TIPS & BRTO - Florida Interventional Specialists

Image-guided treatment for the complications of portal hypertension.

Florida Interventional Specialists provides expert care for the complications of cirrhosis and portal hypertension at Tampa General Hospital — the #1 transplant center in the nation by total volume, a top-five US center for liver transplant volume, and home to the Center for Liver Disease and Transplant. Same-day TIPS and BRTO procedures are delivered as part of a coordinated multidisciplinary plan with hepatology, transplant hepatology, gastroenterology, and the TGH transplant surgery team.

When cirrhosis is advanced, the pressure inside the liver’s blood supply rises and finds its way out through paths it shouldn’t take — into bulging veins around the esophagus and stomach that can bleed, into fluid that fills the abdomen or chest, into kidneys that begin to fail. TIPS and BRTO are image-guided procedures that fix the underlying problem from the inside without surgery. They are done from a small needle access — no incision — and they can stabilize patients who feel like they’re running out of options, often as a bridge while they wait for a liver transplant.

TIPS and BRTO at FIS are performed at Tampa General Hospital — the #1 transplant center in the nation by total volume.

A center of excellence for chronic liver disease and transplant

Florida Interventional Specialists provides expert image-guided care for portal hypertension at Tampa General Hospital — the #1 transplant center in the nation by total volume and a top-five US center for liver transplant volume. The TGH liver transplant program began in 1987, has performed more than 3,000 liver transplants, and is ranked #1 in Florida. For patients with cirrhosis and portal hypertension, the depth of multidisciplinary expertise at TGH — hepatology, transplant hepatology, transplant surgery, gastroenterology, and interventional radiology working as one team — is what defines a true center of excellence.

What are TIPS and BRTO?

TIPS stands for transjugular intrahepatic portosystemic shunt. The high pressure that builds up in the portal venous system because of cirrhosis is what drives the major complications. TIPS creates a small, controlled internal channel through the liver — using a covered stent — that lets blood take a shortcut from the high-pressure side to the low-pressure side. Once pressure drops, variceal bleeding usually stops, ascites stops re-accumulating as quickly, and hepatic hydrothorax often resolves.

BRTO stands for balloon-occluded retrograde transvenous obliteration. Some patients with cirrhosis develop a particular kind of large bleeding gastric varix that drains into a natural shortcut between the portal system and the kidney’s vein. BRTO uses that same natural shortcut backwards — a balloon catheter is advanced from the venous side to close the varices off from below. Variants called PARTO and CARTO use vascular plugs or coils with gelatin sponge to do similar work. TIPS and BRTO are complementary procedures — each is better suited to different clinical situations, and the choice is made jointly by the multidisciplinary team.

When are these procedures considered?

The most common indications are:

Refractory or recurrent variceal bleeding from esophageal varices that has not been controlled with beta blockers and endoscopic band ligation
Refractory ascites requiring repeated large-volume paracentesis
Refractory hepatic hydrothorax requiring repeated thoracentesis
Hepatorenal syndrome as a bridge to medical optimization or transplant
Bleeding gastric varices (GOV2, IGV1, IGV2) — typically treated with BRTO when a suitable spontaneous shunt is present
Hepatic encephalopathy attributable to a large spontaneous portosystemic shunt — treated by closing the shunt
Bridge to liver transplant for selected decompensated patients on the TGH transplant pathway

What the day looks like

You’ll be admitted to Tampa General Hospital — usually the day of the procedure for elective cases, sometimes already an inpatient if the procedure is urgent. TIPS is performed under sedation or general anesthesia. We numb a small spot on the right side of the neck and advance a thin catheter through the heart and into a hepatic vein, using live X-ray imaging the entire way. A controlled channel is created through the liver to a portal vein branch, a covered stent is placed across the channel, and the stent is gently dilated to a target pressure measured directly through the catheter. BRTO is performed similarly but from the femoral vein in the groin — a balloon is advanced through the natural shunt and the gastric varices are closed from below.

Total procedure time is typically 90 to 180 minutes. Most patients stay in the hospital for at least one night for observation. Doppler ultrasound checks confirm the shunt is working as intended.

A bridge to transplant when needed

For patients with decompensated cirrhosis who are being evaluated for or are already listed for liver transplant, TIPS and BRTO are often used to stabilize life-threatening complications and improve quality of life during the wait. Care is coordinated directly with the TGH Transplant Institute and the Center for Liver Disease and Transplant, so that interventional radiology is one part of a unified plan rather than a stand-alone treatment. That integration is one of the reasons TGH delivers excellent outcomes for some of the country’s most complex liver patients.

References

de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII — Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959–974.
Boyer TD, Haskal ZJ; American Association for the Study of Liver Diseases. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology. 2010;51(1):306.
Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996;11(1):51–58.
García-Pagán JC, Caca K, Bureau C, et al; Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362(25):2370–2379.

