TIPS (Transjugular Intrahepatic Portosystemic Shunt)

Introduction

If your doctor has spoken to you about a TIPS procedure, you are likely living with cirrhosis or another condition that has raised the pressure inside the blood vessels of your liver. You may have had a bleed from swollen veins in your food pipe (oesophagus), or you may be dealing with fluid that keeps building up in your belly despite medication. TIPS is one of the treatments doctors turn to when these complications become difficult to control by other means.

TIPS stands for transjugular intrahepatic portosystemic shunt. It is a procedure that creates a new channel inside the liver to lower the pressure in the portal vein, the large vein that carries blood from the digestive organs into the liver. It is done by an interventional radiologist, a doctor trained to perform image-guided procedures through small openings in the skin rather than through traditional surgery.

This article explains what TIPS is, why it is performed, who it may help, what the alternatives look like, how the procedure itself unfolds, and what recovery and long-term follow-up usually involve. It is written for patients who already have a diagnosis and are weighing TIPS as part of their care, or who have already had the procedure and want to understand what comes next.

What Is TIPS?

To understand TIPS, it helps to picture how blood normally moves through the liver. Blood from the stomach, intestines, pancreas, and spleen collects into the portal vein and flows through the liver, where it is filtered before continuing on to the heart. When the liver becomes scarred — most often from cirrhosis — this blood has trouble passing through. Pressure builds up behind the liver in the portal vein. Doctors call this portal hypertension.

High portal pressure pushes blood into smaller veins that are not built to carry it. These veins can swell into varices in the food pipe and stomach, and they can leak fluid into the abdomen (ascites) or the space around the lungs (hepatic hydrothorax). Varices can bleed dangerously. Ascites can be uncomfortable and difficult to manage.

TIPS lowers portal pressure by giving blood a shortcut. The interventional radiologist creates a tunnel inside the liver that connects the portal vein to a nearby hepatic vein, which drains directly toward the heart. A small metal mesh tube called a stent is placed in this tunnel to hold it open. Most TIPS procedures today use a covered stent — a stent lined with a thin layer of fabric — because these stay open longer than older bare-metal stents.

The procedure is called transjugular because the radiologist accesses the liver through the internal jugular vein in the neck, threading instruments down through the heart and into the hepatic veins. It is called intrahepatic because the new channel is created entirely within the liver. And it is called a portosystemic shunt because it shunts blood from the portal system into the systemic (whole-body) circulation, bypassing some of the liver's filtering work.

Why Is TIPS Performed?

TIPS is used to manage complications of portal hypertension when medication and other less invasive treatments are not enough. The main reasons doctors consider TIPS are described below.

Variceal bleeding that cannot be controlled or keeps coming back

Varices in the food pipe or stomach can rupture and bleed. The first-line treatments for variceal bleeding are medications that lower portal pressure and an endoscopic procedure called band ligation, where small rubber bands are placed around the swollen veins to seal them off. When bleeding cannot be stopped by these methods, or when it returns despite them, current guidelines from the American Association for the Study of Liver Diseases (AASLD) and the Baveno consensus support TIPS as the next step.

In some patients with a high risk of rebleeding, doctors may consider an early TIPS — performed within a few days of the first bleed rather than waiting for a second one. The Baveno consensus describes early TIPS as an option for selected patients with advanced liver disease and acute variceal bleeding, and studies have shown lower rebleeding rates and improved survival in this group.

Ascites that does not respond to standard treatment

Ascites is the build-up of fluid in the abdomen. Most patients are managed with a low-sodium diet and water tablets (diuretics such as spironolactone and furosemide). When fluid keeps coming back despite maximum medical treatment, or when diuretics cause side effects that force them to be stopped, doctors call this refractory ascites. The usual options are repeated drainage of the fluid (large-volume paracentesis) or TIPS.

TIPS reduces portal pressure and allows the body to clear ascites more effectively. Many patients need fewer paracenteses after TIPS, and some no longer need them at all. Whether TIPS is the right choice depends on factors such as the severity of liver function impairment, age, and heart function — a discussion that belongs with the treating team.

Hepatic hydrothorax

Sometimes the fluid from portal hypertension travels upward and collects in the chest, around the lungs. This is called hepatic hydrothorax. It causes breathlessness and often requires repeated drainage. TIPS is one of the treatments used when hydrothorax does not respond to diuretics and sodium restriction.

Budd-Chiari syndrome

Budd-Chiari syndrome is a rarer condition where the hepatic veins, which carry blood out of the liver, become blocked. The blocked outflow causes the liver to swell and the portal pressure to rise. TIPS can re-open a path for blood to leave the liver and is one of the treatment options in selected cases.

Other less common indications

TIPS is also considered for portal hypertensive gastropathy with chronic bleeding, hepatorenal syndrome in specific contexts, and as a bridge to liver transplantation for some patients on the waiting list. These uses are evaluated case by case.

