Successful Reversal of Chronic Incapacitating Post-TIPS Encephalopathy by Balloon Occlusion of the Stent

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a new technique allowing decompression of the portal system without the need for abdominal surgery or general anesthetic. This promising procedure appears safe, and is being evaluated in the context of life threatening uncontrollable variceal hemorrhage as well as ascites refractory to medical treatment. Following TIPS, portal flow diversion is associated with hepatic encephalopathy in up to 25% of patients. This is most often mild and treatable but may become uncontrollable, incapacitating and even life threatening in up to 3 to 5% of cases. The authors present two patients in whom such life threatening encephalopathy and stupor was reversed by transjugular balloon occlusion of the TIPS.

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Spontaneous portosystemic shunts in liver cirrhosis: new approaches to an old problem

Therapeutic Advances in Gastroenterology ◽

10.1177/1756284820961287 ◽

2020 ◽

Vol 13 ◽

pp. 175628482096128 ◽

Cited By ~ 1

Author(s):

Judit Vidal-González ◽

Sergi Quiroga ◽

Macarena Simón-Talero ◽

Joan Genescà

Keyword(s):

Liver Cirrhosis ◽

Hepatic Encephalopathy ◽

Portosystemic Shunt ◽

Venous System ◽

Variceal Hemorrhage ◽

Portal Venous System ◽

Portal Flow ◽

Portosystemic Shunts ◽

Intrahepatic Portosystemic Shunt

Portal hypertension is the main consequence of liver cirrhosis, leading to severe complications such as variceal hemorrhage, ascites or hepatic encephalopathy. As an attempt to decompress the portal venous system, portal flow is derived into the systemic venous system through spontaneous portosystemic shunts (SPSSs), bypassing the liver. In this review, we aim to provide an overview of the published reports in relation to the prevalence and physiopathology behind the appearance of SPSS in liver cirrhosis, as well as the complications derived from its formation and its management. The role of SPSS embolization is specifically discussed, as SPSSs have been assessed as a therapeutic target, mainly for patients with recurrent/persistent hepatic encephalopathy and preserved liver function. Furthermore, different aspects of the role of SPSS in liver transplantation, as well as in candidates for transjugular intrahepatic portosystemic shunt are reviewed. In these settings, SPSS occlusion has been proposed to minimize possible deleterious effects, but results are so far inconclusive.

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Risk Factors for Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt in Patients with Hepatocellular Carcinoma and Portal Hypertension

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.243.yao ◽

2015 ◽

Vol 24 (3) ◽

pp. 301-307 ◽

Cited By ~ 8

Author(s):

Jiannan Yao ◽

Li Zuo ◽

Guangyu An ◽

Zhendong Yue ◽

Hongwei Zhao ◽

...

Keyword(s):

Risk Factors ◽

Hepatocellular Carcinoma ◽

Portal Hypertension ◽

Hepatic Encephalopathy ◽

Pressure Gradient ◽

Transjugular Intrahepatic Portosystemic Shunt ◽

Meld Score ◽

Portosystemic Shunt ◽

Portal Flow ◽

Intrahepatic Portosystemic Shunt

Aims: This study aimed at assessing the risk factors for hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) in patients with hepatocellular carcinoma (HCC) and portal hypertension. Method: Consecutive patients (n=279) with primary HCC who underwent TIPS between January 1997 and March 2012 at a single institution were retrospectively reviewed. Patients were followed up for 2 years. Pre-TIPS, peri-TIPS and post-TIPS clinical variables were reviewed using univariate and multivariate analyses to identify risk factors for HE after TIPS. Results: The overall incidence of HE was 41% (114/279). Multivariate analysis showed an increased odds for HE in patients with: >3 treatments with transcatheter arterial chemoembolization (TACE) and/or trans-arterial embolization (TAE) (odds ratio [OR], 4.078; 95% confidence interval [95%CI], 1.748-9.515); hepatopetal portal flow (OR, 2.362; 95%CI, 1.032-5.404); high portosystemic pressure gradient (OR, 1.198; 95%CI, 1.073-1.336) and high pre-TIPS MELD score (OR, 1.693; 95%CI, 1.390-2.062). Odds for HE were increased 1.693 fold for each 1-point increase in the MELD score, and 1.198 fold for each 1-mmHg decrease in the post-TIPS portosystemic pressure gradient. Conclusion: The identification of clinical variables associated with increased odds of HE may be useful for the selection of appropriate candidates for TIPS. Results suggest that an inappropriate decrease in the portosystemic pressure gradient might be associated with HE after TIPS. In addition, >3 treatments with TACE/TAE, hepatopetal portal flow, and high MELD score were also associated with increased odds of HE after TIPS. Key words: – – – .

