Overt hepatic encephalopathy after elective and preemptive TIPS: Risk factors and prognosis.

Background & Aims: Overt hepatic encephalopathy (OHE) develops in 30-50% of patients after transjugular intrahepatic portosystemic shunt (TIPS) placement, depending on patient characteristics and TIPS indication. Data on OHE after preemptive TIPS (pTIPS) are limited. We aimed to assess the prevalence of OHE after pTIPS, to compare OHE after pTIPS and elective TIPS, and to identify risk factors for OHE in each clinical situation. Methods: We performed a single-center observational study of consecutive patients with cirrhosis treated with pTIPS or elective TIPS between 2017 and 2023. Patients were followed until 1 year, death, or liver transplantation (LT). Results: A total of 191 patients were included (pTIPS 85, elective TIPS 106). Patients treated with pTIPS were significantly younger (53 vs. 60 years old, p <0.001), had a higher MELD score (20 vs. 12, p <0.001), and a higher baseline ammonia level (76 vs. 54 μmol/L, p <0.001) compared to those treated with elective TIPS. OHE occurred in 41% of patients undergoing pTIPS compared to 38% of those receiving elective TIPS (p = 0.6). In multivariate analysis, factors associated with the development of OHE in patients undergoing pTIPS were previous cardiac disease (p = 0.02) and sarcopenia (p = 0.016), whereas baseline ammonia (p = 0.022), previous cardiac disease (p = 0.009) and albumin (p = 0.018) were associated with OHE occurrence in patients receiving elective TIPS. In pTIPS, age, MELD score and persistent OHE after TIPS were independently associated with death or LT. In elective TIPS, age, MELD score, OHE, and refractory OHE were independently associated with death or LT. Conclusion: OHE occurs frequently after TIPS, in elective as well as urgent indications. Risk factors for OHE differ in these situations. Persistent OHE after pTIPS and OHE after elective TIPS are associated with poor outcomes and should prompt early discussion of LT candidacy. Impact and implications: This study demonstrates that overt hepatic encephalopathy (OHE) remains a frequent complication after both preemptive and elective transjugular intrahepatic portosystemic shunt (TIPS) placement, though the underlying risk factors differ depending on the clinical indication. Identifying predictors such as cardiac disease, sarcopenia, and baseline ammonia can help refine patient selection and post-TIPS management. The association between OHE and adverse outcomes highlights the need for closer surveillance and timely intervention. Early referral for liver transplantation should be considered in patients who develop persistent or refractory OHE after TIPS.