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Refractory Hepatic Encephalopathy After Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors and Outcomes with Revision

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Abstract

Background and Aims

Hepatic encephalopathy (HE) is a common complication of elective transjugular intrahepatic portosystemic shunt (TIPS) placement and is often successfully medically managed. Risk factors for refractory hepatic encephalopathy (RHE) necessitating revision of TIPS are not well defined. We evaluated the incidence, predictors, and outcomes of post-TIPS RHE necessitating TIPS revision.

Methods

In a retrospective cohort study of 174 consecutive patients undergoing elective TIPS placement (2010–2015), we evaluated the incidence of post-TIPS RHE. Clinical demographics and procedural variables were collected. 1-year outcomes after revision were collected.

Results

Ten of 174 patients (5.7%) developed post-TIPS RHE requiring revision. Significant differences between RHE and non-refractory groups were shunt size > 8 versus ≤ 8 mm (18.5 vs. 3.4%, p = 0.001), history of HE (14 vs. 2%, p = 0.007), and serum albumin levels ≤ 2.5 versus > 2.5 g/dL (13.1 vs. 3.1%, p = 0.020). On multivariate analysis, shunt size  > 8 mm (p = 0.001), history of HE prior to TIPS (p = 0.006), and low serum albumin (≤ 2.5 g/dL) (p = 0.022) remained independent predictors of RHE, controlling for age and Model for End-Stage Liver Disease score. RHE improved in 8 of 10 patients but survival at 1 year without liver transplantation (LT) was only 10%.

Conclusion

While TIPS revision successfully improves RHE in most cases, 1-year mortality rates are high, limiting the value of revision in non-LT candidates. Patients with previous history of HE and low serum albumin levels prior to TIPS may benefit most from the use of shunt sizes < 8 mm to mitigate the risk of RHE.

Level of Evidence

Level 4, case series.

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Funding

This study was not funded.

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Authors and Affiliations

  1. Department of Internal Medicine, Banner University Medical Center Phoenix, Phoenix, AZ, USA

    Michael W. Rowley

  2. College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA

    Myunghan Choi

  3. Department of Interventional Radiology, Banner University Medical Center Phoenix, Phoenix, AZ, USA

    Steve Chen & Kevin Hirsch

  4. Transplant and Advanced Liver Disease Center, Banner University Medical Center Phoenix, 1441 N 12th Street, 2nd Floor, Phoenix, AZ, 85006, USA

    Anil B. Seetharam

  5. University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA

    Michael W. Rowley, Steve Chen, Kevin Hirsch & Anil B. Seetharam

Authors
  1. Michael W. Rowley
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  2. Myunghan Choi
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Correspondence to Anil B. Seetharam.

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Rowley, M.W., Choi, M., Chen, S. et al. Refractory Hepatic Encephalopathy After Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors and Outcomes with Revision. Cardiovasc Intervent Radiol 41, 1765–1772 (2018). https://doi.org/10.1007/s00270-018-1992-2

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  • DOI: https://doi.org/10.1007/s00270-018-1992-2

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