CardioVascular and Interventional Radiology

, Volume 41, Issue 11, pp 1765–1772 | Cite as

Refractory Hepatic Encephalopathy After Elective Transjugular Intrahepatic Portosystemic Shunt: Risk Factors and Outcomes with Revision

  • Michael W. Rowley
  • Myunghan Choi
  • Steve Chen
  • Kevin Hirsch
  • Anil B. SeetharamEmail author
Clinical Investigation
Part of the following topical collections:
  1. TIPS


Background and Aims

Hepatic encephalopathy (HE) is a common complication of elective transjugular intrahepatic portosystemic shunt (TIPS) placement and is often successfully medically managed. Risk factors for refractory hepatic encephalopathy (RHE) necessitating revision of TIPS are not well defined. We evaluated the incidence, predictors, and outcomes of post-TIPS RHE necessitating TIPS revision.


In a retrospective cohort study of 174 consecutive patients undergoing elective TIPS placement (2010–2015), we evaluated the incidence of post-TIPS RHE. Clinical demographics and procedural variables were collected. 1-year outcomes after revision were collected.


Ten of 174 patients (5.7%) developed post-TIPS RHE requiring revision. Significant differences between RHE and non-refractory groups were shunt size > 8 versus ≤ 8 mm (18.5 vs. 3.4%, p = 0.001), history of HE (14 vs. 2%, p = 0.007), and serum albumin levels ≤ 2.5 versus > 2.5 g/dL (13.1 vs. 3.1%, p = 0.020). On multivariate analysis, shunt size  > 8 mm (p = 0.001), history of HE prior to TIPS (p = 0.006), and low serum albumin (≤ 2.5 g/dL) (p = 0.022) remained independent predictors of RHE, controlling for age and Model for End-Stage Liver Disease score. RHE improved in 8 of 10 patients but survival at 1 year without liver transplantation (LT) was only 10%.


While TIPS revision successfully improves RHE in most cases, 1-year mortality rates are high, limiting the value of revision in non-LT candidates. Patients with previous history of HE and low serum albumin levels prior to TIPS may benefit most from the use of shunt sizes < 8 mm to mitigate the risk of RHE.

Level of Evidence

Level 4, case series.


TIPS Hepatic encephalopathy Shunt reduction Shunt closure Nutrition 



This study was not funded.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

For this type of study formal consent is not required.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2018

Authors and Affiliations

  • Michael W. Rowley
    • 1
    • 5
  • Myunghan Choi
    • 2
  • Steve Chen
    • 3
    • 5
  • Kevin Hirsch
    • 3
    • 5
  • Anil B. Seetharam
    • 4
    • 5
    Email author
  1. 1.Department of Internal MedicineBanner University Medical Center PhoenixPhoenixUSA
  2. 2.College of Nursing and Health InnovationArizona State UniversityPhoenixUSA
  3. 3.Department of Interventional RadiologyBanner University Medical Center PhoenixPhoenixUSA
  4. 4.Transplant and Advanced Liver Disease CenterBanner University Medical Center PhoenixPhoenixUSA
  5. 5.University of Arizona College of Medicine PhoenixPhoenixUSA

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