1 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, and after more than 20 years of clinical application and After more than 20 years of clinical application and technical improvement, it has become a reliable treatment for ruptured esophageal variceal bleeding due to PHT. Indications and contraindications for TIPSS The indications for TIPSS are: ① acute or recurrent ruptured esophagogastric variceal bleeding, for which TIPSS has a hemostasis rate of more than 90% and significantly reduces the rate of rebleeding and mortality; ② patients for whom other non-surgical treatments are ineffective and patients with liver function Child B or C who are not suitable for other surgeries; ③ intractable ascites or pleural fluid; ④ hepatorenal syndrome; ⑤ Budd-Chiari syndrome; ⑥Pre-operative preparation for liver transplantation. 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. Methods of TIPSS The Seldinger method and the Richter method are commonly used, and here we only introduce the method of Richter, a German scholar. 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, and a 5F straight lateral port catheter is used to perform direct portal venography and pressure measurement, and then the four parts of the Rups-100 are pushed along the guidewire into the splenic 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 the success of the procedure are: the portal pressure is reduced by 10-20 cmH2O compared to the preoperative pressure, and the pressure difference between the two veins of the shunt channel is optimally 1.6 kPa. Efficacy of TIPSS TIPSS is a minimally invasive treatment that plays the dual role of shunt plus dissection and can effectively prevent bleeding due to re-rupture of the variceal vein. after the establishment of the TIPSS channel, it can reduce the portal pressure and partially improve the renal function, which has a dual effect on control refractory ascites has dual clinical significance. 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, blood flow impingement in the stent, and stent overlength. Stent restenosis can recur bleeding and should be followed up regularly after surgery for early detection, and most patients can maintain patency by re-intervention. New technical advances in TIPSS 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 venous 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 application prospect. 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, providing an important basis for surgery and avoiding unnecessary injuries. 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. 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. The incidence of hepatic encephalopathy is 5%-10%, and the incidence of hepatic encephalopathy is about 20%-30% for bare stent and 10 mm diameter stent. The incidence of hepatic encephalopathy can be avoided by using 8 mm diameter Fluency self-expanding overlapping stent. TIPSS combined with coronary vein embolization Although percutaneous transhepatic portal vein puncture with coronary vein embolization (PTVE) alone can effectively control hemorrhage from esophageal varices, the recurrence rate of bleeding within a short period of time is as high as 35% to 65%, and there are risks of abdominal bleeding and ectopic embolism, so it is rarely used alone. 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 the hemostatic effect was better than that of PTVE alone after TIPS and TIPS plus coronary vein embolization The 2- and 4-year bleed-free rates 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 shunts, reduce the occurrence of hepatic encephalopathy, and help prevent stent stenosis and portal vein thrombosis, and improve clinical efficacy. In summary, TIPSS, with its less invasive and satisfactory? s efficacy, TIPSS has become a common interventional treatment for portal hypertension, and the clinical application should reasonably choose the procedure, perfect the operation method, choose advanced internal stent materials, and minimize complications.