Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A randomized controlled trial

Abstract

Background and Aims Large spontaneous portosystemic shunt (SPSS) is associated with increased risk of HE in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). This study aimed to evaluate whether prophylactic embolization of large SPSS at the time of TIPS creation could reduce the incidence of post‐TIPS HE in patients with cirrhosis and variceal bleeding. Approach and Results From June 2014 to August 2017, 56 patients with cirrhosis and large SPSS planning to undergo TIPS for the prevention of variceal bleeding were randomly assigned (1:1) to receive TIPS alone (TIPS group, n = 29) or TIPS plus simultaneous SPSS embolization (TIPS+E group, n = 27). The primary endpoint was overt HE. TIPS placement and SPSS embolization was successful in all patients. During a median follow‐up of 24 months, the primary endpoint was met in 15 patients (51.7%) in the TIPS group and six patients (22.2%) in the TIPS+E group (p = 0.045). The 2‐year cumulative incidence of overt HE was significantly lower in the TIPS+E group compared with the TIPS group (21.2% vs. 48.3%; HR, 0.38; 95% CI, 0.15–0.97; p = 0.043). The 2‐year incidence of recurrent bleeding (TIPS+E vs. TIPS, 15.4% vs. 25.1%; p = 0.522), shunt dysfunction (12.3% vs. 18.6%, p = 0.593), death (15.0% vs. 6.9%, p = 0.352), and other adverse events was not significantly different between the two groups. Conclusions In patients with cirrhosis treated with TIPS for variceal bleeding, concurrent large SPSS embolization reduced the risk for overt HE without increasing other complications. Concurrent large SPSS embolization should therefore be considered for prophylaxis of post‐TIPS HE.

EASL Clinical Practice Guidelines on the management of hepatic encephalopathy

“…with particular reference to overt HE history 192 ; liver and kidney function, focusing on bilirubin levels, international normalised ratio and urea levels 193 ; a neurological and neuropsychological examination to detect HE, to rule out and manage large spontaneous porto-systemic shunts 194 ; and, finally, microbiome analysis could also help with decision-making in patients with TIPS at risk of overt HE. 195 In summary, new bouts of post-TIPS HE could be modulated by using covered stents 196 and promoting early placement of TIPS.…”

Computed Tomography Images of Spontaneous Portosystemic Shunt in Liver Cirrhosis

“…On the other hand, the presence of large SPSS increases the risk of post-TIPS overt hepatic encephalopathy [ 21 ]. Recently, a randomized controlled trial demonstrates that prophylactic embolization of large SPSS during TIPS procedures can reduce the risk of overt hepatic encephalopathy without any increased risk of other liver-related complications [ 31 , 32 ]. These findings supported embolization of varices and SPSS during TIPS procedures.…”

Pre-emptive TIPSS in Acute Variceal Bleeding: Current Status, Controversies, and Future Directions

“…42 The existence and diameter of the portosystemic shunt (SPSS) is an independent predictor of post-TIPSS hepatic encephalopathy. 43 A recent randomized trial by Lv et al 44 reported a lower risk of HE following TIPSS with concurrent embolization of a large spontaneous portosystemic shunt in patients undergoing TIPSS. Following embolization of large collaterals, the amount of blood shunting through TIPSS was reduced, as it was limited by the diameter of the TIPSS, which is often smaller than the co-existing large SPSS.…”