S3518 Acute Liver Injury Due to Hepatic Infarction After Transjugular Intrahepatic Portosystemic Shunt (TIPS)

INTRODUCTION: Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement addresses portal hypertension by reducing portosystemic pressure gradient by shunting blood from the portal vein to the hepatic vein. Common indications for TIPS are refractory or recurrent bleeding and refractory ascites. TIPS procedures carry a 1-2% mortality rate and common complications include stent dysfunction and hepatic encephalopathy (HE). Hepatic infarction is a rare but serious complication. This is a case of acute liver injury from hepatic infarction after TIPS procedure due, in part, to hepatic artery compression. CASE DESCRIPTION/METHODS: A 50-year-old male with history of decompensated alcoholic cirrhosis, ascites, and bleeding esophageal varices (EV) presented with hematemesis 2 weeks after initial variceal band ligation. Upper endoscopy showed high risk varices and frank blood throughout the stomach. Attempted EV band ligation resulted in recurrent variceal hemorrhage and intra-procedure cardiac arrest with return of spontaneous circulation after 10 minutes. A Minnesota tube was inserted, massive transfusion protocol initiated, and he was transferred to our tertiary care center. Emergent TIPS was performed with a final portosystemic gradient of 5 mmHg, initially 15 mmHg. Minnesota tube was removed the next day. On day 2 after TIPS, he developed asterixis and a marked rise in aminotransferases along with mild INR elevation (Table 1). Abdominal CT showed a patent TIPS but a large area of infarction of hepatic segments 5/6 felt to be in large part due to compression of the right hepatic artery (HA) by the TIPS (Image 1) with a lesser contribution from a right anterior portal vein thrombus (PVT) (Image 2). Transplant work up was initiated but asterixis resolved quickly and he recovered with supportive therapy. DISCUSSION: Acute liver injury and failure from hepatic infarction are rare complications of TIPS. To our knowledge, the literature reports few cases of hepatic infarction due to HA complications, specifically HA compression, after TIPS. This case is unique in that based on the large size and location of infarction, the hepatic artery compression by the TIPS rather than just the partial right PVT was responsible for the injury resulting in acute on chronic liver failure. Hepatic infarction after TIPS is rare, portends a poor prognosis, and should be a consideration in those who develop acute liver injury after procedure.Figure 1.: Infarction involving hepatic segments 5/6 with compression of right hepatic artery by TIPS.Figure 2.: Infarction involving hepatic segments 5/6 with right anterior portal vein thrombus.Table 1.: Lab values. **Patient develops asterixis, elevated AST and ALT, INR > 1.5