TIPS Revision for Post-TIPS Hepatic Encephalopathy: Techniques and Efficacy

Abstract

Purpose: Creation of a transjugular intrahepatic portosystemic shunt (TIPS) can effectively treat complications of portal hypertension, but excessive shunting can cause life-threatening hepatic encephalopathy (HE). If HE occurs after TIPS, revision of the TIPS may be necessary; however, very limited data is available regarding the success of this intervention. We report the efficacy and the techniques of TIPS narrowing in nine patients who developed refractory HE after initial TIPS placement. Methods: We performed a retrospective review of all patients within a 3-year period, who underwent an elective TIPs placement for ascites, who later required narrowing for refractory HE (eight patients), or hepatorenal syndrome with mild encephalopathy (one patient). Results: The present series consist of nine patients (six males) with a mean age of 57±7.6 years. The indication for TIPS placement was refractory ascites in all cases; the underlying etiology of liver disease was NAFLD (three patients), hepatitis C (two patients), alcoholic hepatitis (two patients), autoimmune hepatitis (one patient), and primary biliary cirrhosis (one patient). A total of 11 TIPS revisions were performed on these patients. Nine of 11 were successful. The techniques used were: placement of a parallel stent (four cases), atrium on a wall stent (three cases), and balloon expandable covered stent (four cases). Two of the four parallel stents required revision, with either an atrium on wall stent or balloon expandable stent. Hepato-pedal flow was improved in nine out of the 11 procedures, and correlated with improvement in HE. For successful revisions, hospital admissions for HE decreased from a mean of 3.7±1.8 admissions per patient pre-TIPS revision to 1.5±1.5 admissions post-TIPS revision. The length of stay per HE admission was 6.4±6.1days pre-TIPS revision, and 4.4±3.2 days post-TIPS revision narrowing. The mean porto-systemic gradient change after initial TIPS was 10.5±4 mm Hg, while it was 4.8±2.3 mm Hg after successful narrowing. Three of nine patients developed ascites following TIPS revision, which was easily managed with diuretics. The mean follow-up period was 13.1.9±8.9 months. Conclusion: 1.) TIPS narrowing is an effective modality to manage patients with HE secondary to TIPS placement, with little effect on inducing recurrence of ascites. 2.) The use of an atrium on wall stent or balloon expandable stent appeared to be the more effective technique to revise the TIPS. 3.) Larger studies are required to determine the best technique for TIPS revision.