Clinical experience with transjugular intrahepatic portosystemic shunt downsizing in patients with severe hepatic encephalopathy

Purpose: The purpose of this study was to evaluate the outcomes of Transjugular Intrahepatic Shunt (TIPS) downsizing in the setting of severe hepatic encephalopathy. Data regarding outcomes and factors influencing these outcomes is relatively scarce. This follows a cohort of patients at a tertiary care center who underwent TIPS revision, in an effort to determine the efficacy and complication rate of the intervention. Materials: A list of patients with underlying cirrhosis undergoing TIPS procedures between 2013-2019 at a large volume tertiary care center was obtained. Data collected included patient demographics, reason for TIPS, whether downsizing occurred, reason for downsizing, frequency of paracentesis prior to and after downsizing, grade of hepatic encephalopathy prior to and after downsizing, MELD labs prior to and after downsizing, IR technique used for downsizing, whether patients were liver transplant candidates and/or underwent transplantation, and mortality. Results: A total of 195 patients underwent TIPS placement between 2013-2019. Of those, 16 patients required TIPS downsizing using a balloon-expandable covered stent. The mean MELD was 18.4 just prior to downsizing and 17.6 one week after downsizing. The mean portosystemic gradient was 10.5 mm Hg before downsizing and 22.8 mm Hg after downsizing. TIPS downsizing was successful in decreasing the degree of hepatic encephalopathy from an average of grade 2.8 to grade 0.8 encephalopathy. Nine patients died with post-downsizing gradients of 28-29 mm Hg being among the highest. The two patients who survived to transplant within 8 months of their TIPS had pre and post-downsizing MELD scores of 15 or less. Conclusions: The results of the study suggest TIPS downsizing is effective in reducing hepatic encephalopathy. Most patients who were considered transplant candidates undergoing TIPS downsizing did not survive to transplant unless they were transplanted relatively shortly after TIPS, suggesting that TIPS/downsizing served more as short-term bridge to transplant in these patients. Those that died expectedly had higher MELD scores and post-downsizing portosystemic gradients. Limitations of this study are the small patient size and that it was single center