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

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment tool in decompensated liver cirrhosis that has been shown to prolong transplant-free survival. Hepatic encephalopathy (HE) is a frequent complication of decompensated cirrhosis, eventually induced and/or aggravated by TIPS, that remains a clinical challenge especially in these patients. Therefore, patient selection for TIPS requires careful assessment of risk factors for HE. TIPS procedural parameters regarding stent size and invasive portosystemic pressure gradient measurements thereby have an important role. Endovascular shunt modification, in combination with a conservative medical approach, often results in a significant reduction of symptoms. This review summarizes HE molecular mechanisms and pathophysiology as well as diagnostic and therapeutic approaches targeting shunt-induced HE.

Unique Method of Transjugular Intrahepatic Portosystemic Shunt Reduction for Refractory Hepatic Encephalopathy

“…TIPS is considered a second-line therapy because it can cause postprocedural complications such as HE, TIPS stenosis, and puncture of the liver capsule [6][7][8]11,14]. Our patient returned to the ED several months after TIPS placement, unconscious with a history consistent with recurrent HE that developed after the procedure.…”

“…Our patient returned to the ED several months after TIPS placement, unconscious with a history consistent with recurrent HE that developed after the procedure. HE commonly develops in up to 50% of patients post-TIPS procedure and occurs when there is an accumulation of enteric neurotoxins such as ammonia in the brain, which can then disrupt neural communication and present clinically as behavioral changes, cognitive impairment, and even coma in more severe cases [10,11,15,16]. It is theorized that elevated systemic ammonia levels notably play a key role in the development of HE.…”

“…It is theorized that elevated systemic ammonia levels notably play a key role in the development of HE. In patients post-TIPS, portal blood containing ammonia bypasses the liver, which is normally responsible for detoxifying ammonia [10,11,15]. The TIPS shunts the blood away from the liver parenchyma and into the systemic circulation, allowing undetoxified ammonia to accumulate and gain access to the brain [10,11,15,16].…”

“…The TIPS procedure, however, is sometimes followed by complications such as development of acute hepatic encephalopathy seen in up to 8% of patients, which we present in our case [6][7][8]10,11]. Current literature outlines treatments such as pharmacological therapy, shunt occlusion, and shunt reduction to manage the hepatic encephalopathy [10][11][12][13][14][15][16][17]. In our report, we present a unique method of reducing the TIPS by constraining the existing stent with a single balloon-expandable stent.…”

“…An accepted treatment for uncontrolled variceal hemorrhage is a transjugular intrahepatic portosystemic shunt (TIPS) procedure that shunts portal blood away from the liver parenchyma by creating an intrahepatic channel between the hepatic vein and a branch of the portal vein to relieve hypertension in the portal system [1,[5][6][7][8][9]. The TIPS procedure, however, is sometimes followed by complications such as development of acute hepatic encephalopathy seen in up to 8% of patients, which we present in our case [6][7][8]10,11]. Current literature outlines treatments such as pharmacological therapy, shunt occlusion, and shunt reduction to manage the hepatic encephalopathy [10][11][12][13][14][15][16][17].…”