Case Study of TIPS Revision in Setting of Refractory Hepatic Encephalopathy

Abstract

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is presently used for treatment of complications of portal hypertension in cirrhotic patients. This procedure, although useful, does have two main complications: shunt dysfunction and hepatic encephalopathy (HE). A minority of patients, about 5%, develop severe HE refractory to medical treatment. Here, we would like to report a case wherein shunt reduction was performed for treatment of refractory HE and led to recovery. Patient was a 62 year-old female with a past medical history significant for decompensated liver cirrhosis secondary to nonalcoholic steatohepatitis (BMI 31.25 kg/m2), type 2 diabetes mellitus, stage III chronic kidney disease, and hypertension who presented with increasing confusion and drowsiness for a duration of 3 days. She had received a TIPS placement approximately 2 weeks prior. Following the procedure, the patient had been doing well until 3 days before admission when she began to develop symptoms consistent with hepatic encephalopathy with an ammonia level 313 umol/L. Despite appropriate therapy and work-up of HE, the patient did not show significant improvement after three days of inpatient hospitalization. Due to early onset and lack of improvement of HE post-TIPS and characterization on portal venogram, we made the decision to narrow lumen of TIPS. TIPS revision was performed narrowing lumen from 10 mm to 6 mm using a Viabahn covered stent held in position with 14 mm Cordis SMART stent and 10 mm Amplatzer II vascular plug. Patient started to show resolution of symptoms after the procedure and recovered completely at the time of discharge. Only two options are currently in practice for post-TIPS hepatic encephalopathy refractory to medical treatment: liver transplantation or revision of the shunt. Refractory hepatic encephalopathy can affect up to 5% of patients who receive TIPS. Shunt reduction leads to improvement of symptoms in more than half of cases.Figure 1Figure 2Figure 3