further X-ray guided procedure. Chelsea and Westminster mentions a bruise at the neck entry site and, rarely, damage to the vein or bleeding from the liver where the shunt sits.

The effect that patients most often ask about is confusion. Leeds explains that blood from the bowel then bypasses the liver and chemicals that would normally be filtered can affect brain function. It says about 1 in 10 patients show signs of confusion, which can be treated by changing diet and medicines, but that in about 1% of cases these measures do not work. Plymouth adds that a further procedure to reduce the flow or block the shunt may then be needed.

• Shortness of breath after the procedure, which Plymouth and Leeds say can be treated with a short course of water tablets.

• Passing more urine for the first 24 to 48 hours when the TIPSS was placed for ascites, which the leaflets describe as a sign it is working.

• Worsening liver function, usually temporary but occasionally serious. Leeds puts liver failure at about 1% of patients.

• Infection or sepsis, and in rare cases injury to the bile ducts.

• Reactions to the X-ray contrast dye, and a small radiation exposure which the leaflets say is outweighed by the expected benefit.

Chelsea and Westminster says people are asked to rest in bed for four hours and can then eat and drink. Leeds says most people go home after 2 to 3 days, are advised to limit activity and introduce light exercise after a week, to take around 10 to 14 days off work, and not to drive for at least 72 hours.

The stent is monitored because it can narrow over time. Leeds arranges a scan of the TIPSS at 6 and 12 months and says that around three-quarters of people with a TIPSS may need a balloon procedure to stretch it at some point in their lives. Chelsea and Westminster likewise notes that the shunt may narrow or block and the procedure may need to be repeated, so regular follow-up is important.

A TIPS treats the pressure problem, not the underlying liver disease, so your liver team will continue to manage that alongside it.

It helps to ask how likely confusion is in your own case, and what will be done if it occurs. It is also reasonable to ask which other options have been tried, whether a liver transplant assessment is relevant, and who you should contact if your belly swells again or you start vomiting blood. Vomiting blood or passing black stools is an emergency, and calls for 999 or A&E.

The leaflets are written for patients of NHS liver units and interventional radiology departments, and the referral comes from the doctor looking after your liver disease. Leeds notes that if you live away from the hospital that did the procedure, the follow-up scans can be done at your local hospital, so ask at the time of referral where each stage will take place.