Management of transjugular intrahepatic portosystemic shunt (TIPS)-associated refractory hepatic encephalopathy by shunt reduction using the parallel technique: outcomes of a retrospective case series.
OBJECTIVE
To investigate the reproducibility and technical and clinical success of the parallel technique of transjugular intrahepatic portosystemic shunt (TIPS) reduction in the management of refractory hepatic encephalopathy (HE).


METHODS
A 10-mm-diameter self-expanding stent graft and a 5-6-mm-diameter balloon-expandable stent were placed in parallel inside the existing TIPS in 8 patients via a dual unilateral transjugular approach. Changes in portosystemic pressure gradient and HE grade were used as primary end points.


RESULTS
TIPS reduction was technically successful in all patients. Mean ± standard deviation portosystemic pressure gradient before and after shunt reduction was 4.9 ± 3.6 mmHg (range, 0-12 mmHg) and 10.5 ± 3.9 mmHg (range, 6-18 mmHg). Duration of follow-up was 137 ± 117.8 days (range, 18-326 days). Clinical improvement of HE occurred in 5 patients (62.5%) with resolution of HE in 4 patients (50%). Single episodes of recurrent gastrointestinal hemorrhage occurred in 3 patients (37.5%). These were self-limiting in 2 cases and successfully managed in 1 case by correction of coagulopathy and blood transfusion. Two of these patients (25%) died, one each of renal failure and hepatorenal failure.


CONCLUSIONS
The parallel technique of TIPS reduction is reproducible and has a high technical success rate. A dual unilateral transjugular approach is advantageous when performing this procedure. The parallel technique allows repeat bidirectional TIPS adjustment and may be of significant clinical benefit in the management of refractory HE.
Department of Radiology, Royal Infirmary, Little France, Edinburgh, EH16 4SA, Scotland, UK. danielthomascookson@yahoo.co.uk
Daniel T
DT
Cookson
Zubayr
Z
Zaman
James
J
Gordon-Smith
Hamish M
HM
Ireland
Peter C
PC
Hayes
D000368:Aged; D002404:Catheterization; D016099:Endoscopy, Gastrointestinal; D005260:Female; D006501:Hepatic Encephalopathy / Q000601:surgery*; D006801:Humans; D007601:Jugular Veins / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome