Management of inadvertent puncture of the hepatic capsule accompanied by post-TIPS hemoperitoneum secondary to bleeding diathesis

Abstract

Since its advent, the transjugular intrahepatic portosystemic shunt (TIPS) procedure has been accepted as an effective option to treat patients with complications of portal hypertension. While generally considered a safe procedure, TIPs can be associated with certain complications, including inadvertent puncture of the liver capsule with the needle/catheter combination during needle passes. In addition, the accompanying post-TIPS intraperitoneal hemorrhage has not been well reported and guidelines behind its management are not well described. We present a case of a 33-year-old male with refractory ascites who underwent TIPS, during which the hepatic capsule was inadvertently punctured, leading to the development of hemoperitoneum in the patient due to a bleeding diathesis.

Introduction

The transjugular intrahepatic portosystemic shunt (TIPS) procedure involves creating a conduit from the hepatic vein to the portal vein percutaneously [1]. Initially described by Rösch et al. in 1969, it was an imaging-guided procedure aimed at reducing portal pressure by redirecting blood from the portal to systemic circulation; however, what marked the start of the modern TIPS procedure was the introduction of expandable metallic stents that provided longer-lasting patency by bridging the hepatic parenchyma between the hepatic and portal veins [2,3].

The primary indication for the TIPS procedure is acute gastroesophageal variceal bleeding and refractory ascites that cannot be effectively managed through medical or endoscopic interventions [4]. Other clinical indications include conditions like Budd-Chiari syndrome, hepatic veno-occlusive disease, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome [5]. While TIPS is an excellent option for many patients, it is absolutely contraindicated in individuals with congestive heart failure, severe tricuspid regurgitation, and severe pulmonary hypertension (mean pulmonary pressure > 45 mm Hg). Relative contraindications for TIPS involve anatomical complexities that may impede shunt creation or reduce technical success [6,7]. These include portal or hepatic vein thrombosis, hepatic masses, or multiple cysts [6,7].

Despite new innovations in technology, TIPs can still be associated with direct complications, with reported rates in up to 20% of cases [4]. These complications may include acute liver failure, hepatic encephalopathy, hemorrhage, biliary injury, injury to adjacent organs, TIPS dysfunction, and TIPS migration [1]. In approximately 33% of cases, there can be inadvertent puncture of the liver capsule with the needle or catheter during TIPS needle passes, leading to intraperitoneal hemorrhage in about 1%-2% of cases [1]. We present a case of a 33-year-old male who underwent a TIPS procedure and experienced unintended puncture of the hepatic capsule, resulting in intraperitoneal hemorrhage due to an underlying bleeding diathesis.

Case presentation

A 33-year-old male with a history of alcohol use disorder and seizures presented to the emergency room (ER) following a self-reported seizure at home. On admission, the patient was hypothermic, tachypneic and required Bi-level Positive Airway Pressure (BIPAP) ventilation. Initial computed tomography (CT) imaging of the abdomen and pelvis revealed a cirrhotic liver with extremely large volume ascites and bilateral pleural effusions. The patient was admitted to the step down unit (SDU) with a diagnosis of anion gap metabolic acidosis, sepsis, urinary tract infection (UTI), cirrhosis, and hypoxemic respiratory failure due to bilateral pleural effusions (Table 1).

Table 1.

Important lab values found in the emergency department.

Labs	Reference range	Lab values
White blood cell (WBC)	4.5-11.0/uL	7.15/uL
Hemoglobin	14.0-18.0 g/dL	5.7 g/dL
Hematocrit	42.0%-52.0%	17.10%
Platelets	150-450*10^3/mcL	98/mcL
Albumin	3.5-5.2 g/dL	1.9 g/dL
Alkaline phosphatase	40-129 U/L	150 U/L
Aspartate aminotransferase (AST)	5-40 U/L	61 U/L
Alanine transaminase (ALT)	0-41 U/L	13 U/L
pH	7.35-7.45	7.33
Bicarbonate	22-26 mEq/L	21 mEq/L
Anion gap	8-15 mEq/L	18 mEQ/L

During his stay at the SDU, the patient underwent thoracentesis and paracentesis. On the third day of his admission, the patient developed melena, and gastroenterology was consulted. Interventional radiology was subsequently consulted for a possible TIPs procedure. Before performing TIPS, the patient's MELD score was calculated and found to be 19, which corresponded to a 6% mortality rate 3 months after the procedure. The TIPs procedure was performed 9 days after admission, and 1 unit of platelets was transfused during the procedure.

TIPs began with ultrasound-guided access through the right internal jugular vein, followed by angiography and hepatic venography. The TIPs puncture needle was rotated and advanced to the portal vein, and a guidewire was inserted to confirm portal vein access. Afterward, an angiographic catheter was advanced into the portal vein for portal pressure management, and venography was repeated to visualize varices. After dilating the track with a balloon catheter, a stent was deployed and portal pressure was measured for gradient reduction (Fig. 1).

Fig. 1.

Initial TIPs placement.

Venography was repeated to confirm variceal bleeding had stopped.