Who Is a Candidate?

Not everyone with portal hypertension is a candidate for TIPS. The interventional radiologist and the hepatology (liver) team look at several factors together.

Liver function. TIPS sends blood past the liver instead of through it. This means the liver does less filtering, which can worsen confusion caused by toxins building up in the blood — a condition called hepatic encephalopathy. Patients with very poor liver function may not tolerate this. Doctors use scoring systems such as the Child-Pugh score and the MELD score to estimate the risk. A very high MELD score generally suggests higher procedural risk.

Heart function. After TIPS, more blood returns quickly to the heart. A heart that is already weakened may struggle with this extra load. An echocardiogram (ultrasound of the heart) is usually done before TIPS to check heart function and to look for problems such as right-sided heart failure or pulmonary hypertension.

History of encephalopathy. Patients who have already had episodes of confusion related to liver disease are at higher risk of having more after TIPS. This does not automatically rule out the procedure, but it is weighed carefully.

Other liver findings. Liver cancers in certain positions, widespread tumour, infection in the liver, and severe bile duct obstruction can complicate or prevent TIPS.

Vascular anatomy. The radiologist needs the portal vein to be patent (open). Complete blockage of the portal vein by clot is not an absolute barrier — specialised techniques can sometimes be used — but it changes the difficulty and risk of the procedure.

For older patients and for those with several other medical problems, the decision usually involves a careful balance of benefits against the risk of complications.

TIPS is performed in children with portal hypertension in some specialist centres, but it is much less common than in adults and the technique is adapted to smaller anatomy. Decisions about TIPS in children are made by paediatric hepatology and interventional teams together.

Alternatives to TIPS

Medications

Non-selective beta-blockers such as propranolol, nadolol, and carvedilol lower portal pressure and are widely used to prevent variceal bleeding. Diuretics are the mainstay of ascites management. Octreotide or terlipressin may be used during acute variceal bleeding. These medications often work well and are tried first.

Endoscopic treatments

Variceal band ligation, performed during an endoscopy, is the first-line endoscopic treatment for oesophageal varices. For gastric varices, injection of a glue-like substance (cyanoacrylate) is one approach. Endoscopic treatments can stop active bleeding and reduce the chance of recurrence.

Large-volume paracentesis

For ascites, draining the fluid with a needle every few weeks is a simple and effective approach. Some patients prefer this to TIPS because it does not change the way blood moves through the liver. The trade-off is repeated procedures and, for some, reduced quality of life.

BRTO and related procedures

For certain gastric varices, an interventional radiology technique called balloon-occluded retrograde transvenous obliteration (BRTO) can close off the bleeding vein from the other direction. It is used in selected anatomies and may be combined with or used instead of TIPS.

Surgical shunts

Before TIPS became widely available, surgeons created portosystemic shunts as open operations. These are now rarely done in most centres, but they remain an option in specific cases.

Liver transplantation

For patients whose liver disease has progressed, liver transplantation is the only treatment that addresses the underlying cause rather than its consequences. TIPS does not replace transplantation; in some patients it serves as a bridge while they wait for a donor liver.

Types and Approaches

The basic procedure is similar across patients, but several technical choices shape how it is done.

Covered versus bare-metal stents

Modern TIPS procedures almost always use covered stents — specifically a stent lined with expanded polytetrafluoroethylene (ePTFE). Compared with the older bare-metal stents, covered stents are far less likely to narrow or block over time. Current guidelines from major liver and interventional radiology societies favour covered stents as the standard.

Pre-emptive (early) TIPS

As mentioned above, TIPS performed within the first few days after a variceal bleed in selected high-risk patients is referred to as early or pre-emptive TIPS. This is different from rescue TIPS, which is done when bleeding cannot be stopped in the moment.

Rescue TIPS

When variceal bleeding does not stop despite medication and endoscopic treatment, TIPS may be performed urgently as a rescue procedure. The clinical situation is more challenging, but TIPS can be life-saving in this setting.

Direct intrahepatic portosystemic shunt (DIPS)

In situations where the standard transjugular approach is difficult — for example, when the hepatic veins are blocked — a related technique called DIPS may be used, in which the connection is made directly between the inferior vena cava and the portal vein. This is a specialised variation done in selected centres.

Preparing for TIPS

Preparation begins days or weeks before the procedure, depending on whether it is planned or urgent.

Tests. You can expect blood tests (including liver function, kidney function, clotting, and a full blood count), imaging of the liver and its blood vessels (usually a CT or MRI with contrast, or a Doppler ultrasound), and an echocardiogram. These help the team confirm that TIPS is technically feasible and that your heart and other organs can manage the change in blood flow.

