Combined Transjugular Intrahepatic Portosystemic Shunt Creation and Spontaneous Portosystemic Shunt Embolization for Hepatic Encephalopathy

Embolization of spontaneous portosystemic shunts (SPSS) causing hepatic encephalopathy (HE) in liver cirrhosis patients can prompt portal hypertension complications such as ascites and variceal bleeding. These sequelae can theoretically be mitigated while still addressing HE by trading the large anatomic/physiologic SPSS for a small synthetic shunt in the form of a transjugular intrahepatic portosystemic shunt (TIPS). This study assessed the preliminary clinical outcomes of combined TIPS plus SPSS embolization to manage medically refractory HE.

Materials and Methods: This IRB-approved single center retrospective descriptive study spanned 9 patients (5 male, mean age 62 years, mean MELD score 15) with liver disease and HE (mean West-Haven grade 3; 3/9, 33% hospitalized within 3-months pre-procedure) refractory to lactulose and rifaximin therapy who underwent both TIPS and SPSS embolization between 2018-2022. Five patients underwent concurrent TIPS and SPSS embolization, and 4 patients had staged procedures. Patients were maintained on lactulose and rifaximin post-procedure. Measured outcomes included post-procedural HE rates, change in West-Haven (WH) grade, HE associated hospitalizations, and post-procedural portal hypertension related adverse events.

Results: TIPS was successfully performed with the Viatorr Controlled Expansion stent in all cases (8 mm in 5 patients, 10 mm in 4 patients). Mean maximal SPSS diameter was 18 mm. SPSS embolization was successful in all cases after one (n=6) or two (n=3) procedure sessions. There was no difference in pre- vs. post procedure portosystemic pressure gradient (8.5 vs. 6.9 mm Hg, P=0.202). HE improved in 100% (9/9) cases and resolved in 44% (4/9) of cases. Mean decrease in WH grade was 2.2 (P< 0.0001). Only 1/9 (22%) patients were hospitalized for HE within 3-months after TIPS and complete SPSS embolization. No patients developed ascites or variceal hemorrhage during median 3 months follow-up.

Conclusion: Combined TIPS and SPSS embolization—trading a large physiologic shunt for a small manmade shunt—may be an effective approach to medically refractory HE by improving HE while mitigating PH-related complications that may arise due to isolated SPSS embolization. Further investigation in larger patient cohorts is needed to better characterize the clinical outcomes of this approach.