P0761 - Post-TIPS Hepatic Infarction

Sunday, October 24, 2021

3:30 PM – 7:00 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Award: Presidential Poster Award

Presenting Author(s)

Omar Khan, MD

Louisiana State University Health Sciences Center
Shreveport, LA, United States

Award: Presidential Poster Award

Omar Khan, MD, Christopher Oglesby, DO, Hrishikesh Samant, MD
Louisiana State University Health Sciences Center, Shreveport, LA

Introduction: Trans jugular intrahepatic portosystemic shunts (TIPS) are a strategy used in cirrhotic patients who have refractory ascites or variceal bleeding, or hepatorenal syndrome. TIPS aim at reducing portal pressure by bypassing the portal system via shunt from the portal vein to the hepatic vein. Complications include stent migration, hemorrhage, hepatic encephalopathy, hepatic infarction, and acute liver failure.

Case Description/Methods: A 64-year-old gentleman with a past medical history of alcoholic liver cirrhosis (MELD 11, Childs-Pugh C) with esophageal varices and hepatic encephalopathy, hepatitis C in remission, hypertension, vitamin D deficiency, tobacco use, and history of marijuana use presented for an elective TIPS procedure due to refractory ascites, as well as concern for FLOOD syndrome of a new necrotic left inguinal hernia with leaking ascitic fluid and an umbilical hernia. Prior to admission, the patient was undergoing paracentesis every 2 weeks with about 10 liters removed each time, despite being on a maximum tolerated dose of diuretics. On admission, the patient had unremarkable liver chemistries and coagulation profile. After the TIPS procedure, the liver enzymes and coagulation profile began to rise, but with no change in the patient’s mentation. A CT of the abdomen/pelvis noted an infarction in segments 6 & 7 suggestive of an intrahepatic right portal vein thrombosis. Supportive care and heparin drip were then initiated for 2 days with 3 days of full dose lovenox on discharge. The patient had a subsequent near normalization of INR and liver enzymes within one week. The FLOOD syndrome and ulcerated region completely resolved within 2 weeks.

Discussion: In cirrhosis, the fibrotic liver tissue increases the resistance in portal pressure against blood flow, leading to complications such as ascites and varices. These can be mitigated with TIPS in select patients. Post-TIPS hepatic infarction is a rare complication without a definitive pathophysiology but is postulated to be due to either relative hypoperfusion with redirection of blood into systemic circulation, possible hepatic vein thrombosis, direct injury to hepatic artery during procedure, or occlusion/malfunction of the TIPS itself. Treatment depends on the severity of the injury. If fulminant liver failure is present, the stent should undergo occlusion and reduction. If there is infarction without evidence of acute liver failure, supportive care is sufficient with short term anticoagulation if a thrombus is suspected.

Figure: Figure 1: CT Abd/pelvis prior to TIPS
Figure 2: inguinal hernia with Suspected FLOOD syndrome
Figure 3: CT Abd/Pelvis post-TIPS with wedge infarct in segment VI and VII with findings suggestive of right portal vein thrombosis
Figure 4: CT Abd/Pelvis post-TIPS visualizing stent placement

	Admission	Day 1 AM s/p TIPS	Day 1 PM s/p TIPS	Day 2 s/p TIPS	Day 3 s/p TIPS
AST	23	631	3444	2383	733
ALT	16	273	1235	1174	640
Total Bilirubin	0.3	0.8	0.8	1.2	0.7
Prothrombin Time	12.7			16.6
INR	1.11			1.44
Activated Partial Thromboplastin Time				32.4	105.2

Table: Transaminase and Coagulation Profiles

Disclosures:

Omar Khan indicated no relevant financial relationships.

Christopher Oglesby indicated no relevant financial relationships.

Hrishikesh Samant indicated no relevant financial relationships.

Omar Khan, MD, Christopher Oglesby, DO, Hrishikesh Samant, MD. P0761 - Post-TIPS Hepatic Infarction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.