What is the most common complication following Transjugular Intrahepatic Portosystemic Shunt (TIPS)?

Hepatic Encephalopathy is the Most Common Complication Following TIPS

The most common complication following Transjugular Intrahepatic Portosystemic Shunt (TIPS) is hepatic encephalopathy (HE), which occurs in 30-55% of patients. 1

Incidence and Pathophysiology

• Hepatic encephalopathy after TIPS has been reported with incidence rates as high as 55%, making it the most frequently encountered post-procedural complication 1
• The development of post-TIPS HE is directly related to the portosystemic shunting that allows neurotoxic substances (particularly ammonia) to bypass hepatic metabolism and reach the brain 1
• The rate of HE is dependent on patient factors and assessment methods, with more thorough evaluation identifying higher incidence rates 1

Risk Factors for Post-TIPS Hepatic Encephalopathy

• Age - older patients have higher risk of developing post-TIPS HE 1
• Severity of liver disease - Child-Pugh score ≥10 is associated with increased risk 1
• History of previous episodes of hepatic encephalopathy 1
• Size of the shunt - larger diameter stents are associated with higher rates of encephalopathy 1
• Diabetes mellitus - recently recognized as a risk factor, possibly due to altered renal handling of ammonia 1
• Non-alcoholic etiology of liver disease - associated with 9.2 times higher relative risk compared to alcoholic liver disease 2
• Female gender - associated with 3 times higher relative risk 2
• Hypoalbuminemia - each 1 g/dL decrease associated with 2.2 times higher relative risk 2

Clinical Presentation and Impact

• Post-TIPS HE can range from mild cognitive changes to severe confusion and coma 1
• The impact on quality of life can be devastating, with family members often reporting profound changes in cognition and personality 1
• Common descriptions from caregivers include phrases like "I no longer recognize my husband/wife" 1
• Most cases (78%) can be controlled with medical therapy, but approximately 22% may progress despite treatment 2

Prevention and Management Strategies

• Pre-TIPS assessment should include thorough evaluation for risk factors of HE, especially in elective procedures 1
• History of debilitating encephalopathy is considered a contraindication to TIPS, particularly in emergency settings 1
• Smaller diameter stents (8mm vs 10mm) may be considered to reduce the risk of HE, though this must be balanced against the risk of inadequate portal pressure reduction 1
• Adjunctive embolization of competing shunts (like spontaneous splenorenal shunts) may help preserve portal blood flow and reduce HE risk 1
• First-line medical management includes:
  • Protein-restricted diet 3
  • Non-absorbable disaccharides (lactulose) 3
  • Non-absorbable antibiotics (rifaximin) 3
• For refractory cases (3-7% of patients), more invasive approaches may be needed:
  • Shunt reduction using constrained stents or stent-grafts 3
  • Shunt occlusion with coils or balloons in severe cases 3
  • Liver transplantation in suitable candidates 3

Other Complications of TIPS

While hepatic encephalopathy is the most common complication, other potential complications include:

• Procedural bleeding (hemobilia, hemoperitoneum) - occurs in <10% of cases 1
• Shunt thrombosis and stenosis - particularly common with uncovered stents (up to 80%) 1
• Hepatic ischemia - rare but can occur due to altered blood flow 1
• Infection - including TIPS-related infection ("TIPSSitis") 1
• Cardiac complications - including heart failure due to increased cardiac output 1

Conclusion

Hepatic encephalopathy is definitively the most common complication following TIPS placement, occurring in 30-55% of patients. Proper patient selection, risk assessment, and management strategies are essential to minimize this significant complication and improve outcomes.