Question: You are asked to see a 55 year old male with diuretic-refractory ascites for TIPS evaluation.  After explaining that the procedure will not extend his life (but may help his quality of life), you perform a workup to determine if he is a good candidate for TIPS.  Which of the following investigations is unnecessary?

A. rule out hepatocellular carcinoma

B. rule out portal vein thrombosis

C. rule out pulmonary hypertension

D. rule out coronary disease

Answer:  Transjugular intrahepatic portosystemic shunting (TIPS) is most often used for refractory variceal bleeding and refractory ascites.  By placing a stent from the hepatic vein to the portal vein, portal pressures are decreased, often with clinical benefit.

It is important to run a checklist to be sure somebody is an optimal candidate; the checklist centers on 3 organs, including liver, heart and brain.  From a liver standpoint, it’s important to exclude HCC, PVT and be sure the bilirubin is not higher than 4.

The brain is also straightforward; be sure the patient has no history of recurrent moderate to severe hepatic encephalopathy.  The shunt will divert more blood from the sinusoids and therefore less detoxification occurs.

Lastly, be sure the heart can withstand the anticipated increased inflow that TIPS will introduce.  Right or left sided CHF, or significant pulmonary hypertension are contraindications.  Coronary disease in itself is not a contraindication as long as the heart is pumping efficiently.

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