Reviewing your medicines. Tell the team about every medicine you take, including over-the-counter products and herbal preparations. Blood thinners and certain other medicines may need to be paused or adjusted. Diuretic doses may be reviewed.

Fasting. You will usually be asked not to eat for several hours before the procedure. Sips of water for medicines may be allowed; the team will give you specific instructions.

Consent and discussion. The interventional radiologist will explain the procedure, the expected benefits for your specific situation, and the risks. This is a good time to ask about hepatic encephalopathy risk, what the recovery will look like for you, and how follow-up will work.

TIPS is usually done in an interventional radiology suite, a room with specialised imaging equipment.

Anaesthesia. The procedure is often done under deep sedation or general anaesthesia. The choice depends on the centre's practice and your overall condition. You will not feel the procedure.

Access through the neck. Once you are settled and monitored, the radiologist cleans the skin on the right side of the neck and numbs the area. A small needle is used to enter the internal jugular vein. A thin guidewire is passed through the needle, and over this wire a sheath (a short plastic tube) is placed into the vein.

Travelling to the liver. Using X-ray guidance, the radiologist threads catheters (long, thin tubes) down through the superior vena cava, into the right side of the heart, and then into one of the hepatic veins inside the liver.

Creating the channel. From the hepatic vein, a special needle is used to puncture through liver tissue into a branch of the portal vein. This is the most delicate step and is guided by X-ray and sometimes ultrasound imaging.

Measuring the pressure. Once the portal vein is reached, the radiologist measures the pressure difference between the portal and hepatic veins — the portosystemic pressure gradient. This number guides how the procedure proceeds.

Placing the stent. The channel through the liver is widened with a balloon, and the covered stent is then placed across it, holding the new pathway open. Pressure is measured again to confirm that it has dropped to the target range. The aim is generally to bring the gradient down enough to relieve the complication without lowering it so much that encephalopathy becomes very likely.

Treating varices if needed. In some cases, the radiologist will also inject material into specific bleeding varices to close them off (a step called embolisation).

The first day

You will be monitored in a recovery area or a high-dependency unit. The team will watch for bleeding at the neck site, check your vital signs, and look for early signs of complications such as confusion or breathing trouble. A Doppler ultrasound of the liver may be done in the first day or two to confirm that the stent is open and blood is flowing through it as expected.

The first week

Most patients stay in hospital for a few days. The team adjusts your medications — particularly diuretics — based on how your body responds. Some patients notice early relief of ascites and breathing symptoms; for others, the improvement takes longer.

It is common to feel tired during this period. Mild discomfort at the neck access site usually settles within days. You may be advised to avoid heavy lifting for a short time.

The first weeks to months

Ascites and hydrothorax often improve gradually as the body adjusts to the new flow pattern. Diuretics are tapered down as fluid resolves. Body weight and abdominal measurements help the team track progress.

Hepatic encephalopathy — episodes of confusion, sleepiness, or forgetfulness — can appear at any time after TIPS but is most common in the first few months. Many cases are mild and respond well to medications such as lactulose and rifaximin.

Follow-up imaging

The stent is monitored with Doppler ultrasound, usually around two to four weeks after the procedure, then every three to six months for the first year, and at regular intervals afterwards. The schedule depends on the centre. If imaging suggests the stent is narrowing, a follow-up procedure called a TIPS revision may be done to widen it again.

Risks and Complications

Like every procedure, TIPS carries risks. Understanding them helps you and your team plan and respond.

Hepatic encephalopathy

Many episodes are mild and managed with diet adjustments and medications — lactulose, which helps the bowels clear ammonia, and rifaximin, an antibiotic that reduces ammonia-producing bacteria. In a small number of patients, encephalopathy is severe and persistent, and the stent may need to be narrowed deliberately (called shunt reduction) to balance benefit and side effect.

Worsening liver function

Reducing blood flow through the liver can worsen liver function in some patients, especially those whose liver was already very impaired. This is one reason careful candidate selection matters.

Bleeding

Bleeding can occur at the neck access site, inside the liver during channel creation, or from accidental puncture of a nearby vessel or the bile duct. Serious bleeding is uncommon but possible.

Heart strain

The sudden increase in blood returning to the heart can stress an already weakened heart and, rarely, cause heart failure to worsen.

Stent problems

The stent can narrow or block over time. Covered stents are much less prone to this than the older bare-metal stents, but it can still happen and may require revision. Stent migration (movement out of position) is rare.

Infection

Infection of the stent (endotipsitis) is rare but serious. Standard infections of the bloodstream can also occur.

Contrast and radiation

TIPS uses iodine-based contrast and X-ray imaging. Patients with poor kidney function need careful planning to limit kidney strain. Radiation exposure is kept as low as possible.

