Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

Table 3 Complications associated with transjugular intrahepatic portosystemic shunt placement and prevention or management strategies

Complication	Prevention/management
Carotid artery puncture during internal jugular vein access	Using ultrasound and fluoroscopic guidance for jugular venous access
Right atrial perforation	Avoid keeping the large 10-F sheath in the right atrium after the procedure
Capsular laceration during wedged hepatic venography	Using closed bag system for CO2 delivery/gentle injection of iodinated contrast
Hepatic capsular transgression or extrahepatic portal venous puncture	Using guidance for portal venous access
Non-target TIPS stent insertion into biliary tract or hepatic artery	Using guidance (USG/IVUS/CBCT) for portal venous access, confirm successful puncture with contrast injection
TIPS stent migration	Careful stent deployement and maintaining wire access across the stent until satisfactory, positioning is confirmed with portal venography, in case retrieval is needed
Early shunt occlusion	Positioning the proximal end of the stent till the hepatico-caval junction; thrombectomy, thrombolysis and restenting can be done for establishing flow
Hernia incarceration	Pre-TIPS hernia repair; alternatively, keeping a high index of suspicion after TIPS and prompt referral to a surgeon for management

CO₂: Carbondioxide; TIPS: transjugular intrahepatic portosystemic shunt; USG: Ultrasonography; IVUS: Intravascular ultrasound; CBCT: Cone beam computed tomography.