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Adjustable Small-Diameter TIPS

10.1093/med/9780199986071.003.0081 ◽

2018 ◽

Author(s):

Zubin Irani ◽

Sara Zhao

Keyword(s):

Hepatic Encephalopathy ◽

Transjugular Intrahepatic Portosystemic Shunt ◽

Small Diameter ◽

Portosystemic Shunt ◽

Shunt Revision ◽

Metal Stents ◽

Ptfe Graft ◽

Variceal Hemorrhage ◽

Graft Material ◽

Intrahepatic Portosystemic Shunt

Transjugular intrahepatic portosystemic shunt (TIPS) was first described by Rosch et al. in 1969, and in 1982, Colopinto et al. described its first clinical application in a patient with cirrhosis and variceal hemorrhage. It was not until 1988 that the first metal-lined shunt was created, and in 1997 the first polytetrafluoroethylene (PTFE)-lined stent was used in humans for shunt revision after stenosis, created by pinning the Gore PTFE graft material between two metal stents. Introduced in 2000, the Viatorr stent graft is now the most commonly used device for TIPS. One of the major side effects of TIPS creation is hepatic encephalopathy (HE). This chapter discusses the adjustable small-diameter transjugular intrahepatic portosystemic shunt.

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TIPS in the Treatment of Variceal Bleeding

Digestive Disease Interventions ◽

10.1055/s-0038-1629915 ◽

2017 ◽

Vol 01 (04) ◽

pp. 265-271

Author(s):

Joseph Morrison ◽

Andrew Lipnik ◽

Ron Gaba

Keyword(s):

Variceal Bleeding ◽

Selection Criteria ◽

Gastric Varices ◽

Portosystemic Shunt ◽

Variceal Hemorrhage ◽

Life Threatening ◽

Intrahepatic Portosystemic Shunt ◽

Patient Selection Criteria ◽

Early Tips

AbstractVariceal bleeding is a life-threatening complication of portal hypertension. In recent years, transjugular intrahepatic portosystemic shunt (TIPS) creation has cemented a role in the management of acute refractory bleeding and recurrent variceal hemorrhage. This article aims to review the use of TIPS in patients with variceal bleeding, with a focus on accepted procedure indications, patient selection criteria, TIPS technique, clinical outcomes, and contemporary issues, such as early TIPS in acute variceal hemorrhage, the role of adjuvant embolotherapy, and TIPS utility for gastric varices.

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Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt in Patients with Recurrent Variceal Hemorrhage

Gastroenterology Research and Practice ◽

10.1155/2013/398172 ◽

2013 ◽

Vol 2013 ◽

pp. 1-5 ◽

Cited By ~ 16

Author(s):

Popovič Peter ◽

Zore Andrej ◽

Šurlan Popovič Katarina ◽

Garbajs Manca ◽

Skok Pavel

Keyword(s):

Hepatic Encephalopathy ◽

Transjugular Intrahepatic Portosystemic Shunt ◽

Endoscopic Therapy ◽

Observation Time ◽

Portosystemic Shunt ◽

Variceal Hemorrhage ◽

Portosystemic Encephalopathy ◽

Elective Treatment ◽

Intrahepatic Portosystemic Shunt ◽

The Difference

Purpose. The purpose of this study was to determine the incidence and predictors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic therapy (ET) in the elective treatment of recurrent variceal hemorrhage.Methods. Seventy patients were treated with elective TIPS and fifty-six patients with ET. Median observation time was 46.28 months in the TIPS group and 42.31 months in the ET group.Results. 30 patients (42.8%) developed clinically evident portosystemic encephalopathy in TIPS group and 20 patients (35.6%) in ET group. The difference between the groups was not statistically significant (P=0.542;χ2test). The incidence of new or worsening portosystemic encephalopathy was 24.3% in TIPS group and 10.7% in ET group. Multivariate analysis showed that ET treatment (P=0.031), age of>65years (P=0.022), pre-existing HE (P=0.045), and Child's class C (P=0.051) values were independent predictors for the occurrence of HE.Conclusions. Procedure-related HE is a complication in a minority of patients treated with TIPS or ET. Patients with increased age, preexisting HE, and higher Child-Pugh score should be carefully observed after TIPS procedure because the risk of post-TIPS HE in these patients is higher.

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Evolution of Retrograde Transvenous Obliteration Techniques

Seminars in Interventional Radiology ◽

10.1055/s-0038-1660796 ◽

2018 ◽

Vol 35 (03) ◽

pp. 185-193 ◽

Cited By ~ 1

Author(s):

Christopher Molvar ◽

Mihir Patel

Keyword(s):

Portal Pressure ◽

Hepatic Function ◽

Portosystemic Shunt ◽

Variceal Hemorrhage ◽

Esophageal Variceal ◽

Gastrorenal Shunt ◽

Life Threatening ◽

Intrahepatic Portosystemic Shunt ◽

Life Threatening Complication ◽

Gastric Variceal Hemorrhage

AbstractGastric variceal hemorrhage is a life-threatening complication of portal hypertension with a poorer prognosis compared with esophageal variceal hemorrhage. The presence of an infradiaphragmatic portosystemic shunt, often a gastrorenal shunt, allows for treatment with retrograde transvenous obliteration (RTO). RTO is an evolving treatment strategy, which includes balloon-assisted RTO, plug-assisted RTO, and coil-assisted RTO, for both gastric variceal hemorrhage and hepatic encephalopathy. RTO techniques are less invasive than transjugular intrahepatic portosystemic shunt creation, with the benefit of improved hepatic function, but at the expense of increased portal pressure. This article discusses the techniques of RTO, including patient eligibility, as well as technical and clinical outcomes, including adverse events.

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