1, the pathogenesis of portal hypertension Portal hypertension (PHT) is the result of increased pressure in the portal vein and its branches due to poor blood flow and increased blood flow in the portal venous system, the hemodynamic changes of PHT include: (1) increased resistance of the outflow portal vessels, forming a portal collateral circulation; (2) increased systemic blood volume, dilatation of visceral vessels and peripheral vessels, etc. . Cirrhosis accounts for 80% to 90% of the causes of portal hypertension, mainly alcoholic cirrhosis in the West and hepatitis-induced cirrhosis in our country. Chronic schistosomiasis cirrhosis and splenomegaly can also lead to portal hypertension. pHT can cause serious consequences, such as upper gastrointestinal bleeding due to esophagogastric fundic varices, which can be fatal. Further development leads to hypersplenism and intractable ascites. Reduction of portal hypertension and proper management of various complications are the main objectives of treatment. Clinically applied treatment methods include surgical treatment, interventional radiotherapy, endoscopic ligation and drug sclerotherapy and in situ liver transplantation. Dissection and shunt and combined surgery are the main measures to treat the complications of portal hypertension because of their effectiveness in controlling bleeding. Minimally invasive treatment is preferred for those who have significant liver function impairment and cannot tolerate surgery and trauma due to anesthesia. The establishment of intrahepatic shunts through interventional radiological techniques and embolization of coronary veins or fundic varices to prevent and treat esophagogastric variceal bleeding are particularly widely used in clinical practice. This article describes the role of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in cirrhosis and its recent progress. 2. Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) In 1988, the Transjugular Intrahepatic Portosystemic Stent Shunt (TIPSS) technique was formally applied to clinical practice at the University of Freiburg, Germany, and was successful. After more than 20 years of clinical application and technical improvement, it has become a reliable treatment for ruptured esophageal variceal bleeding caused by PHT. 2.1 Indications and contraindications for TIPSS 2.1.1 The indications for TIPSS are: ① acute or recurrent ruptured esophagogastric variceal bleeding, the hemostasis rate of TIPSS for this condition is over 90%, and the rebleeding rate and mortality rate are significantly reduced; ② patients for whom other non-surgical treatments are ineffective and patients with liver function Child B or C grade who are not suitable for other surgeries; ③ recalcitrant ascites or pleural fluid. ④hepatorenal syndrome; ⑤Budd-Chiari syndrome; ⑥pre-operative preparation for liver transplantation. 2.1.2 Contraindications to TIPSS: ① relative contraindications: sepsis, portal vein thrombosis or cancer thrombosis, severe chronic obstructive pulmonary disease, portal hypertension due to hepatic artery-portal fistula, etc.; ② absolute contraindications: cardiac insufficiency, renal failure, advanced hepatic failure, hepatic cystic disease, portal spongiform degeneration, hepatocellular carcinoma near the 1st and 2nd hepatic hilum, advanced hepatic encephalopathy, etc. 2.2 Methods of TIPSS The Seldinger method and the Richter method are commonly used, and only the method of Richter, a German scholar, is introduced here. Preoperatively, the patient should be examined by CT and MRI to identify the spatial relationship between the hepatic vein and portal vein and to improve the patient’s nutritional status. The right internal jugular vein is punctured, and Rups-100 is delivered into the right hepatic vein via the internal jugular vein, superior vena cava, right atrium, and inferior vena cava under the guidance of a guidewire. The right hepatic vein or the inferior vena cava of the hepatic segment is selected by ultrasound guidance as the starting point of the puncture, and the right or left branch of the portal vein is punctured toward the portal vein to reduce blind puncture and injury. After confirming that the portal vein is penetrated, a 0.035inch hydrophilic membrane guidewire is sent through the cannula to the splenic vein or superior mesenteric vein, a 5F straight lateral port catheter is used for direct portal venography and pressure measurement, and then the four parts of the Rups-100 are pushed along the guidewire into the splenic vein or superior mesenteric vein. The location of the puncture point can be observed by contrast after puncturing the portal vein. The puncture tract is dilated with an 8-10 mm/6 cm balloon, and the direct shunt tract is examined by contrast for contrast spillage or traffic with the bile duct, and a metal endoprosthesis of 8-10 mm diameter is placed. The placement of the stent must completely cover the hepatic parenchymal channel, and the channel must not be at an angle to the hepatic vein. Again direct portal venography and manometry are performed. The criteria for successful surgery are: the portal pressure is reduced by 10-20 cmH2O compared with the preoperative pressure, and the pressure difference between the two veins of the shunt channel is optimally 1.6 kPa. 2.3 Efficacy of TIPSS TIPSS is a minimally invasive treatment, which plays the dual role of shunt plus dissection and can effectively prevent bleeding due to re-rupture of the variceal vein. after the TIPSS channel is established, it can reduce the portal pressure and partially improve After the establishment of TIPSS channel, it can reduce the portal pressure and partially improve the renal function, which has double clinical significance in controlling refractory ascites. The patient’s blood cell and platelet counts were elevated. Liver function child-Pugh grade C and severe cirrhotic shrinkage of the liver affect the success rate of surgery and have poor outcome. Stent access stenosis or occlusion and hepatic encephalopathy are two major complications after TIPS, which also affect the medium and long-term outcome of TIPS. Stent stenosis or occlusion may be related to stent angulation with hepatic vein, local bile leakage irritation, intra-stent blood flow impact, and stent overlength. Stent restenosis can recur with bleeding, and regular follow-up should be performed after surgery for early detection, and most patients can maintain patency through re-intervention. 