What are the potential side effects of a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure in a patient with liver disease, such as cirrhosis?

TIPS Side Effects and Complications

Hepatic encephalopathy is the most common and clinically significant complication of TIPS, occurring in 30-50% of patients, and should be the primary concern when counseling patients about this procedure. 1, 2

Major Complications

Hepatic Encephalopathy (Most Common)

• Incidence ranges from 25-50% in most series, with rates as high as 55-61% when systematically assessed 1, 2, 3
• The impact on quality of life can be devastating, with family members frequently reporting profound personality changes and cognitive decline 2
• Post-TIPS encephalopathy is more severe than that seen with large-volume paracentesis, despite similar overall incidence rates 1
• In approximately 8% of cases, hepatic encephalopathy persists despite optimal medical treatment, potentially requiring shunt reduction or occlusion 4

Risk factors for developing post-TIPS hepatic encephalopathy include: 2, 3

• Advanced age (older patients consistently have higher risk)
• Child-Pugh Class C, particularly score ≥10
• History of previous hepatic encephalopathy episodes
• Hyponatremia
• Renal dysfunction
• Sarcopenia
• Diabetes mellitus
• Larger stent diameter (>8mm increases refractory HE risk from 3.4% to 18.5%)

Acute Procedural Complications (Less Common)

The following complications occur in less than 5% of patients: 1

• Bleeding (including hemobilia and hemoperitoneum)
• Infection and sepsis
• Damage to blood vessels and bile ducts
• Fever

Cardiovascular Complications

• Heart failure can develop due to increased cardiac output, right atrial pressure, and pulmonary artery pressure 1
• Patients with diastolic dysfunction and ejection fraction of 50-60% are at particular risk for diastolic heart failure, which may shorten survival 1
• TIPS induces acute hemodynamic changes including increased cardiac output and secondary reduction in systemic vascular resistance 1

Renal Complications

• Acute kidney injury and renal failure can occur, particularly in patients with baseline renal dysfunction 1
• In patients with severe intrinsic renal disease (stage 4/5), elective TIPS is not recommended due to unacceptably high rates of severe encephalopathy 1
• Higher baseline creatinine is associated with lesser natriuretic effect and increased frequency of hepatic encephalopathy 1

Hepatic Complications

• Liver failure can develop, particularly in patients with advanced liver disease 1
• Hepatic infarction is a rare but serious complication that can greatly complicate the course in patients with already compromised liver function 5
• Progressive liver failure may occur despite initial stability 5

Shunt-Related Complications

• Shunt thrombosis and stenosis occur in up to 80% of cases with uncovered stents 1
• Modern polytetrafluoroethylene-covered stents have significantly reduced this complication rate 1
• Regular surveillance with Doppler ultrasound at 6-12 month intervals is necessary 4

Absolute Contraindications (When TIPS Should Not Be Performed)

The following are accepted contraindications regardless of clinical setting: 1

• Significant pulmonary hypertension
• Heart failure or severe cardiac valvular insufficiency
• Rapidly progressive liver failure
• Severe or uncontrolled hepatic encephalopathy
• Uncontrolled systemic infection or sepsis
• Unrelieved biliary obstruction
• Polycystic liver disease (though successful case reports exist)
• Extensive primary or metastatic hepatic malignancy

Risk Mitigation Strategies

To minimize complications, the following pre-procedural assessment is essential: 1

• Specialized scans to evaluate liver and surrounding vessels
• Liver and kidney function tests
• Coagulation studies
• Cardiac function testing
• Nutritional/dietary assessment
• Testing for covert/minimal hepatic encephalopathy using psychometric hepatic encephalopathy score (PHES) and critical flicker frequency (CFF) testing 2

Technical modifications to reduce hepatic encephalopathy risk: 2

• Use smaller diameter controlled-expansion stents (8mm vs >8mm) for elective TIPS in ascites
• Consider staged dilation approach rather than full dilation at initial placement 4

Management of Post-TIPS Complications

When hepatic encephalopathy develops: 2

• First-line treatment: lactulose and rifaximin per standard HE treatment guidelines
• For persistent or refractory HE despite maximal medical therapy: consider TIPS stent diameter reduction or occlusion

Common pitfall: TIPS in patients with very advanced liver disease (Child-Pugh >13 points), encephalopathy, and multi-organ failure does not usually alter patient outcomes and should be avoided 1