Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) creation is effective in treating the sequelae of decompensated liver cirrhosis—including medically refractory ascites and variceal bleeding—by decompressing the portal venous system through a manmade portosystemic conduit within the liver. However, the altered physiology in which splenomesenteric blood bypasses intrahepatic portal venous perfusion can precipitate varying degrees of hepatic encephalopathy (HE). While the majority of post-TIPS HE cases can be treated medically, some require escalated management strategies, including endovascular interventions to modify the indwelling TIPS and/or occlude competitive physiologic spontaneous portosystemic shunts. This review article details the epidemiology, risk factors, diagnosis, classification, and treatment of post-TIPS HE.

Keywords

interventional radiology - transjugular intrahepatic portosystemic shunt - hepatic encephalopathy - complication - embolization

Financial Support, Disclosures, and Conflicts of Interest

R.C.G. received (prior 36 months) research grants from U.S. National Institutes of Health (active), Society of Interventional Radiology (active), Guerbet USA LLC (active), U.S. Department of Defense (inactive), Janssen Research & Development LLC (inactive), NeoTherma Oncology (inactive), TriSalus Life Sciences (inactive); consultant/advisor for Sus Clinicals Inc. and Astellas Pharma. No other authors have disclosures.

^* Both authors contributed equally to this work.

Publication History

Article published online:
04 May 2023

• References

• 1 Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 2010; 51 (01) 306
• 2 Pereira K, Carrion AF, Martin P. et al. Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy. Liver Int 2015; 35 (12) 2487-2494
• 3 Schindler P, Heinzow H, Trebicka J, Wildgruber M. Shunt-induced hepatic encephalopathy in TIPS: current approaches and clinical challenges. J Clin Med 2020; 9 (11) 3784
• 4 American Association for the Study of Liver Diseases, European Association for the Study of the Liver. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. J Hepatol 2014; 61 (03) 642-659
• 5 Coronado WM, Ju C, Bullen J, Kapoor B. Predictors of occurrence and risk of hepatic encephalopathy after TIPS creation: a 15-year experience. Cardiovasc Intervent Radiol 2020; 43 (08) 1156-1164
• 6 Bai M, Qi X, Yang Z. et al. Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review. J Gastroenterol Hepatol 2011; 26 (06) 943-951
• 7 Casadaban LC, Parvinian A, Minocha J. et al. Clearing the confusion over hepatic encephalopathy after TIPS creation: incidence, prognostic factors, and clinical outcomes. Dig Dis Sci 2015; 60 (04) 1059-1066
• 8 Butterworth RF. Hepatic encephalopathy in cirrhosis: pathology and pathophysiology. Drugs 2019; 79 (Suppl. 01) 17-21
• 9 Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy – definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 2002; 35 (03) 716-721
• 10 Rose CF, Amodio P, Bajaj JS. et al. Hepatic encephalopathy: novel insights into classification, pathophysiology and therapy. J Hepatol 2020; 73 (06) 1526-1547
• 11 Allaire M, Walter A, Sutter O. et al. TIPS for management of portal-hypertension-related complications in patients with cirrhosis. Clin Res Hepatol Gastroenterol 2020; 44 (03) 249-263
• 12 Lv Y, Chen H, Luo B. et al. Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: a randomized controlled trial. Hepatology 2022; 76 (03) 676-688
• 13 Maleux G, Verslype C, Heye S, Wilms G, Marchal G, Nevens F. Endovascular shunt reduction in the management of transjugular portosystemic shunt-induced hepatic encephalopathy: preliminary experience with reduction stents and stent-grafts. AJR Am J Roentgenol 2007; 188 (03) 659-664