2.4 New technical advances in TIPSS 2.4.1 Application of Viatorr stent The TIPSS technique combines the advantages of restrictive shunt plus flow dissection to establish an effective intrahepatic portal shunt tract, reduce portal vein pressure, and provide significant short-term relief of portal hypertension, but stent stenosis, blockage, or displacement, and these complications seriously affect the medium- and long-term efficacy of TIPS. Early shunt obstruction is associated with acute thrombosis in the shunt and incomplete deployment of the internal support, while late shunt stenosis and obstruction may be due to high intimal hyperplasia of the shunt. In order to improve the mid- and long-term outcomes of TIPS, a number of clinical centers in China and abroad have conducted extensive studies on the operative techniques and new stent materials. The new expanded polytetrafluoroethylene (ePTFE) overlay stent, the Viatorr stent, has a self-expanding function and better anastomosis with the vessel. It has a 2 cm bare area at the portal vein end, and the parenchymal part and the hepatic vein end are covered with ePTFE, so that the portal vein blood flow into the liver is not blocked after TIPSS, and the covered part can isolate the hepatic parenchyma and prevent the pseudo-endothelial hyperplasia caused by bile overflow. Christophe Bureau et al. demonstrated that the patency rate at 2 years was 76% and 36% (P=0.001) in the overmolded stent group and bare stent group, respectively, and no hepatic encephalopathy occurred. The rates of 67% and 51% (P < 0.05), recurrence of clinical symptoms 10% and 29% (P < 0.05), and mortality 58% and 45% (P < 0.05), respectively, were statistically significant. The widespread use of the new TIPS overlay stent significantly improved the patency rate of the shunt, reduced the incidence of bleeding and ascites, and the incidence of hepatic encephalopathy was also reduced or not increased compared with the traditional stent, reducing postoperative monitoring and re-intervention, improving the medium and long-term efficacy efficacy and economic ratio, and has a better prospect of application. 2.4.2 Improvement of puncture technique The application of CT and MR vascular three-dimensional reconstruction technology shows the anatomy and variation of hepatic and portal veins, the distance and angle between vessels, and identifies the adjacent relationship of liver tissues, which provides an important basis for surgery and avoids unnecessary injury. The use of direct puncture of portal branches through the inferior vena cava of the hepatic segment, which creates a short and straight shunt, can solve the problem of stent angulation. Analysis of some data shows that the stent stenosis rate in the group with portal vein puncture through the inferior vena cava of the hepatic segment is lower than that in the group with portal vein puncture through the right hepatic vein. 2.4.3 Stent diameter selection Portal-body shunt hepatic encephalopathy is another common complication of TIPSS, and a moderate shunt is a key factor to reduce the occurrence of such complications. Domestic and foreign studies have shown that 8mm diameter overlapping stent can not only achieve shunt effect but also avoid the occurrence of hepatic encephalopathy, the incidence of which is 5%~10%, the incidence of hepatic encephalopathy of bare stent and 10mm diameter overlapping stent is about 20%~30%, Yang has shown that the use of 8mm diameter Fluency self-expanding overlapping stent can not only maintain certain shunt flow but also avoid the occurrence of hepatic encephalopathy caused by large shunt flow. The incidence of hepatic encephalopathy can be avoided. 2.5 TIPSS combined with coronary vein embolization Although pure percutaneous transhepatic portal vein puncture with coronary vein embolization (PTVE) can effectively control hemorrhage from esophageal varices, the recurrence rate of bleeding within a short period of time is as high as 35%-65%, and there is a risk of abdominal bleeding and ectopic embolism, so it is rarely used alone in clinical practice. Tesdal et al. prospectively compared 95 patients with portal hypertension treated with TIPS and TIPS plus coronary vein embolization, respectively, with a follow-up of (48.7±37.8) months, and TIPS and TIPS plus coronary vein embolization had a better hemostatic effect than PTVE alone. The bleeding-free rates at 2 and 4 years after coronary vein embolization were 61% and 53% and 84% and 81%, respectively. TIPS combined with variceal coronary vein embolization can reduce the occurrence of gastrointestinal rebleeding, increase portal blood flow, increase hepatic perfusion, improve liver function, reduce the caliber of intrahepatic shunt, reduce the occurrence of hepatic encephalopathy, and help prevent stent stenosis and portal vein thrombosis, and improve clinical efficacy. In conclusion, TIPSS has become a common interventional treatment for portal hypertension with its small trauma and satisfactory efficacy. Clinical application should reasonably choose the procedure, improve the operation method, select advanced endoprosthesis materials, and minimize complications. At the same time, molecular biology and clinical research should be effectively combined to give full play to its clinical treatment advantages and usher in a new era of TIPSS treatment.