A patient with cirrhosis and refractory hepatic hydrothorax not controlled by diuretics or thoracentesis is referred for TIPS (transjugular intrahepatic portosystemic shunt). Which absolute contraindication to TIPS should be excluded before the procedure?

• A Polycystic liver disease with multiple cysts near the hepatic veins ✓
• B Mild hepatic encephalopathy (grade I–II)
• C Serum bilirubin >5 mg/dL (severe hepatic dysfunction)
• D Portal hypertension with gastric varices

Explanation

Absolute contraindications to TIPS include: right heart failure or elevated right heart pressures (cannot tolerate increased venous return), severe hepatic failure (Child-Pugh C with bilirubin >5 mg/dL, INR >5 — relative contraindication, not absolute), uncontrolled systemic infection or biliary sepsis, severe tricuspid regurgitation, and polycystic liver disease where multiple cysts make needle passage and stent placement technically impossible or highly dangerous. Mild encephalopathy is a relative contraindication (TIPS worsens encephalopathy). Portal hypertension with gastric varices is actually an indication for TIPS. Bilirubin >5 is a relative but important contraindication, not absolute per all guidelines.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.