Thursday, December 27, 2012

Endovascular Management of TIPS-related Hepatic Encephalopathy

Hepatic encephalopathy is a common complication that occurs after creation of a TIPS shunt. It is typically managed conservatively with modifications in diet and medication. In patients who do not respond to conservative management, liver transplantation may be an option. Some endovascular techniques aimed at reducing the amount of blood shunted away from the liver may also be employed.
  • shunt occlusion via embolic agents
    • has risk of variceal rebleeding
    • sudden changes in hemodynamics (cardiac output, hypotension, metabolic acidosis) can be fatal
    • reversible shunt occlusion using short term balloon occlusion of the TIPS can prevent complications from variceal rebleeding (occlusive balloon can be deflated if life threatening bleeding occurs and thus TIPS can be reopened)
  • shunt reduction
    • using constrained stents to reduce the lumen of the shunt
    • makes it difficult to regulate blood flow through the shunt, especially around the constrained portions
      • adjunct embolization of the dead space around the shunt can be performed
      • use of constrained covered stent grafts has allowed better control of flow through the shunt while reducing its lumen
  • retrograde embolization of a splenorenal shunt with ethanolamine oleate
    • can only be done when a spontaneous splenorenal shunt is present
    • maintains patency of TIPS
    • severe renal dysfunction and pulmonary edema are among some of the side effects of ethanolamine usage
Madoff DC, Wallace MJ, Ahrar K, et al. TIPS-related hepatic encephalopathy: management options with novel endovascular techniques. Radiographics 2004;24:21-36.

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