Management Of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt With The Reducing Stent

Background and Objective:Transjugular intrahepatic portosystemic shunt(TIPS)is a method of placing an expandable metal stent into the liver parenchyma through the jugular vein and hepatic vein catheter,establishing a shunt of the intrahepatic portal vein and hepatic vein to reduce the pressure of the portal vein,which has become an important strategy in the management of complications of portal hypertension(PHT).Since 1988,Rossle et al.used TIPS for clinical treatment of variceal hemorrhage for the first time,TIPS has established relatively complete operating standards,indications and contraindications.However,the two major problems of restenosis and hepatic encephalopathy(HE)after TIPS have always plagued the development of TIPS.Recently,with the use of polytetrafluoroethylene(PTFE)-covered stent grafts,complications such as restenosis and thrombosis after TIPS have been reduced,and stent patency has been improved.However,post-TIPS HE remains a concern.Although the incidence of overt hepatic encephalopathy(OHE)did not increase after placement of PTFE-covered stent,the incidence(24%)was still high,which severely restricted the application of TIPS in the treatment of portal hypertension.Treatment strategies for post-TIPS HE vary depending on the clinical manifestation.In patients with episodic post-TIPS HE,treatment is focused on general management,nutritional support,identification and correction of the precipitating events.In general,standard medical treatment includes lactulose and rifaximin.However,approximately 3-7%of patients have recurrent or persistent HE despite compliance with medical therapy.Endovascular intervention has played an important role in improving post-TIPS HE.Endovascular techniques include shunt occlusion and shunt reduction.The rapid increase of postoperative portal pressure and the occurrence of recurrent variceal hemorrhage and increased risk of ascites restrict the development of shunt occlusion.Therefore,shunt reduction plays a key role in the management of post-TIPS HE.Our study is to examine the safety and efficiency of a constrained,hourglass shape stent device with a silk suture in the management of TIPS-related HE.Materials and Methods:We conducted a retrospective analysis of 8 patients with post-TIPS HE and performed shunt reduction with a constrained,hourglass shape stent device because of the onset of severe hepatic encephalopathy refractory to a protein-restricted diet and conventional medical therapy with lactulose and rifaximin from Shandong Provincial Hospital Affiliated to Shandong University from June 2008 to June 2018.They were followed up until death or September 2018.Follow up patients'general condition,hepatic encephalopathy,gastrointestinal bleeding,ascites and other symptoms,treatment measures,stent patency and additional treatment,death time,cause of death and other events.Statistical analysis was performed using SPSS 25.0 statistical software.The results were expressed as mean ± standard deviation,and t-test was used for comparison between variables.Results:1.Eight patients were successfully operated in one operation,and the technical success rate was 100%.2.The portal vein pressure before the shunt reduction was 14.63±6.82 mmHg(range 7-26 mmHg)and postoperative 25.25±9.60 mmHg(range 13-43 mmHg).The difference was statistically significant(paired t-test,t=6.315,p<0.001).HE symptoms were alleviated,and the HE grade was reduced from grade ?-? to grade 0-I.3.Five patients were currently alive,two patients died,and one patient was lost to follow-up.The mean follow-up time was 167 weeks(range 15-486 weeks).During the follow-up,one patient died of liver cancer and liver failure at 56 weeks after shunt reduction,and one patient died of upper gastrointestinal bleeding at 392 weeks after shunt reduction.No hepatic encephalopathy occurred.Two patients suffered from symptoms of hepatic encephalopathy at 8 and 15 weeks postoperatively,which was relieved after drug treatment.Two patients with upper gastrointestinal hemorrhage after shunt reduction were treated with endoscopic therapy and no hepatic brain symptoms occurred.One patient suffered from shunt dysfunction and was treated with a second TIPS.This patient did not have symptoms of hepatic encephalopathy at the end of follow-up.Conclusion:The use of suture-constrained PTFE-covered stent for the treatment of post-TIPS HE is safe and effective.