Refractory Hepatic Encephalopathy Research Articles

Refractory hepatic encephalopathy due to concomitant transjugular intrahepatic portosystemic shunt and spontaneous mesocaval shunt controlled by embolization of the competitive portosystemic shunt

Spontaneous mesocaval shunt (SMCS) is an uncommon cause of refractory encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) creation. We report a patient who presented with refractory hepatic encephalopathy (HE) post-TIPS creation for variceal bleeding in whom a SMCS was found. Percutaneous transhepatic occlusion of the SMCS reduced the portal vein flow diverted from the liver and provided sufficient liver perfusion to reverse the HE while maintaining satisfactory decompression of esophageal varices.

Incidence, Natural History, and Risk Factors of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt With Polytetrafluoroethylene-Covered Stent Grafts

The aim of this study was to assess the incidence, natural history, and risk factors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) with the new polytetrafluoroethylene (PTFE)-covered stent grafts in cirrhotic patients. Seventy-eight cirrhotic patients treated by TIPS with PTFE-covered stent grafts and followed by the same medical team--according to a prospective protocol for diagnostic workup and surveillance strategy--were reviewed. The follow-up was 19.9 +/- 20.6 months. At least one episode of HE occurred in 35 of 78 (44.8%) patients. The probability of remaining free of HE was 53.8% (95% confidence interval [CI] 41.4-66.2] at 1 yr and 50.9% at 2 yr (95% CI 38.2-63.8%). The total number of HE episodes was 89. Fifty-five percent of the episodes were grades III-IV. The occurrence of HE tended to be constant during the follow-up, probably because of the very low incidence of shunt dysfunction (13.6% at 2 yr). Moreover, in six patients, a refractory HE required the reduction of the shunt diameter. One patient died due to variceal bleeding after this procedure. At a multivariate analysis, an older age, high creatinine levels, and low serum sodium and low albumin values were shown to be independent factors for the occurrence of HE. Serum creatinine level was the only variable related to the development of refractory HE at the logistic multivariate analysis. HE after TIPS with PTFE-covered stent grafts is frequent; its incidence is not confined to the first post-TIPS period, but it has the tendency to be frequent over time. Refractory HE occurred in 8% of patients and may be successfully managed by reducing the stent diameter. The selection of patients undergoing TIPS placement should be very accurate, especially for those subjects with abnormal creatinine level.

Surgical Disconnection of Patent Paraumbilical Vein in Refractory Hepatic Encephalopathy

Refractory hepatic encephalopathy (HE) frequently develops in patients with cirrhosis and portal-systemic shunt. Recently, patients with refractory HE associated with portal-systemic shunt have been treated with interventional radiology. We describe a promising new treatment for portal-systemic shunt, ligation of the patent paraumbilical vein (PUV) after partial splenic embolization, in patients with refractory HE. Four patients with cirrhosis (3 women and 1 man; mean age, 56 years) and refractory HE due to a patent PUV were studied. Patency of the PUV had recurred in 1 patient after primary occlusion by interventional radiological procedures. The Child-Pugh class was B in 2 patients and C in 2. Before the present treatment, all patients had been hospitalized at least 3 times because of recurrent HE. Partial splenic embolization was performed in all patients to decrease portal venous pressure before surgery. Surgical ligation of the patent PUV was performed under epidural anesthesia. The patent PUV was carefully skeletonized and doubly ligated. Esophageal varices were evaluated with upper gastrointestinal endoscopy before and after surgery. The mean follow-up duration was 15.8 months. After ligation, there were no clinically significant complications. Esophageal varices were unchanged. The serum ammonia level was higher before surgery (162.3 +/- 56.4 mug/dL, mean +/- SD) than after surgery (41.8 +/- 20.2 mug/dL; p=0.0299). No patient had symptoms of HE. Ligation of the patent PUV is an effective treatment for patients with refractory HE.

Management of Transjugular Intrahepatic Portosystemic Shunt–Induced Refractory Hepatic Encephalopathy with the Parallel Technique: Results of a Clinical Follow-up Study

To retrospectively evaluate the safety, feasibility, and midterm clinical outcome of the use of the parallel technique to treat transjugular intrahepatic portosystemic shunt (TIPS)-induced hepatic encephalopathy (HE) refractory to medical treatment. Additionally, factors potentially influencing clinical results after shunt reduction are assessed. Seventeen patients (11 men and 6 women) presenting with TIPS-induced HE refractory to medical treatment underwent shunt reduction with use of the parallel technique. West Haven HE grades before shunt reduction were IV and III in seven patients each and II in three patients. Mean portosystemic pressure gradient (PSPG) before shunt reduction was 6.8 mm Hg (range, 2-16 mm Hg). Relations between change in patients' mental state and several clinical parameters were analyzed. In all patients, it was technically feasible to reduce the shunt with use of the parallel technique. PSPG after reduction increased by a mean of 5.8 mm Hg (range, 1-12 mm Hg; P < .0001). Mental state grades with regard to HE after shunt reduction were 0 (n = 6), I (n = 4), II (n = 3), III (n = 1), and IV (n = 3). Clinical improvement (n = 7; 41%) or complete disappearance (n = 6; 35%) of HE occurred in 76% of the patients, which is statistically significant (P = .0002). No clear relation could be established between change in mental state regarding HE and any of the potentially influencing factors. Management of TIPS-induced HE with use of the parallel technique is feasible and safe. It results in an increase of PSPG, which is associated with an improvement in neuropsychiatric status in most patients.

