Clinical Outcomes and Efficacy of TIPS Downsizing in a Large Academic Medical Center

Purpose: The transjugular intrahepatic portosystemic shunt (TIPS) placement is a cornerstone in treating the complications of portal hypertension. One of the most well-known complications of the procedure is the onset of hepatic encephalopathy (HE). TIPS downsizing is a recognized intervention for medically refractory HE. We evaluated patient factors associated with the efficacy and morbidity/mortality of TIPS downsizing.

Materials and Methods: A retrospective study was conducted at Emory University Hospitals with institutional review board approval. Patients who underwent TIPS downsizing were identified during two study periods: March 2010–September 2013 and October 2022–January 2025. Records of 150 TIPS revision cases were identified. 126 were excluded for not representing downsizing procedures. Twenty-four records were reviewed, and 3 were excluded for lacking available EHR data. The final cohort included 21 cases (18 downsizes and 3 complete closures). Clinical and demographic data were extracted from the medical record. The primary outcome was resolution of HE following downsizing. Statistical analysis was performed using SPSS (IBM Corp., Armonk, NY).

Results: Among 21 cases (62±11 years; 38% females; 14% Black, 81% White; 100% non-Hispanic), 18 were downsizes and 3 were closures. 14 (70%) cases used the hourglass technique; the remaining 4 were done by stent relining. The leading indication for downsize was refractory HE in 19 (90%) of cases. After downsizing, only 9 (43%) had documented HE resolution. On univariate analysis, the West Haven HE Grade (p = 0.014) was significantly associated with HE resolution, with lower initial grades predicting a higher likelihood of symptom improvement. Use of dialysis (p = 0.888) and change in ammonia (p = 0.226) were not significant. Determination of mean time to symptom resolution was limited by inconsistent documentation within the medical record.

Conclusion: When determining the need and potential outcome for reduction of a TIPS, West Haven grading may be the highest yield clinical metric. Patients with a West Haven score of ≤ 2 may be more likely to have resolution of symptoms after downsizing. Ammonia may not be a valid data point to follow for HE.