TIPS Modification in the Management of Shunt-Induced Hepatic Encephalopathy: Analysis of Predictive Factors and Outcome with Shunt Modification

Abstract

Purpose: To evaluate predictive parameters for the development of Hepatic Encephalopathy (HE) after Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement and for success of shunt modification in the management of shunt-induced HE. Methods: A retrospective analysis of all patients with TIPS (n = 344) has been performed since 2011 in our university liver center. n = 45 patients with HE after TIPS were compared to n = 48 patients without HE after TIPS (case-control-matching). Of n = 45 patients with TIPS-induced HE, n = 20 patients received a reduction stent (n = 18) or TIPS occlusion (n = 2) and were differentiated into responders (improvement by at least one HE grade according to the West Haven classification) and non-responders (no improvement). Results: Older patient age, increased serum creatinine and elevated International Normalized Ratio (INR) immediately after TIPS placement were independent predictors for the development of HE. In 11/20 patients (responders, 55%) undergoing shunt modification, the HE grade was improved compared with nine non-responders (45%), with no relevant recurrence of refractory ascites or variceal bleeding. A high HE grade after TIPS insertion was the only positive predictor of treatment response (p = 0.019). A total of 10/11 responders (91%) survived the 6 months follow-up after modification but only 6/9 non-responders (67%) survived. Discussion: Older patient age as well as an increased serum creatinine and INR after TIPS are potential predictors for the development of HE. TIPS reduction for the treatment of TIPS-induced HE is safe, with particular benefit for patients with pronounced HE.

Shunt-Induced Hepatic Encephalopathy in TIPS: Current Approaches and Clinical Challenges

“…Within these concepts it is important to be aware of patient safety in the course of TIPS modification, particularly regarding the recurrence of the primary TIPS indication, especially variceal bleeding and ascites [ 19 , 20 , 86 , 87 ]. Recent main studies analyzing the effect of shunt modification in patients with refractory post-TIPS HE are summarized in Table 4 [ 4 , 19 , 66 , 87 , 88 , 89 ]. While shunt reduction at the time of the pivotal study by Kochar et al was still a technical challenge, today, ready-to-use reduction stents offer the opportunity to easily downsize the shunts in a standardized manner [ 86 , 87 , 89 ].…”

“…Recent main studies analyzing the effect of shunt modification in patients with refractory post-TIPS HE are summarized in Table 4 [ 4 , 19 , 66 , 87 , 88 , 89 ]. While shunt reduction at the time of the pivotal study by Kochar et al was still a technical challenge, today, ready-to-use reduction stents offer the opportunity to easily downsize the shunts in a standardized manner [ 86 , 87 , 89 ]. From the data available, shunt reduction to 5 mm does not lead to relapse of variceal bleeding or refractory ascites in the majority of patients, demonstrating that reduction is mostly safe and should preferably be performed compared to complete shunt occlusion.…”

“…However, endovascular shunt modification is not always successful in managing HE while possibly the presence of large collaterals and the deterioration of the liver function is more important than the changes in portal hemodynamics [ 38 , 87 ]. In a recent study, it has been shown that a higher HE grade after TIPS as only positive predictor for response to shunt modification, independent of liver function and PPG [ 89 ]. Non-responders reveal poor prognosis between 27–67% survival rate of 6-month follow-up following shunt modification, while liver transplantation remains the ultimate treatment [ 86 , 87 , 89 ].…”

“…In a recent study, it has been shown that a higher HE grade after TIPS as only positive predictor for response to shunt modification, independent of liver function and PPG [ 89 ]. Non-responders reveal poor prognosis between 27–67% survival rate of 6-month follow-up following shunt modification, while liver transplantation remains the ultimate treatment [ 86 , 87 , 89 ].…”

Evaluation of impact of elective invasive examinations in patients with transjugular intrahepatic portosystemic shunt in the long-term follow up

“…Hepatic encephalopathy occurs in up to 50 % of patients after TIPS insertion whilst pharmaceutical prophylaxis of HE after TIPS remains disputed [34][35][36][37]. When dietary and pharmaceutical treatment of post TIPS HE fails, TIPS revision including modification of TIPS diameter or complete occlusion often remain the last treatment option [38][39][40]. Indeed, the size (diameter) of shunt is related to the development of HE, and even survival.…”