Portal hypertension is an important pathophysiologic link in the development of cirrhosis and one of the important clinical manifestations of the decompensated stage of cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is one of the key measures to reduce portal pressure in patients with cirrhosis by creating a shunt tract within the liver parenchyma between the hepatic vein and the portal vein in a minimally invasive way, which significantly reduces the portal resistance from the structural point of view. Selection of appropriate cases can effectively reduce complications of cirrhosis such as rebleeding of esophagogastric varices and recurrence of ascites, improve the quality of life of cirrhotic patients, and reduce or delay the need for liver transplantation. TIPS has been used in clinic for more than 20 years, after a series of concepts, techniques, equipment and combined drug therapy exploration, the effectiveness and safety of this technology is maturing, and the patients are obviously benefited in survival time and quality, which is widely recognized by domestic and foreign counterparts. Over the past 5 years, the annual implementation of TIPS in China has exceeded I000 cases, and in 2013, the Gastroenterology Interventional Group of the Chinese Medical Association invited some domestic experts in related disciplines to reach the following consensus on the treatment of cirrhosis and portal hypertension with TIPS, which is aimed at helping more clinicians to rationally apply this minimally invasive procedure in the treatment of cirrhosis and portal hypertension. I. Indications of TIPS (I) Esophagogastric varices rupture and bleeding (EGVB) The incidence of esophagogastric varices in patients with liver cirrhosis is about 30%-70%, and within 1 year after the discovery of definite esophagogastric varices, about 30% of the patients have the risk of EGVB. 1. Acute EGVB: The patient mortality rate is about 20% within 6 weeks, and resuscitative treatment is required for fatal hemorrhage. On the basis of maintaining airway patency and blood circulation stabilization, according to the conditions of each hospital, we consider: ① remedial TIPS, which is the second-line solution for the failure of drug combined with endoscopic treatment; ② early TIPS, i.e., TIPS as the first-line solution for resuscitation within 72h after massive bleeding. Early TIPS has a hemostatic success rate of >95%, which is more effective in controlling fatal hemorrhage and reducing rebleeding than drug-combined endoscopic therapy, reduces intensive care and hospitalization time, and significantly improves patient survival. Patients with cirrhosis Child-Pugh class C, but with a score <13, may benefit more from early tips. < p=""> 2. EGVB secondary prophylaxis: After acute EGVB cessation, patients are at high risk of rebleeding and death. In untreated patients, the average rebleeding rate is 60% within 1-2 years and the mortality rate can be 33%, thus all patients recovering from acute bleeding should receive secondary prophylaxis. Although the rebleeding rate of varicose veins after TIPS (9.0%-40.6%) is significantly lower than that of pharmacologic and endoscopic treatments (20.5%-60.6%), due to the lack of sufficient data from clinical studies on the survival rate of TIPS in recent years, pharmacologic and endoscopic treatments are still the first choice of secondary prophylaxis, and TIPS is the second-line option. (ii) Refractory ascites The average survival of patients with refractory ascites is about 6 months.TIPS is the first-line treatment for refractory ascites, which not only reduces portal pressure and relieves ascites, but also improves urinary sodium excretion and renal function.TIPS relieves ascites and improves the survival rate, which is superior to peritoneal puncture and drainage. (iii) Refractory hepatic pleural effusion TIPS relieves refractory hepatic pleural effusion and reduces the need for thoracentesis, but the effect on survival is unclear. Due to the lack of effective measures for refractory hepatic pleural effusion, TIPS is still considered an important treatment for refractory hepatic pleural effusion. (iv) Hepatorenal syndrome (HRS) The median survival time for HRS is only 3 months, including I month for untreated type I. TIPS may improve renal function by increasing renal perfusion and may improve survival in patients with type 2 HRS. (v) Buga’s syndrome (BCS) BCS is posthepatic portal hypertension caused by obstructive lesions of the hepatic venous outflow tracts and the inferior vena cava in the posterior segment of the liver from a variety of causes. Short-range occlusion of the hepatic vein or inferior vena cava, with a high rate of long-term patency by balloon dilatation or combined stent implantation, generally does not require TIPS.TIPS establishes an artificial shunt channel through the portal vascular bed to reduce portal pressure and improve hepatic stasis and hepatic function, which is suitable for patients who have failed to undergo medical treatment or angioplasty. (F) Portal vein thrombosis (PVT) PVT is a common complication of cirrhotic portal hypertension, the incidence rate can be as high as 36%, and its mechanism involves the decrease of portal venous blood flow rate and the imbalance of coagulation function caused by cirrhotic portal hypertension.PVT not only aggravates the existing portal hypertension, but also reduces the hepatic perfusion and impairs the hepatic function, and the lack of timely treatment can result in the formation of extensive occlusion of the portal vein and spongiform changes. TIPS can not only open the portal vein, reduce its pressure and increase its flow rate, but also prevent the recurrence of PVT. Contraindication to TIPS 1. Absolute contraindication: unproven portal hypertension in cirrhosis. 