Procedural mortality

TIPS is performed in patients who are often quite ill. Procedure-related mortality is generally low in elective settings and higher in emergency rescue situations or in patients with severely impaired liver function.

Life After TIPS

For many patients, life after TIPS feels meaningfully better. Ascites that needed regular drainage often subsides. Variceal rebleeding becomes much less likely. Breathing improves when hepatic hydrothorax was the problem. People often feel they have more space in their abdomen and can eat more comfortably.

At the same time, TIPS does not cure cirrhosis. The underlying liver disease continues, and the management of that disease — whether it involves treating viral hepatitis, stopping alcohol use, managing metabolic factors, or planning for transplantation — remains essential.

Medications

You may be on lactulose or rifaximin to reduce the risk or severity of encephalopathy. Diuretics may continue at lower doses. Beta-blockers are sometimes adjusted because the portal pressure is now lower. Your hepatology team will tailor this.

Diet

Most patients can return to a normal diet, with continued attention to salt intake if any residual ascites is present. Protein restriction was once advised after TIPS but is no longer routinely recommended; current practice favours adequate protein intake to maintain muscle mass, which itself helps reduce encephalopathy.

Alcohol

Avoiding alcohol is essential for almost all patients with cirrhosis, regardless of the original cause. Even in non-alcoholic liver disease, alcohol accelerates damage.

Activity

Light activity can usually resume within days. Heavier exercise is reintroduced gradually as you feel ready. Walking is widely encouraged as it helps appetite, sleep, and overall recovery.

Follow-up

Regular follow-up with the hepatology team and periodic Doppler ultrasound of the TIPS are part of ongoing care. Endoscopic surveillance of varices, screening for liver cancer (typically every six months with ultrasound, sometimes with blood tests), and management of any other complications continue as before.

If you are on a transplant pathway

For patients listed for liver transplantation, TIPS is generally compatible with later transplant surgery. The transplant team will be aware of the stent and plan accordingly.

Frequently Asked Questions

How long does the TIPS stent last?

Covered stents stay open in most patients for many years. Some narrow over time and need to be revised, which is usually a simpler procedure than the original TIPS. Regular ultrasound follow-up helps catch problems early.

Will I feel the stent inside me?

No. The stent sits inside the liver tissue and is not felt from outside. There is nothing visible on the surface of the body.

Can TIPS be reversed?

TIPS is not routinely reversed. If the shunt is causing severe encephalopathy, the radiologist can reduce its diameter or close it off, which lowers the amount of blood bypassing the liver.

How soon will my ascites improve?

Some people notice less fluid build-up within days. For others, it takes weeks to months for ascites to subside. Diuretic doses are usually adjusted during this time. If ascites does not improve as expected, the team will check the stent and review other causes.

Can I still have a liver transplant after TIPS?

Yes. TIPS does not prevent transplantation. In fact, for some patients it serves as a bridge during the waiting period.

Is TIPS painful?

The procedure itself is done under sedation or anaesthesia, so it is not felt. Afterwards, the neck access site may be sore for a few days. Significant pain after TIPS is uncommon and should be reported to your team.

Why is hepatic encephalopathy more common after TIPS?

The liver normally filters substances such as ammonia from the blood. When some blood bypasses the liver through the shunt, more of these substances reach the brain, which can cause confusion. The risk varies between patients and is managed with diet, medications, and, occasionally, adjustments to the stent.

Will I need any special precautions when travelling?

Most patients can travel normally once recovered. Carry a summary of your procedure and a list of medications. Long flights are usually safe but discuss with your team if you are within the first few weeks after TIPS or have other risk factors.

What if I have another bleed after TIPS?

Rebleeding after a well-functioning TIPS is much less common than without TIPS, but it can happen. If you notice vomiting of blood, black tarry stools, or sudden weakness, seek emergency care immediately. The team will check whether the stent is still open and whether further treatment is needed.

How is TIPS monitored over the long term?

Doppler ultrasound is the main tool. It looks at the flow speed and direction through the stent. If the ultrasound suggests narrowing, a catheter-based check (venography) may be done and the stent widened if needed.

Conclusion

TIPS is a well-established procedure for managing some of the most difficult complications of portal hypertension. By creating a controlled bypass inside the liver, it lowers the pressure that drives variceal bleeding, ascites, and hepatic hydrothorax. For carefully selected patients, it can bring significant relief and reduce the need for repeated drainage procedures or further bleeding episodes.

TIPS does not treat the underlying liver disease, and it carries real risks — most notably hepatic encephalopathy. The decision to proceed, and the choice between TIPS and other options such as continued medical management, repeated paracentesis, BRTO, or transplantation, is shaped by your specific anatomy, the severity of your liver and heart function, your history of complications, and your goals of care. Your hepatology and interventional radiology team can walk you through how those factors come together in your situation, and what follow-up will look like in the months and years after the procedure.