Management of Refractory Hepatic Encephalopathy After Insertion of TIPS: Long-Term Results of Shunt Reduction With Hourglass-Shaped Balloon-Expandable Stent-Graft

OBJECTIVE. The purpose of this study was to review the use of an hourglass-shaped expanded polytetrafluoroethylene (ePTFE) stent-graft to reduce transjugular intrahepatic portosystemic shunts in patients with hepatic encephalopathy refractory to conventional medical therapy. MATERIALS AND METHODS. From January 2000 through December 2008, 189 transjugular intrahepatic portosystemic shunt procedures were performed with self-expanding stent-grafts. After a mean period of 43.4 +/- 57 weeks, hepatic encephalopathy developed in 12 patients and did not respond to conventional medical therapy with lactulose, nonabsorbable antibiotics, and a protein-restricted diet. In all cases, shunt reduction was performed with an hourglass-shaped balloon-expandable ePTFE stent-graft inserted into the original shunt. RESULTS. Technically successful shunt reduction with an immediate increase in portosystemic gradient was achieved in all patients. Symptoms of hepatic encephalopathy disappeared a mean of 22.3 hours (range, 18-26 hours) after the procedure. After a mean follow-up period of 73.9 +/- 61.88 weeks, no recurrence of hepatic encephalopathy was found. One patient (8.3%) needed dilation of the hourglass-shaped stent-graft after 37 weeks because of recurrence of ascites. At the end of the study, five patients (41.6%) were alive in good clinical condition. Four patients (33.3%) died of cardiovascular failure 1, 2, 24, and 96 weeks after the corrective procedure. Eight months after the reduction procedure, one patient (8.3%) underwent orthotopic liver transplantation, which resulted in clinical improvement. Two patients (16.6%) were lost to follow-up 15.6 and 46.8 weeks after the procedure. CONCLUSION. Shunt reduction with an hourglass-shaped ePTFE balloon-expandable stent-graft seems effective in reducing shunt flow and rapidly improving the patient's clinical condition. With this technique, shunt diameter can be modified on the basis of the patient's clinical condition.