2394 Development of Hepatic Infarct After Successful Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement

Abstract

INTRODUCTION: Transjugular intrahepatic portosystemic shunt (TIPS) placement has now been well established as an effective and considered relatively safe treatment for the management of sequelae of portal hypertension. Hepatic infarction is an uncommon, potentially fatal complication after a TIPS procedure but rarely reported in cirrhosis patients with a low MELD (Model for End Stage Liver Disease). Here, we present a case of large hepatic infarct developing within a day of successful placement of TIPS in a patient with low MELD, which resolved with supportive treatment. CASE DESCRIPTION/METHODS: We present a 55 y/o Caucasian lady with Laennec cirrhosis with MELD 15 and normal bilirubin, who underwent elective TIPS placement for refractory ascites at our tertiary care center. Patient tolerated the procedure well with normal monitored vitals post procedure. However, she started complaining of right upper quadrant abdominal pain on next day with elevated transaminases and INR (40- fold and 2- fold increase from her baseline, respectively) with a stable bilirubin, CBC and creatinine. CT triple phase of the liver revealed a large hypodensity involving segments 6, 7 of the liver, suggestive of massive hepatic infarction and a patent TIPS. Patient not being a suitable candidate for liver transplant (with a history of recently diagnosed bladder carcinoma), was managed with supportive measures- Fluid, albumin, pain control and antibiotics. Liver enzymes continued to improve with return to baseline in 2 weeks. Subsequent clinic follow up showed complete control of ascites. DISCUSSION: Potential sequelae of TIPS are reported more frequently in cirrhotic with a MELD score greater than 18. Hepatic infarction is an uncommon development after a TIPS procedure. However, physicians must be aware of this virtually serious, post TIPS complication in cirrhotics even with a low MELD, which may progress to acute liver failure, with a need for liver transplant. Though our patient responded to supportive care, we think, an ideal patient planned for elective TIPS should be aware of this rare phenomenon. Prompt diagnosis is imperative to decrease the mortality from hepatic infarction.