TIPS for Portal Hypertension, BRTO and Transplant Rescue

Interventional radiology treats portal hypertension and its complications through the veins and arteries rather than by open surgery. The core procedures are a transjugular liver biopsy and pressure measurement for diagnosis, stents and balloons for Budd-Chiari syndrome, BRTO or PARTO for bleeding gastric varices, TIPS for portal hypertension that endoscopy or medication cannot control, and catheter-based rescue when a transplanted liver loses its blood supply.

Dr. Shobhit Singh, Consultant - Intervention Radiologist - Gastroenterology & Hepatology, BLK-Max Super Speciality Hospital, New Delhi, India, works alongside a liver transplant and gastroenterology team, and these vascular procedures are a routine part of that work. This article follows the sequence he presented, from diagnosis to transplant rescue. The oncology side of his practice is covered in the complete guide to hepatobiliary interventional radiology.

Transjugular liver biopsy: when a standard biopsy is unsafe

A transjugular liver biopsy samples the liver from inside its veins, so any bleeding stays within the circulation. It is the alternative when a standard needle biopsy through the skin would be too risky.

For most liver diagnoses, such as confirming cirrhosis or characterising a tumour other than HCC, a percutaneous biopsy is standard: a needle is passed through the skin into the liver, a core of tissue is taken and the needle is withdrawn. Hepatocellular carcinoma itself is generally diagnosed on imaging without a biopsy.

Patients with chronic liver disease (CLD) often cannot have a percutaneous biopsy. They may have coagulopathy, meaning a high INR or a low platelet count, ascites in the abdomen, or be taking anticoagulants. Any of these makes bleeding after a needle puncture through the liver capsule dangerous.

How a transjugular biopsy is done

1. Under ultrasound guidance, the internal jugular vein in the neck is cannulated, just as for a central line.
2. A catheter is passed down through the superior vena cava (SVC), across the right side of the heart, into the inferior vena cava (IVC) and then into a hepatic vein.
3. A biopsy needle is advanced through the catheter, and multiple samples are taken from within the liver, using ultrasound and fluoroscopy together.

Because the samples are taken from inside the hepatic vein, any bleeding drains into the systemic circulation rather than out of the liver into the peritoneal cavity.

If the jugular veins are not patent, or the IVC is narrowed, the same procedure can be performed from the femoral vein in the groin. In one of Dr. Singh's patients, who already had an IVC stent, the catheter was passed through the struts of the stent to reach the liver and take samples.

HVPG: measuring portal pressure

The hepatic venous pressure gradient (HVPG) is an indirect measurement of the pressure in the portal vein, and it can be measured in the same sitting as a transjugular biopsy.

A catheter with a balloon at its tip is guided through the jugular vein and SVC into a hepatic vein. With the balloon inflated, the catheter records the wedged hepatic venous pressure, which reflects portal pressure; with it deflated, it records the free hepatic venous pressure. The difference between the two is the HVPG. The same catheter can also measure the pressure in the IVC, the right atrium and even the pulmonary artery, which helps to place the patient within the classification of portal hypertension.

What the HVPG values mean

• 5 mmHg or less: normal.
• Above 5 mmHg: portal hypertension.
• 10 mmHg or more: clinically significant portal hypertension, which predicts decompensation.
• Above 12 mmHg: the level at which complications such as ascites and variceal bleeding mostly occur.

Measuring HVPG identifies patients at risk earlier, before those complications appear.

Budd-Chiari syndrome

Budd-Chiari syndrome is an obstruction of the hepatic venous outflow tract: blood cannot leave the liver normally. The blockage can sit at the level of the inferior vena cava, at the hepatic veins, or further along the outflow.

Treatment depends on the level:

• IVC narrowing. Through the jugular or femoral route, a wire is passed across the narrowing, which is then dilated with a balloon (angioplasty) or held open with a stent.
• Hepatic vein obstruction. The same approach of balloon angioplasty or stenting is used.
• When reopening the vein is not feasible. A TIPS is created, or a direct intrahepatic portosystemic shunt (DIPS), which connects the portal vein directly to the IVC.

Surgical mesocaval or mesoatrial shunts were more commonly performed in the past and are still done, but interventional procedures are increasingly taking over because they are minimally invasive.

Case: hepatic vein stenosis after transplant

One post-transplant patient developed hepatic vein stenosis. Through the jugular route, contrast injected into the hepatic vein failed to pass into the IVC. A wire was placed across the narrowing, a stent was deployed and balloon angioplasty expanded it. The final run showed contrast flowing freely out of the liver, and the hepatic venous velocity on ultrasound increased.

Bleeding gastric varices: BRTO and PARTO

In a cirrhotic patient with portal hypertension, veins in the oesophagus and stomach become engorged with blood, and if the pressure keeps rising they can rupture and bleed. Oesophageal varices are generally managed endoscopically with band ligation, and gastric varices with glue injection.