Frequently asked questions

What is TIPS?

TIPS — transjugular intrahepatic portosystemic shunt — is an image-guided procedure that creates a controlled internal channel through the liver to lower the high pressure in the portal venous system caused by cirrhosis. A small covered stent is placed inside the liver, connecting an inflow vessel (portal vein) to an outflow vessel (hepatic vein). With less pressure in the portal system, variceal bleeding, refractory ascites, and refractory hepatic hydrothorax improve.

What is BRTO?

BRTO — balloon-occluded retrograde transvenous obliteration — is an image-guided procedure that closes a specific kind of large gastric varix from the venous side. A balloon catheter is advanced through a natural shunt that drains the gastric varices into the renal vein, the balloon is inflated, and the varices are obliterated with sclerosant or with coils and gelatin (variants known as CARTO and PARTO). BRTO is a complementary procedure to TIPS, with each better suited to different clinical situations.

Why have my procedure at Tampa General Hospital?

Tampa General Hospital is the #1 transplant center in the nation by total volume, a top-five US center for liver transplant volume, and home to the Center for Liver Disease and Transplant. The TGH liver transplant program has performed more than 3,000 liver transplants since its founding in 1987 and is ranked #1 in Florida. For patients with cirrhosis and portal hypertension, that depth of multidisciplinary expertise — hepatology, transplant hepatology, transplant surgery, gastroenterology, and interventional radiology working as one team — is what defines a true center of excellence.

Will TIPS make hepatic encephalopathy worse?

TIPS can precipitate or worsen hepatic encephalopathy because it routes some portal blood directly into the systemic circulation, bypassing the liver’s filtering function. Modern controlled-diameter shunts and careful patient selection have substantially reduced this risk. When encephalopathy is the dominant problem rather than variceal bleeding or ascites, the right answer is often the opposite — closing a spontaneous shunt with BRTO or PARTO. Encephalopathy is monitored closely after TIPS and managed in close coordination with hepatology.

Is TIPS or BRTO a bridge to liver transplant?

Often, yes. TIPS and BRTO can stabilize patients with decompensated cirrhosis, control bleeding, reduce the burden of repeated paracentesis or thoracentesis, and improve nutrition and quality of life while patients are evaluated and listed for transplant. Care is coordinated directly with the TGH Transplant Institute and the Center for Liver Disease and Transplant.

Who performs these procedures?

TIPS and BRTO are performed by interventional radiologists. At Florida Interventional Specialists, the procedures are delivered as part of a coordinated multidisciplinary plan with hepatology, transplant hepatology, gastroenterology and advanced endoscopy, and — when relevant — the TGH transplant surgery team.

Schedule a consultation in Tampa, FL

TIPS and BRTO referrals come most often from the patient’s hepatologist, transplant hepatologist, or gastroenterologist. We coordinate scheduling, pre-procedure imaging review, and post-procedure follow-up directly with the referring team. Florida Interventional Specialists provides this care at Tampa General Hospital, with patients coming from across Florida and beyond.

Call 813-844-4570

A center of excellence

FIS provides expert image-guided care at Tampa General Hospital — the #1 transplant center in the nation by total volume and home to the Center for Liver Disease and Transplant. More than 3,000 liver transplants performed since 1987.

813-844-4570

Monday – Friday, 8:00 AM – 5:00 PM

TIPS & BRTO at a glance

Performed at: Tampa General Hospital
Procedure time: 90–180 minutes
Anesthesia: Sedation or general
Access: Right internal jugular (TIPS); femoral or jugular (BRTO)
Hospital stay: Typically overnight or longer
Coordinated with: Hepatology, transplant hepatology, transplant surgery, GI/advanced endoscopy

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Tampa Bay’s Women’s Health and Fibroid Community

Florida Interventional Specialists provides image-guided, minimally invasive treatments for uterine fibroids, heavy menstrual bleeding, and adenomyosis to women across Tampa, St. Petersburg, Clearwater, Brandon, Wesley Chapel, and the Gulf Coast region.

Image-guided treatment for the complications of portal hypertension.

What are TIPS and BRTO?

When are these procedures considered?

What the day looks like

A bridge to transplant when needed

References

Frequently asked questions

What is TIPS?

What is BRTO?

Why have my procedure at Tampa General Hospital?

Will TIPS make hepatic encephalopathy worse?

Is TIPS or BRTO a bridge to liver transplant?

Who performs these procedures?

Schedule a consultation in Tampa, FL

Call 813-844-4570

A center of excellence

TIPS & BRTO at a glance

Tampa Bay’s Women’s Health and Fibroid Community

Florida Interventional Specialists

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