TIPS evaluation

Dr Yuranga Weerakkody◉ and Dr Matt A. Morgan◉ et al.

TIPS evaluation is useful to ensure that the shunt is working properly and
that no stenosis has occurred within the stent. Ultrasound is often used as a
first-line modality.

Radiographic features
Ultrasound
The normal TIPS should show color Doppler flow throughout its length. The
in-stent velocities are typically higher than in a native portal vein  .
1

Trending stent velocities over multiple exams adds specificity to a single

evaluation. If there is a concern for a stenosis based on a combination of
abnormal findings, venography can be pursued.

Normal
 normal TIPS velocity: 90-190 cm/sec
 normal portal vein velocity before entering the TIPS: ~30 cm/sec
 phasic waveform
 the portal vein branches normally reverse their flow into the shunt

Stenosis
 color Doppler aliasing at the site of the stenosis
 velocity of >190 cm/sec at a stenotic segment
 velocity of <90 cm/sec in nonstenotic segments
 velocity <30 cm/sec in the pre-stent portal vein (accessory sign)
 complete occlusion: lack of color Doppler flow
Always be sure to thoroughly evaluate the hepatic vein distal to the stent as
well.

3D and 4D ultrasound techniques to evaluate TIPS flow volumes are being

developed as a possible improvement over using velocities  . 3

Venography
To be added. If you have some interventional radiology experience and
would like to add to this article, click "Edit Article" above.

Practical points
 when using color Doppler ultrasound for evaluation, remember to take
angle correction into account to avoid false positives; if there is an area of
the TIPS without color flow, make sure the TIPS is not approaching 90
degrees relative to the transducer
 patency of covered TIPS stents is better than bare metal stents and
many centers do not evaluate them on a regular schedule, only when
there is a suspicion for stent failure
 recently placed TIPS stents often contain a small amount of gas in the
wall of the stent, so if a baseline ultrasound exam is desired, consider
waiting a week for the gas to resorb before imaging