When endoscopy fails, interventional radiology offers retrograde transvenous obliteration: balloon-occluded (BRTO), plug-assisted (PARTO) or coil-assisted (CARTO). The procedure closes the abnormal venous channels opened up by portal hypertension.

Benefits

• It controls and prevents life-threatening bleeding.
• It maintains, and can improve, liver function.
• Compared with TIPS, it does not increase the risk of hepatic encephalopathy (confusion caused by toxins the liver no longer clears).
• Compared with TIPS, it carries a lower risk of rebleeding.

Risks

Closing the shunt raises pressure elsewhere in the portal system. Afterwards, oesophageal varices can worsen and ascites can increase, so patients must be selected carefully. In some, portal hypertension rises further and a TIPS is eventually needed.

Dr. Singh's priority is BRTO or PARTO first; if the patient is not a candidate, portal pressure is reduced with a TIPS. Current guidance (AASLD 2024) treats TIPS and BRTO as alternatives for gastric variceal bleeding, with the choice depending on the patient's venous anatomy and liver function.

Case: closing a splenorenal shunt

One patient had multiple large spontaneous splenorenal (lienorenal) shunts feeding gastric varices. The team went from the IVC into the renal vein, mapped the shunt with contrast and placed a metal plug that blocked it. With the shunt closed, the gastric varices collapsed and bleeding was prevented. Another patient was treated the same way, with a plug obliterating the gastric varices. After the procedure, portal flow to the liver generally increases, which is a sign that it has succeeded.

TIPS for portal hypertension: the transjugular intrahepatic portosystemic shunt

A TIPS lowers portal pressure by creating a stent-lined channel inside the liver between the high-pressure portal vein and a low-pressure hepatic vein. Dr. Singh performs it for patients whose ascites, or oesophageal or gastric varices, are not controlled by endoscopy or medication.

How a TIPS is created

1. Through the jugular vein, the catheter passes into the IVC and then into a hepatic vein.
2. A needle is passed from the hepatic vein through the liver tissue into the portal vein, and contrast confirms the position.
3. The tract is dilated with a balloon.
4. A stent is placed between the hepatic vein and the portal vein.

The stent acts as a tunnel between the portal and systemic circulations. Blood that could not enter the liver because of high pressure now flows through the stent into the IVC and the heart. Portal pressure falls, and the oesophageal or gastric varices and the ascites reduce. In Dr. Singh's summary, a TIPS connects high pressure to low pressure through a stent; CT after the procedure shows the stent bridging the portal vein and the hepatic vein.

Vascular complications after liver transplant

A transplanted liver depends on its new blood vessels. When the hepatic artery bleeds or clots after surgery, interventional radiology can often save the graft without reoperation.

Pseudoaneurysm

A pseudoaneurysm is a leak from an artery contained by surrounding tissue, which can rupture and bleed. In one post-transplant patient, CT showed a contrast-filled outpouching consistent with active arterial bleeding, and Doppler ultrasound showed the yin-yang sign, the swirling, turbulent flow typical of a pseudoaneurysm. Angiography of the hepatic artery confirmed contrast escaping from the same site.

The options are glue, gel foam particles or coils (see the DSA and embolisation cost guide), chosen according to feasibility and how much of the artery must be preserved. In this case the team selectively injected glue. Another option is to place coils on both sides of the pseudoaneurysm (the front door and back door) to exclude it completely.

Hepatic artery thrombosis

In another patient, the hepatic artery showed no flow two to three days after transplant. CT showed the common hepatic artery stopping short of the liver, and angiography from the femoral artery confirmed complete occlusion: no contrast reached the liver.

The team infused alteplase, a tissue plasminogen activator that dissolves clot. Flow returned but only slowly. To augment it, they performed proximal splenic artery embolisation, so that blood previously diverted to the spleen went to the liver instead. Contrast then flowed freely into the liver, the hepatic artery was patent, and the hepatic arterial flow had increased further.

In a third patient, with a fully thrombosed hepatic artery, alteplase restored flow within 30 minutes to an hour, and the graft was saved.

Why the spleen matters

The spleen and the liver draw their arterial blood from the same source, the coeliac trunk. If splenic flow is high, the arterial supply to the liver falls; this diversion is known as splenic artery steal. To augment hepatic arterial flow, the spleen sometimes has to be compromised: Dr. Singh's team often performs partial splenic embolisation so that more blood is diverted to the liver, and arterial velocity in the graft rises afterwards.

When to refer for portal hypertension and transplant complications

For a referring physician, the message of this part of the session is that cirrhosis, portal hypertension and transplant complications have catheter-based options that are less invasive than surgery: a safe tissue diagnosis despite coagulopathy, a pressure measurement that predicts decompensation, endoscopy-failure options for variceal bleeding, and rescue of a failing graft. The liver transplant cost guide and the hepatobiliary and liver transplant specialty page cover the transplant pathway itself. For tumour treatments in the same patients, see TACE and TARE for liver cancer. The audience's questions are answered on the live discussion page, and specialists who perform these procedures are listed under interventional radiology.