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Objective:
To evaluate the efficacy and safety of the transjugular intrahepatic portosystemic shunt (TIPSS) for the treatment of refractory hepatic hydrothorax (RHH) in patients with cirrhosis.

Materials and Methods:
Retrospective review of patients with cirrhosis and RHH underwent TIPSS procedures at our institution between 2010 to 2022 was performed. The demographic data, operative data, outcomes, complications, and postoperative follow up were analyzed.

Results:
A total of 42 patients with RHH underwent TIPSS at our institution from 2110 to 2022. Two patients were excluded as no follow-up was available. Forty patients were included in this study, 24 (60%) men and 16 women (40%). The average age at the time of TIPSS was 56 years. Etiologies of liver disease were alcoholic cirrhosis in 12 patients (30%), hepatitis C (HCV) in 13 (32.5%) patients, nonalcoholic steatohepatitis in 5 (12.5%) patients, cryptogenic cirrhosis in 5 (12.5%) patients, primary biliary cirrhosis (PBC) in 4 (10%) patients, and one (2.5%) patient with autoimmune hepatitis. Pre-TIPSS mean of Model for End Stage Liver Disease (MELD) score was 13. The diameter of the stent was 10 mm in 27 (67.5%) patients and 8 mm in 13 (33.5%) patients. The average pre-TIPSS portosystemic gradient (PSG) was 18 mmHg, and the average post-TIPSS gradient was 6 mmHg. The mean follows up time was 12 months. At 6 weeks after TIPSS, 35 patients did not require thoracentesis, 4 patients underwent one thoracentesis, and one patient underwent chest tube placement. At 12 weeks after TIPSS, 31 patients required no thoracentesis, 4 underwent one thoracentesis, two patients required additional interventions (one pleurx and one pleurodesis), one patient underwent liver transplantation and two patients died. At 24 weeks after TIPSS, 21 patients required no thoracentesis, five patients required chest tubes, one patient had recurrent hydrothorax, one additional patient underwent liver transplantation, and nine patients died. Twenty-seven (67.5%) patients developed hepatic encephalopathy after the procedure. Two (5%) patients underwent liver transplantation within one year of the TIPSS. Thirty-day mortality after TIPSS was reported. The mortality rate at 1 year was 32.5%.

Conclusion:
TIPSS is an effective treatment option for refractory HH with 77.7% clinical success rate at 6 months after TIPSS. However, TIPSS for RHH is associated with higher risk of encephalopathy (67.5%) compared to TIPSS for RA (20 - 50%) with a similar 1-year mortality rate at 33%.