2. Relative contraindications: ① Child-Pugh score > 13; ② renal insufficiency; ③ severe right heart failure; ④ moderate pulmonary hypertension; ⑤ severe coagulation disorders; ⑥ uncontrolled intrahepatic or systemic infection; ⑦ biliary obstruction; ⑧ polycystic liver; ⑨ extensive primary or metastatic hepatic malignant tumors; ⑩ portal spongiform change. Third, TIPS operation process (a) preoperative preparation 1. elective TIPS (selective TIPS): blood and urine routine, liver and renal function, blood glucose, electrolytes and coagulation function are preoperative basic examination. Abdominal enhanced CT or MRI is an important examination to understand the condition of liver, portal vein and hepatic vein, which helps to assess the degree of opening of collateral circulation of portal vein belonging to the branch, and to understand the presence or absence of thrombus and portal spongiosis. The detection of the etiology of cirrhosis is beneficial to the causal treatment before and after TIPS. For severe anemia, severe platelet reduction or coagulation dysfunction, it should be improved as much as possible. 2. Salvage TIPS: when drug and endoscopic treatment cannot stop bleeding. When surgical indications are lost, a triple-lumen double-bladed tube can be used for temporary compression of hemostasis to create conditions for salvage TIPS and complete the above examination as much as possible. 3. Doctor-patient communication: Before the implementation of TIPS, the operating physician should explain in detail to the patient and his family the necessity of TIPS, the expected results and possible surgical complications, and the patient’s designated principal to sign the informed consent. (B) TIPS routine operation techniques 1.TIPS puncture kit: Ring and Rosch-Uchida are the 2 most commonly used TIPS puncture kits at present, with similar components and operation methods, the main difference being the supporting puncture needles. There is no significant difference in the success rate and complications between the two puncture kits, and the surgeon can choose according to his/her personal experience. 2. Vascular access: The right internal jugular vein is usually chosen as the access route for TIPS, which can provide a straighter and smoother path and is favorable for operation. If necessary, the internal jugular vein can be punctured under ultrasound guidance to avoid damage to the internal carotid artery or complications such as pneumothorax. If the right internal jugular vein is obstructed or the puncture is not smooth, the left internal jugular vein, the right external jugular vein or the subclavian vein can also be chosen. 3. Hepatic vein cannulation: A balloon catheter is inserted into the hepatic vein and the hepatic venous pressure gradient (HVPG) is measured to clarify the diagnosis. The TIPS kit is introduced into the hepatic vein, and the right or middle hepatic vein is usually chosen; the left hepatic vein, which is smaller and almost perpendicular to the inferior vena cava, is usually not chosen. Hepatic venography confirms the location, and exchange of balloon catheters or wedging of a catheter into the hepatic parenchyma for CO2 imaging helps to understand the portal vein anatomy. 4. Portal vein puncture: The right branch of the portal vein is usually located anterior to the right hepatic vein and posterior to the middle hepatic vein, while the left branch of the portal vein is located anterior to the middle hepatic vein and posterior to the left hepatic vein. According to the preoperative imaging data or intraoperative CO2 imaging to guide the portal vein puncture, the target point of puncture should be the intrahepatic portal vein branch within 2cm of the bifurcation of the portal vein. After the catheter is pumped back into the portal vein, a small amount of contrast agent is injected, the location of the puncture is clarified, the guidewire is introduced to exchange the catheter, the portal vein is imaged and the portal vein pressure is measured, and the portal vein pressure gradient (PPG) is calculated. 5. Stent implantation: after portal venography, a balloon catheter with a length of 4-8 cm and a diameter of 8-10 mm was selected to dilate the intrahepatic shunt tract. When expanding the balloon, 2 depressions (pressure marks) on the balloon represent the distance between the hepatic vein and the portal vein, i.e. the length of the shunt tract, and a PTFE-coated stent with a diameter of 8-10 mm is placed. The venous end of the stent should be continued to the confluence of the hepatic vein and inferior vena cava. After stent implantation, portal venography is performed again and post-TIPS PPG is measured.The general recommendation is a postoperative PPG of <12 mmHgdmmHg (133 kPa) or a 25% decrease from the baseline value. (C) TIPS expansion technique is a supplement to conventional TIPS, which can improve its effectiveness, increase the success rate of special cases, and expand the indications. 