Right heart failure is an absolute contraindication to TIPS, as these patients respond badly to arrival of high-volume portal venous flow directly into their compromised right hearts. Fatal cases of congestive heart failure have occurred. Severe hepatic encephalopa-thy or liver failure is a relative contraindication to TIPS, as the shunt decreases intrahe-patic portal venous flow in most patients, potentially diminishing already compromised function. That being said, TIPS is often performed in this patient population on a "nothing to lose" basis, as it is sometimes the only available therapy for a severely encephalopathic patient who is also bleeding. Whereas untreatable encephalopathy, liver failure, and death sometimes do result, many patients do surprisingly well, and seemingly unsalvageable patients can sometimes be salvaged. Severe coagulopathy caused by liver dysfunction is unfortunately common in this patient population, but is only a relative contraindication to TIPS. The procedure can be performed safely in patients with coagulopathy or thrombocytopenia by careful attention to technique; capsular punctures are to be avoided. Patients who are in DIC at the time of shunt rarely do well. Cavernous transformation of the portal vein can preclude TIPS, but can sometimes be overcome by transhepatic access into an intrahepatic portal vein branch followed by recanalization of the main portal vein via PTA and stent. Although most patients with cavernous transformation are well enough collateralized to avoid sequelae of portal hypertension; those needing shunt should be referred to an experienced operator.

Fig. 1. Portal and hepatic venous anatomy.

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