TIPS procedure/interventional group
AKI, TIPS
Placement of TIPS is an interventional radiological procedure. A central access over the right jugular vein is obtained. Through this central access, the right hepatic vein is catheterized and then a needle is introduced in the hepatic vein. Under fluoroscopic and sonographic guidance, the needle is introduced through the liver parenchyma to the (right) portal vein branch. Once in the portal vein, the puncture tract (between the hepatic vein and the portal vein) is dilated with a balloon and an 8–10-mm controlled-expansion ePTFE (expanded PTFE) covered stent-graft is placed. The TIPS should be placed initially with an 8-mm diameter.A second measurement of the portal pressure gradient should be done after a maximum of 72 h. In this procedure, the portal pressure gradient will be calculated as the difference between the pressure in the main portal vein and in the vena cava inferior at the junction with the hepatic veins. If terlipressin is still being administered by the second measurement, this medication should be paused at least for 6 h before the measurement.The aim is to reduce the pressure to 8–10 mmHg, depending on the clinical characteristics of the patient. In the case of a very high (> 24 mmHg) or very low (< 15 mmHg) initial gradient, the aim would be to reduce the pressure from 25 to 50% [A routine TIPS requires approximately 15–20 min of X-ray fluoroscopy. Different measures (such as reducing the field of exposure, reducing the rate of fluoroscopy) are undertaken to reduce exposure. A second measurement of the portal pressure gradient requires on average approximately 2 min of X-ray fluoroscopy. During the procedure, use of contrast medium should be minimized. Management of patients after TIPS should be done according to local standards; anticoagulation or anti-aggregation is not recommended taking into account the increased risk of these treatments in the context of AKI.