• 14 Bajaj JS, Cordoba J, Mullen KD. et al; International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN). Review article: the design of clinical trials in hepatic encephalopathy – an International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) consensus statement. Aliment Pharmacol Ther 2011; 33 (07) 739-747
• 15 Dharel N, Bajaj JS. Definition and nomenclature of hepatic encephalopathy. J Clin Exp Hepatol 2015; 5 (Suppl. 01) S37-S41
• 16 Mumtaz K, Ahmed US, Abid S, Baig N, Hamid S, Jafri W. Precipitating factors and the outcome of hepatic encephalopathy in liver cirrhosis. J Coll Physicians Surg Pak 2010; 20 (08) 514-518
• 17 Poudyal NS, Chaudhary S, Kc S. et al. Precipitating factors and treatment outcomes of hepatic encephalopathy in liver cirrhosis. Cureus 2019; 11 (04) e4363
• 18 Bohra A, Worland T, Hui S, Terbah R, Farrell A, Robertson M. Prognostic significance of hepatic encephalopathy in patients with cirrhosis treated with current standards of care. World J Gastroenterol 2020; 26 (18) 2221-2231
• 19 Kimer N, Gluud LL, Pedersen JS, Tavenier J, Møller S, Bendtsen F. The Psychometric Hepatic Encephalopathy Syndrome score does not correlate with blood ammonia, endotoxins or markers of inflammation in patients with cirrhosis. Transl Gastroenterol Hepatol 2021; 6: 8
• 20 Wuensch T, Ruether DF, Zöllner C. et al. Performance characterization of a novel electronic number connection test to detect minimal hepatic encephalopathy in cirrhotic patients. Eur J Gastroenterol Hepatol 2017; 29 (04) 456-463
• 21 Zeng X, Zhang LY, Liu Q. et al. Combined scores from the EncephalApp Stroop Test, number connection test B, and serial dotting test accurately identify patients with covert hepatic encephalopathy. Clin Gastroenterol Hepatol 2020; 18 (07) 1618-1625.e7
• 22 Li SW, Wang K, Yu YQ, Wang HB, Li YH, Xu JM. Psychometric hepatic encephalopathy score for diagnosis of minimal hepatic encephalopathy in China. World J Gastroenterol 2013; 19 (46) 8745-8751
• 23 Labenz C, Toenges G, Schattenberg JM. et al. Outcome prediction of covert hepatic encephalopathy in liver cirrhosis: comparison of four testing strategies. Clin Transl Gastroenterol 2020; 11 (06) e00172
• 24 Riggio O, Masini A, Efrati C. et al. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled study. J Hepatol 2005; 42 (05) 674-679
• 25 Liu J, Wehrenberg-Klee EP, Bethea ED, Uppot RN, Yamada K, Ganguli S. Transjugular intrahepatic portosystemic shunt placement for portal hypertension: meta-analysis of safety and efficacy of 8 mm vs. 10 mm stents. Gastroenterol Res Pract 2020; 2020: 9149065
• 26 Liu J, Ma J, Zhou C. et al. Potential benefits of underdilation of 8-mm covered stent in transjugular intrahepatic portosystemic shunt creation. Clin Transl Gastroenterol 2021; 12 (06) e00376
• 27 Wang CY, Xiong B, Liu JC. et al. [Effect of underdilated stent on the occurrence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation]. Zhonghua Nei Ke Za Zhi 2022; 61 (05) 537-542
• 28 Gaba RC, Parvinian A, Minocha J. et al. Should transjugular intrahepatic portosystemic shunt stent grafts be underdilated?. J Vasc Interv Radiol 2015; 26 (03) 382-387
• 29 Chen L, Xiao T, Chen W. et al. Outcomes of transjugular intrahepatic portosystemic shunt through the left branch vs. the right branch of the portal vein in advanced cirrhosis: a randomized trial. Liver Int 2009; 29 (07) 1101-1109
• 30 Xue H, Yuan J, Chao-Li Y. et al. Follow-up study of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension. Dig Dis Sci 2011; 56 (11) 3350-3356
• 31 Bai M, He CY, Qi XS. et al. Shunting branch of portal vein and stent position predict survival after transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2014; 20 (03) 774-785
