Severe Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt (TIPS): Value of Shunt Reduction and Occlusion

Hepatic encephalopathy (HE) after implantation of the transjugular intrahepatic portosystemic Shunt (TIPS) is generally well treatable. Severe and refractory HE might be treated with shunt reduction or occlusion. We performed a retrospective study between January 2004 and January 2016. Out of 456 TIPS implantations, 17 patients (3,7%) were treated with shunt reduction and 6/17 patients with additional shunt occlusion. 16 patients received an uncovered reducing stent, 1 patient a balloon expandable metallic stent. Occlusion was performed with bucrylatorvascular plugs.TIPS implantation was performed due to ascites in 8 patients (47,1%) and variceal bleeding in 7 patients (41,2%). Three patients (17,6%) had grad I HE before TIPS. Portal systemic gradient (PSG) dropped from 21 to 8mmHg. After a median follow up time of 2.3 months TIPS reduction was performed due to refractory HE. Five patients with liver failure and/or multi organ failure before TIPS reduction died within 4 weeks. Six patients received shunt occlusion due to missing success of shunt reduction. PSG increased from 10 to 12mmHg after reduction and from 16 to 29mmHg after occlusion. Improvement of HE was observed in 10 patients (59%). Four patients showed again refractory ascites, 1 patient variceal bleeding. TIPS reduction and/or occlusion can lead to improvement of post-TIPS HE. But it leads to increase of PSG and therefore can be responsible of reappearance of ascites or varices. Patients with liver failure do not benefit of shunt reduction / occlusion.