venous pressure and the severity of PSE after TIPS are inversely related. 12 In 1992, Sanyal et al reported a post-TIPS patient with Naked we came into the world, and naked we shall depart hemolytic anemia and progressive hepatic encephalopathy from it.
(HE), which they attributed to the stent, 13 although the Aesop, Fables relationship between the encephalopathy and the hemoly-Transjugular intrahepatic portosystemic shunts sis was not clear. The patient, a Korean man with post-(TIPS) is an exciting new technique for the treatment HCV cirrhosis, received a Wallstent implant (Schneider, of portal hypertension. In the 8 years since it was first Inc., Minneapolis, MN) following an episode of hemordescribed, 1 it has been reported to be almost magical rhage from esophageal varices. Over the next 10 days, in its control of portal hypertension 2,3 and bleeding varthe serum bilirubin level increased and the hemoglobin ices 4 and semimagical in its treatment of refractory concentration decreased, in the absence of further bleedascites. 5,6 However, it is not free of problems. It has ing. Intravascular hemolysis was diagnosed, based on caused a broad spectrum of complications 7 and has these findings and the appearance of schistocytes in the been plagued by a variety of malfunctions. 8,9 The most peripheral blood smear, reticulocytosis, hypohaptoglobincommon of the complications are procedural, primarily emia, hemosiderinuria, and a negative Coomb's test. Worsperforations of the capsule of the liver or of abdominal ening HE required a liver transplantation, after which the organs that are associated with intra-abdominal hemhemolysis promptly subsided. At the time of liver transorrhage. Infection, arrhythmias, thrombosis, misplaced plantation, they observed in the explanted liver that the or migrating stents, and nephrotoxicity are common Wallstent protruded into the portal and hepatic veins. The occurrences.
intrahepatic portion of the stent was completely endotheli-Based on the similarity of TIPS to portosystemic alized, but the extrahepatic, intravenous ends of the stent, anastomoses (PSA) it was predicted that portosystemic which consisted of bare wires, protruded into the portal encephalopathy (PSE) would be a common metabolic and hepatic veins (Fig. 1). They postulated that the hemocomplication. Indeed, 25% to 35% of patients who have lysis resulted from traumatic injury to erythrocytes flowundergone TIPS implantation have promptly develing through the naked steel wires of the stent that prooped new or worsened PSE. 10 The frequency and severtruded into the veins. In the absence of a positive Coomb's ity of PSE after PSA, whether spontaneous, surgical, test, which excludes antibodies to gamma globulins, macor interventional are proportional to the size of the roglobulins and complement, of spur cells, of sepsis, of shunt. 11 Most descriptions of post-TIPS PSE mention hepatocellular carcinoma or of disseminated intravascular that it tends to be mild, easily treatable, and of short hemolysis or of any other detectable cause for hemolysis, duration. 12 The primary effects of TIPS are an immedi-I believe that the diagnosis of traumatic, stent-related heate reduction in portal venous pressure followed by an molysis was a brilliant one. It is supported by the occurincrease in the occurrence of PSE, usually within the rence of an identical syndrome seen in patients with synfirst month. 12 The mildness of the PSE, its responthetic heart valves 14 and related syndromes. 15 It's siveness to therapy and its disappearance within a few disappearance after removal of the stent during liver months, probably reflect the small diameters of the transplantation further supports that diagnosis. stents, which rarely exceed 10 mm, and the develop-Having made the diagnosis of stent-induced, traument within 6 months of implantation of intimal prolifmatic hemolysis in their first patient, Sanyal and his eration, which tends to cause progressive stenosis of associates attempted to determine exactly how frethe shunts. 8,9 In fact, careful examination of already quently post-TIPS hemolysis occurs in a prospective, controlled trial. In the article under discussion in this issue of HEPATOLOGY, 16 they reported studying 100 sta-Abbreviations: TIPS, transjugular intrahepatic portosystemic shunts; PSA, ble cirrhotic patients, 60 of whom had undergone TIPS, portosystemic anastomoses; PSE, portosystemic encephalopathy; HE, hepatic 40 of which were performed for esophagogastric bleedencephalopathy.
ing and 20 of which had undergone implantation for