• 32 Casado M, Bosch J, García-Pagán JC. et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998; 114 (06) 1296-1303
• 33 Chung HH, Razavi MK, Sze DY. et al. Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with Viatorr stent graft: what is the critical low threshold to avoid medically uncontrolled low pressure gradient related complications?. J Gastroenterol Hepatol 2008; 23 (01) 95-101
• 34 Bureau C, Thabut D, Jezequel C. et al. The use of rifaximin in the prevention of overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt: a randomized controlled trial. Ann Intern Med 2021; 174 (05) 633-640
• 35 Seifert LL, Schindler P, Schoster M. et al. Recurrence of hepatic encephalopathy after TIPS: effective prophylaxis with combination of lactulose and rifaximin. J Clin Med 2021; 10 (20) 4763
• 36 Kerlan Jr RK, LaBerge JM, Baker EL. et al. Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 1995; 6 (06) 917-921
• 37 Pattynama PM, Wils A, van der Linden E, van Dijk LC. Embolization with the Amplatzer vascular plug in TIPS patients. Cardiovasc Intervent Radiol 2007; 30 (06) 1218-1221
• 38 Sze DY, Hwang GL, Kao JS. et al. Bidirectionally adjustable TIPS reduction by parallel stent and stent-graft deployment. J Vasc Interv Radiol 2008; 19 (11) 1653-1658
• 39 Fanelli F, Salvatori FM, Rabuffi P. et al. Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt reduction with hourglass-shaped balloon-expandable stent-graft. AJR Am J Roentgenol 2009; 193 (06) 1696-1702
• 40 Blue RC, Lo GC, Kim E. et al. Transjugular intrahepatic portosystemic shunt flow reduction with adjustable polytetrafluoroethylene-covered balloon-expandable stents using the “sheath control” technique. Cardiovasc Intervent Radiol 2016; 39 (06) 935-939
• 41 Shah RJ, Alqadi MM, Duvvuri M. et al. Clinical outcomes and patency after transjugular intrahepatic portosystemic shunt reduction for overshunting adverse events. J Vasc Interv Radiol 2022; 33 (12) 1507-1512
• 42 Jacquier A, Vidal V, Monnet O. et al. A modified procedure for transjugular intrahepatic portosystemic shunt flow reduction. J Vasc Interv Radiol 2006; 17 (08) 1359-1363
• 43 Cookson DT, Zaman Z, Gordon-Smith J, Ireland HM, Hayes PC. Management of transjugular intrahepatic portosystemic shunt (TIPS)-associated refractory hepatic encephalopathy by shunt reduction using the parallel technique: outcomes of a retrospective case series. Cardiovasc Intervent Radiol 2011; 34 (01) 92-99
• 44 De Keyzer B, Nevens F, Laenen A. et al. Percutaneous shunt reduction for the management of TIPS-induced acute liver decompensation: a follow-up study. Ann Hepatol 2016; 15 (06) 911-917
• 45 Rowley MW, Choi M, Chen S, Hirsch K, Seetharam AB. Refractory hepatic encephalopathy after elective transjugular intrahepatic portosystemic shunt: risk factors and outcomes with revision. Cardiovasc Intervent Radiol 2018; 41 (11) 1765-1772
• 46 Joseph AS, Sandhu B, Khalil A, Lopera J. Transjugular portosystemic shunt reductions: a retrospective single-center experience. J Vasc Interv Radiol 2019; 30 (06) 876-884
• 47 Schindler P, Seifert L, Masthoff M. et al. TIPS modification in the management of shunt-induced hepatic encephalopathy: analysis of predictive factors and outcome with shunt modification. J Clin Med 2020; 9 (02) 567
• 48 Sarwar A, Esparaz AM, Chakrala N. et al. Efficacy of TIPS reduction for refractory hepatic encephalopathy, right heart failure, and liver dysfunction. AJR Am J Roentgenol 2021; 216 (05) 1267-1272
• 49 Laleman W, Simon-Talero M, Maleux G. et al; EASL-CLIF-Consortium. Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy. Hepatology 2013; 57 (06) 2448-2457
• 50 Álvarez-López P, Campos-Varela I, Quiroga S. et al. Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy. Ann Hepatol 2022; 27 (03) 100687