🔵 Anesthesia for TIPS (Transjugular Intrahepatic Portosystemic Shunt)

🔷 Overview

• TIPS is a percutaneous, image-guided procedure to create a low-resistance channel between the portal vein and hepatic vein, bypassing the liver sinusoids.
• It is used to reduce portal hypertension and decompress the portal venous system.

🔷 Indications

• Refractory variceal bleeding (most common)
• Refractory ascites
• Hepatorenal syndrome (selected cases)
• Budd-Chiari syndrome
• Portal vein thrombosis (non-occlusive)
• Hepatic hydrothorax

🔶 Goals of Anesthesia

1. Hemodynamic stability
2. Prevention of bleeding
3. Management of hepatic encephalopathy
4. Minimize respiratory depression
5. Avoid worsening of renal function

🔷 Preoperative Assessment

1. Liver Disease Severity

• Child-Pugh and MELD score (MELD >18–20 indicates higher risk)
• Encephalopathy (pre-existing cognitive status)
• Nutritional status, coagulopathy, ascites

2. Cardiac Evaluation

• Echo: rule out high-output cardiac failure or portopulmonary hypertension
• TIPS increases preload → can precipitate cardiac decompensation

3. Renal Function

• Patients often have HRS or pre-renal AKI
• Careful fluid/electrolyte assessment

4. Coagulation Profile

• Platelets, INR, fibrinogen
• TEG/ROTEM preferred

🔷 Anesthesia Technique

🔹 1. Choice of Anesthesia

• MAC (Monitored Anesthesia Care) with sedation: most commonly used
• General Anesthesia (GA): selected cases (difficult airway, long procedure, poor cooperation, severe encephalopathy, aspiration risk)

Sedation agents preferred:

• Midazolam: Use minimal dose due to hepatic encephalopathy risk
• Dexmedetomidine: Good choice (minimal respiratory depression, hemodynamic stability)
• Fentanyl/Remifentanil: Small titrated doses

🔹 2. Airway Considerations

• Many patients have ascites, delayed gastric emptying → aspiration risk
• Consider RSI if GA needed
• Ensure NPO status and premedication with metoclopramide + H2 blocker/PPI

🔹 3. Monitoring

• Standard ASA monitoring
• Invasive arterial BP monitoring
• Central venous access: already obtained via IJ for TIPS catheter
• Capnography essential (especially under sedation)
• TEE if cardiac compromise suspected (in GA cases)

🔷 Intraoperative Management

🔹 1. Hemodynamic Considerations

• Sudden increase in preload after shunt placement can precipitate cardiac failure
• SVR may drop, especially in cirrhotic patients
• Maintain MAP ≥65 mmHg
• Use vasopressors (phenylephrine, norepinephrine) over fluids

🔹 2. Bleeding Risk

• Risk of hepatic vein or portal vein perforation
• Coagulopathy may be present → TEG-guided correction
• Prepare for transfusion if needed

🔹 3. Oxygenation

• Ascites, pleural effusion → decreased FRC
• Avoid oversedation
• Provide supplemental O₂, semi-upright position

🔷 Postoperative Concerns

1. Hepatic Encephalopathy

• Common after TIPS due to shunting of ammonia-rich blood
• Monitor for confusion, altered sensorium
• Lactulose +/- rifaximin in high-risk patients

2. Bleeding or Hemoperitoneum

• Sudden hypotension → suspect vascular perforation
• Imaging, surgical backup may be needed

3. Heart Failure

• Especially in patients with marginal EF or unrecognized cardiomyopathy

4. Respiratory Depression

• Avoid benzodiazepines, monitor closely for CO₂ retention

🔷 Summary Table

🔷 High-Yield Viva/MCQ Points

• TIPS increases preload, thus can unmask latent heart failure.
• Encephalopathy is a common post-TIPS complication.
• Dexmedetomidine is ideal due to minimal respiratory depression.
• Avoid midazolam in high-risk encephalopathy.
• Lactulose prophylaxis may reduce risk of encephalopathy.
• Low albumin and high MELD are predictors of poor outcome post-TIPS.