Rapid Recurrence of Hepatic Hydrothorax After Transjugular Intrahepatic Portsystemic Shunt (TIPS) Placement
Document Type
Conference Proceeding
Publication Date
5-2025
Publication Title
American Journal of Respiratory and Critical Care Medicine
Abstract
Hepatic hydrothorax (HH) is a rare complication of cirrhosis characterized by pleural effusion without primary cardiac or pulmonary causes. It affects approximately 10% of patients with advanced liver disease. Transjugular Intrahepatic Portosystemic Shunt (TIPS) is an essential intervention for managing refractory HH as it decreases portal hypertension and fluid accumulation. Although rapid recurrence after TIPS is uncommon, it poses significant challenges, making it vital to understand its mechanisms and enhance post-TIPS management for better outcomes. A 64-year-old man with history of alcoholic cirrhosis presented with worsening shortness of breath five days post-TIPS procedure. Over the past year, he had undergone multiple paracenteses and thoracenteses due to refractory ascites and HH. Despite optimal medical management, including Lasix, Aldactone, and strict sodium restriction, he continued to require repeated thoracentesis, prompting the TIPS procedure. Initially, he experienced symptom relief, but returned five days later with dyspnea and pleuritic chest pain. A chest X-ray revealed a right-sided pleural effusion, absent during the previous TIPS admission. Repeat thoracentesis drained 2 liters of fluid, showing transudative characteristics. A Doppler ultrasound confirmed a patent TIPS. Symptoms resolved post-thoracentesis. The patient was scheduled for outpatient follow-up with hepatology for further management and potential liver transplantation. Initial HH management mirrors ascites treatment, focusing on sodium restriction and diuretics. For refractory HH, American Association for the Study of Liver Diseases (AASLD) recommends TIPS or liver transplantation. While TIPS effectively reduces portal hypertension and fluid accumulation, its success rate varies from 42-79%, with fewer than two-thirds achieving complete symptom relief. Most partial responders experience fluid re-accumulation within 3-6 months, whereas our patient had recurrence in less than a week. Refractory HH can result from factors beyond TIPS dysfunction, including advanced liver disease, hepatorenal syndrome, altered pleural-peritoneal pressure dynamics, incorrect stent size or placement, or underlying cardiac/pulmonary conditions. In our case, none of these factors were present, yet the patient still experienced rapid recurrence. Patients with refractory HH may need serial thoracentesis, indwelling pleural catheters, chemical pleurodesis, or VATS, all with associated risks or need for repeat procedures. Recently, alpha pumps have emerged as a promising option for refractory cases. Persistent HH post-TIPS, as seen in this case, presents significant management challenges. There is a lack of data on managing refractory HH post-TIPS. More controlled studies are needed to understand risk factors associated with HH recurrence post-TIPS, optimize treatment strategies and improve patient outcomes.
Volume
211
First Page
A6265
Last Page
A6265
Recommended Citation
Moazzam M, Bin Hameed U, Nazneen W. Rapid recurrence of hepatic hydrothorax after transjugular intrahepatic portsystemic shunt (TIPS) placement. Am J Respir Crit Care Med. 2025 May;211:A6265. doi:10.1164/ajrccm.2025.211.Abstracts.A6265
DOI
10.1164/ajrccm.2025.211.Abstracts.A6265
Comments
American Thoracic Society (ATS) International Conference, May 16-21, 2025, San Francisco, CA