E3483. Endovascular Management for Refractory Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation
  1. Jacob Schneider; University of Nebraska Medical Center
  2. John Burt; University of Nebraska Medical Center
  3. Andrew Mezher; University of Nebraska Medical Center
  4. Lei Yu; University of Nebraska Medical Center
Hepatic encephalopathy (HE) is commonly seen in patients who have undergone transjugular intrahepatic portosystemic shunt (TIPS) placement for variceal bleeding and/or refractory ascites. Most patients with mild HE respond well to medical management alone. However, a small percentage of patients develop refractory HE despite maximal medical therapy and require liver transplantation or endovascular intervention such as TIPS reduction and TIPS occlusion.

Educational Goals / Teaching Points
This exhibit discusses the contributing factors, classification, and medical management of HE following TIPS placement. Secondly, it presents techniques for TIPS occlusion in the management of refractory HE. Lastly, it compares various TIPS reduction methods, highlighting technique considerations, complications, and postprocedure care.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
TIPS is pivotal in managing portal hypertension and its sequelae, including variceal bleeding and refractory ascites. TIPS procedures are extraordinarily effective at reducing portal pressures, but new or worsening HE is frequently encountered after TIPS placement. Diverting portal venous flow from the liver and the lack of liver filtration of ammonia leads to hyperammonemia and HE. Dietary modification, with lactulose and rifaximin are used to manage patients with mild HE. Refractory HE requires endovascular intervention to occlude or downsize the portosystemic shunt. Shunt occlusion is achieved by placing coils or vascular plugs within TIPS. Occlusion is usually not a favorable choice as fatal sequela can occur, such as variceal bleeding might recur. Multiple shunt reduction techniques have been described. Two main types of reduction (parallel and hourglass techniques) use a bare metal stent or stent graft and will be discussed using schematic illustrations. Case presentations will highlight clinical management and decision-making processes, key technique steps, stent choices for reduction, fluoroscopic monitoring to identify intraoperative complications, and postprocedure management.

Refractory HE is a serious and debilitating complication of TIPS creation and can be successfully managed with endovascular interventions. It is crucial to be familiar with the different TIPS reduction techniques and how to optimize endovascular management based on the patient’s circumstance and their unique anatomy.