1. TIPS supplemented with variceal vein endovascular embolization: A recent prospective clinical controlled study showed that TIPS supplemented with esophagogastric variceal vein endovascular embolization significantly improved stent patency at 6 months (96.2% vs. 82.0%) and reduced the 2-year rebleeding rate (29.0% vs. 47.0%) compared with single TIPS. 2. Direct portal shunt via inferior vena cava (DIPS): the transjugular vein puncture needle is delivered into the segmental inferior vena cava, direct puncture via the segmental inferior vena cava, and puncture via the hepatic caudate lobe parenchyma to the portal vein, and the stent is placed in the caudate lobe parenchyma to establish a lateral-lateral portacaval shunt channel through the caudate lobe. This technique is suitable for patients with portal hypertension who have atrophied or occluded hepatic veins or have difficulty in finding them. 3. Percutaneous transhepatic transportal perforation stenting: under image guidance, percutaneous transhepatic perforation of the portal vein is performed, and then retrograde perforation of the hepatic vein or hepatic inferior vena cava is performed through the portal vein; after the guidewire enters into the inferior vena cava, the catcher is sent in through the jugular vein to draw the guidewire out of the body through the jugular vein, and the rest of the operation is similar to the conventional TIPS for portal stenting. Complications of TIPS The complications of TIPS are mainly related to operation and shunt. Most of the operation-related complications can be alleviated by symptomatic treatment, and the incidence of fatal complications is 0.6%-4.3%. Intraoperative ultrasound, CO2 imaging and other auxiliary guidance methods can further reduce the occurrence of such complications. Shunt failure is most often caused by acute thrombosis and pseudo-endothelial hyperplasia within the stent. Prevention of acute thrombosis is detailed in postoperative management. Pseudoendothelial hyperplasia within the stent, non-smooth surface of the shunt tract, long-term irritation and injury to the liver parenchyma and hepatic veins from high-velocity blood flow, and poor biocompatibility of the stent itself are associated. The problem of shunt tract failure had brought the clinical application of TIPS to a low point. With the advancement of stent structure and material, the problem of shunt failure has been greatly improved. In a randomized controlled study, a polytetrafluoroethylene-coated stent was associated with a significant reduction in 1-year shunt failure compared with a bare stent (10% versus 50%), and the simultaneous embolization of abnormal collateral circulation with TIPS also helped to maintain shunt patency. The incidence of hepatic encephalopathy is positively correlated with patients' preoperative hepatic function Child-Pugh score and shunt diameter; therefore, Child-Pugh classification should be chosen for elective surgery whenever possible. V. Postoperative management of TIPS 1. Postoperative anticoagulation: Acute thrombus is mostly formed 24h after surgery, which can be confirmed by ultrasonography or angiography, and is related to bile leakage, hypercoagulable state and inappropriate choice of stent. Although there is a lack of evidence from clinical studies on the anticoagulation treatment regimen in the postoperative period, most of the scholars suggest that short-term anticoagulation after surgery, such as low molecular heparin, can reduce the occurrence of acute thrombus. Whether to use drugs such as antiplatelets after surgery also needs further clinical studies. Ultrasonography is the preferred method to follow up the shunt tract after TIPS, and portal venography can confirm the diagnosis of shunt tract failure, and the management measures mainly include balloon dilatation, stent implantation, or parallel TIPS. Hepatic encephalopathy: Hepatic encephalopathy after TIPS mostly occurs within six months after the operation, which is not only related to the patients' preoperative hepatic function status, but also related to postoperative infections, constipation, improper use of drugs, excessive protein intake In addition to the preoperative liver function condition, it is also related to postoperative infection, constipation, inappropriate use of drugs, excessive protein intake, and increased cerebral perfusion in the short term after operation. 3. The successful application of TIPS needs to emphasize the advantages of gastroenterology in patient selection, perioperative management and postoperative follow-up management. Gastroenterologists should continue to incorporate vascular intervention knowledge in the diagnosis and management of cirrhosis. When TIPS is successfully rooted in gastroenterology, patients with cirrhosis and portal hypertension will benefit significantly.