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Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy

¹ Department of Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
² Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK

Correspondence to:
Correspondence to:
Dr N Kochar
Department of Hepatology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK; nkochar{at}staffmail.ed.ac.uk

Background: Post-transjugular intrahepatic portosystemic stent shunt (TIPSS) hepatic encephalopathy (HE) can occur in up to one third of patients. In 5%, this can be refractory to optimal medical treatment and may require shunt modification. The efficacy of shunt modification has been poorly studied.

Aims: To evaluate the efficacy of and natural history following TIPSS modification for treatment of refractory HE.

Methods: From a dedicated database, we selected and further studied patients who had TIPSS modification for refractory HE.

Results: Over a 14 year period, of 733 TIPSS insertions, 211(29%) patients developed HE post-TIPSS. In 38 patients, shunt modification (reduction (n = 9) and occlusion (n = 29)) was performed for refractory HE. Indications for TIPSS were: variceal bleeding (n = 32), refractory ascites (n = 5), and other (n = 1). Child’s grades A, B, and C were noted in 11%, 47%, and 42% of cases, respectively. HE improved in 58% of patients and remained unchanged or worsened in 42%, with similar results for occlusions and reductions. Following shunt modification, variceal bleeding recurred in three patients and ascites in three. Twenty five patients have died (liver related in 15) at a median duration of 10.2 months. Three patients died due to procedure related complications following shunt occlusions (mesenteric infarction (n = 2) and septicaemia (n = 1)). Median survival of patients whose HE did not improve following shunt modification was 79 days compared with 278 days in patients whose did (p<0.05). No variables independently predicted response to shunt modification.

Conclusions: TIPSS modification is a useful option for patients with refractory HE following TIPSS insertion. Due to the significant risk of iatrogenic complications with shunt occlusions, shunt reduction is a safer and preferred option.

Abbreviations: TIPSS, transjugular intrahepatic portosystemic stent shunt; HE, hepatic encephalopathy; VBL, variceal band ligation

Keywords: transjugular intrahepatic portosystemic stent shunt; TIPSS modification; TIPSS occlusion; hepatic encephalopathy

This article has been cited by other articles:

				S. Masson, H.A. Mardini, J.D. Rose, and C.O. Record Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion: a decade of experience QJM, June 1, 2008; 101(6): 493 - 501. [Abstract] [Full Text] [PDF]