A Modified Procedure for Transjugular Intrahepatic Portosystemic Shunt Flow Reduction

The authors present a modified transjugular intrahepatic portosystemic shunt (TIPS) flow reduction procedure to treat TIPS-related refractory hepatic encephalopathy, giving the results and follow-up on six patients. A 6-mm-diameter Uni Wallstent was introduced over a guide wire and deployed beyond the angulated portion of the TIPS. A Wallgraft was then introduced over the same guide wire, pushed through the Uni Wallstent coaxially, and deployed in the TIPS. All cases were technically and clinically successful. There were no deaths in the first month after the procedure. In this study, three patients had more than 1 year's patency.

Reduced Stents and Stent-Grafts for the Management of Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation

Hepatic encephalopathy (HE) is a common complication encountered by patients after transjugular intrahepatic portosystemic shunt (TIPS) creation. Although most patients respond well to conservative medical therapy, up to 7% of patients do not and require more invasive therapeutic approaches. One option is emergent liver transplantation; however, most patients are not suitable candidates. During the past decade, various percutaneous techniques have been described that alter the hemodynamics through the TIPS by occluding it with coils or balloons or by reducing its diameter using constrained stents or stent-grafts. These endovascular techniques have produced symptomatic improvement in many patients with refractory HE, with either complete resolution or substantial reduction of HE symptoms that can be controlled with additional medical therapy. Unfortunately, despite all attempts, some patients remain incapacitated and ultimately die. Further research is necessary to improve our understanding of HE after TIPS creation so that less invasive and safer procedures can be developed to treat this difficult clinical problem.

TIPS-related hepatic encephalopathy: management options with novel endovascular techniques.

Hepatic encephalopathy is a common complication that develops after creation of a transjugular intrahepatic portosystemic shunt (TIPS). Although most patients respond well to conservative medical therapy (ie, protein-restricted diet, nonabsorbable disaccharides, nonabsorbable antibiotics), a small percentage of patients (3%-7%) do not benefit from these methods and require more invasive therapeutic approaches. One option is emergent liver transplantation, but the majority of patients are not suitable candidates. Recently, various percutaneous techniques have been described that alter the hemodynamics through the shunt by occluding it with coils or balloons or by reducing its diameter by inserting constrained stents or stent-grafts. Other techniques have been used for patients with TIPS-related hepatic encephalopathy in whom spontaneous splenorenal shunts are present. In many patients with refractory hepatic encephalopathy, these percutaneous techniques have produced symptomatic improvement, with either a complete resolution or a substantial reduction in hepatic encephalopathy symptoms that can be controlled with medical therapy. Unfortunately, despite all attempts, some patients remain incapacitated and ultimately die. Further research is necessary to improve our understanding of TIPS-related hepatic encephalopathy so that newer, less invasive and safer procedures can be developed to treat this difficult clinical problem.

Coil embolization of large spontaneous splenorenal shunt for chronic refractory hepatic encephalopathy

Coil embolization of large spontaneous splenorenal shunt for chronic refractory hepatic encephalopathy

Management of TIPS-related Refractory Hepatic Encephalopathy with Reduced Wallgraft Endoprostheses

The purpose of this study is to evaluate the feasibility of constrained endografts used for the treatment of transjugular intrahepatic portosystemic shunt (TIPS)-related refractory hepatic encephalopathy (HE). Because the clinical status of two patients worsened (return of intractable ascites requiring transplantation, n = 1; death, n = 1) after complete balloon occlusion, six patients were treated with constrained/modified Wallgraft endoprostheses placed within the preexisting TIPS. Shunt reductions were technically successful in all six patients, as shown by an immediate mean portosystemic gradient increase of 9.3 mm Hg. Clinical improvement was achieved in five patients within 72 hours of reduction. The remaining patient continued to decline and died 3 weeks later. Two endografts completely occluded within 8 months without HE recurrence. This technique offers an attractive alternative to previously described shunt reduction methods.

A case of alcoholic liver cirrhosis with refractory hepatic encephalopathy successfully treated with obliteration of ileocolic vein-inferior vena cava shunt

A case of alcoholic liver cirrhosis with refractory hepatic encephalopathy successfully treated with obliteration of ileocolic vein-inferior vena cava shunt

The reducing stent: treatment for transjugular intrahepatic portosystemic shunt-induced refractory hepatic encephalopathy and liver failure.

To examine the efficacy of a stent device in reducing the diameter of transjugular intrahepatic portosystemic shunts (TIPS) in patients with progressive liver failure or with shunt-induced hepatic encephalopathy. Seven patients with TIPS (four with severe hepatic encephalopathy, three with progressive liver failure) underwent transjugular implantation of a stent designed to reduce the flow through the original TIPS channel. Implantation of the reducing stent proceeded without complication. Duplex sonography showed that stent flow decreased by 41% +/- 18 (mean +/- standard deviation). The four patients with hepatic encephalopathy showed substantial improvement. Concentrations of plasma ammonium and serum bilirubin improved considerably. In contrast, functional impairment progressed in the three patients treated for liver failure. The patients soon died. With the limited experience of treating these seven patients, the authors suggest that shunt-induced hepatic encephalopathy can be effectively treated with implantation of a reducing stent. Hepatic failure, however, is a deleterious complication that seems to be irreversible.