On the same night, post-TIPs procedure, the patient was found to be somnolent with a systolic blood pressure (SBP) in the 80s for which a rapid response (RRT) was called. Hemoglobin levels were found to have decreased (4.5, a drop from 8.5 g/dL) and white blood cell (WBC) count was found to be elevated. Two units of red blood cells were transfused urgently and a CT abdomen was performed, which revealed the shunt to be patent, but interval development of a large area of decreased enhancement of the liver within posterior segments of the right hepatic lobe was found. Furthermore, interval development of dense material within the lesser sac and along the lateral border of the liver, worrisome for hemorrhagic products/blood clots was found (Fig. 2).

Fig. 2.

Noncontrast CT abdomen and pelvis demonstrating hemoperitoneum (arrows pointing to it).

No site of active extravasation was clearly identified. Soon thereafter, he was upgraded to the intensive care unit (ICU) and received an additional 4 units of red blood cells, 5% albumin, 2 units of cryoprecipitate, and 3 units of fresh frozen plasma.

Over the next few days, the patient received multiple transfusions due to a drop in hemoglobin levels. Hematology was consulted due to coagulopathy, evidenced by prolonged INR/PT and aPTT levels. Their recommendations included administering 10 mg of intravenous vitamin K daily for 3 days and transfusing cryoprecipitate to achieve a fibrinogen level of 100-120. For minor bleeding, 1 unit of cryoprecipitate per 10 kg of body weight was suggested, while for major bleeding, 1 unit of cryoprecipitate per 5 kg of body weight was recommended. The patient's platelet count was to be maintained above 50,000, and they were given 1000 micrograms of subcutaneous cyanocobalamin once. Additionally, ferrous sulfate supplementation was started 3 times a day, and folic acid supplementation was continued. In case of life-threatening bleeding, 4-factor prothrombin complex concentrate was recommended, with a potential risk for venous thromboembolism and disseminated intravascular coagulation.

On the 16th day of hospitalization, the patient underwent another angiogram, which showed no active extravasation (Fig. 3).

Fig. 3.

Post-TIPs celiac angiogram showing no extravasation.

A post-TIPs venogram was performed which showed a patent TIPs shunt (Fig. 4)

Fig. 4.

Post-TIPS venogram showing patent TIPs shunt.

The patient's hemoglobin and hematocrit stabilized and he was discharged from the hospital. Despite being referred for transfer to a liver transplant center, the patient was denied and instead advised to follow up as an outpatient with an end-stage renal disease center.

Discussion

Hemoperitoneum associated with TIPS procedures is a rare occurrence and most commonly arises during the puncture of the intrahepatic portal vein. This can lead to liver capsule penetration or injury to the extrahepatic portal vein. When this occurs, patients can present with tachycardia, significant hypotension, and in severe cases, hemorrhagic shock. Transgression of the liver capsule with the needle or catheter occurs in approximately 33% of TIPs cases. Of these, intraperitoneal hemorrhage is found in 1%-2% of cases, although some studies have reported rates upwards of 6% [1,8]. Other organs such as the gallbladder, right kidney, hepatic flexure of the colon, and duodenum may be affected during the breach of the liver capsule [1,8]. In certain instances, this may result in hemobilia, cholangitis, or intrabiliary clot formation [1,8]. In our case, no other organs were affected, and the intraperitoneal hemorrhage occurred later that night following the TIPS procedure, during which the liver capsule was inadvertently punctured. The subsequent hemoperitoneum was the direct result of the underlying bleeding diathesis.

A study by Yin et al. [9] reported that the incidence of major post-TIPS complications occurred in about 3.2% of patients while 0.74% experienced hemoperitoneum out of a total of 948 patients. In yet another study by Dariushnia et al. [10] hemoperitoneum was reported in 0.5% of all TIPS cases. These cases required blood transfusions or other interventions. Another study by Griffin et al. reported that out of 71 patients who underwent the TIPS procedure, inadvertent puncture of the liver capsule occurred in 4 patients, with one of them developing hemoperitoneum [9].

Management of post-TIPs intraperitoneal hemorrhage has not been well established in the literature. One approach to prevent post-TIPS complications has been the use of the Model for End-Stage Liver Disease (MELD) scoring system. The MELD score is commonly used to assess short-term mortality risk in patients undergoing TIPS and can be calculated by plotting serum bilirubin levels, serum creatinine levels, and international normalized ratio in a formula. A MELD score greater than 18 has been associated with a poorer prognosis [1]. One study conducted by Kim et al. [11] showed higher early and overall mortality in patients with MELD scores ≥14 who underwent TIPS compared to those with MELD scores <14. In this specific case, the patient's MELD score was 19, which corresponded to a 6% mortality rate 3 months after the procedure. Another preventive measure for post-TIPS hemoperitoneum involves utilizing the coagulation profile as a guide for management. Current guidelines by the Society of Interventional Radiology recommend that the INR be less than 1.8, and the platelet count be greater than 50,000/uL [12].

In this case, the hematology team suggested administering 10 mg of intravenous vitamin K daily for 3 days and transfusing cryoprecipitate to achieve a fibrinogen level of 100-120. Furthermore, they recommended maintaining the patient's platelet count above 50,000, giving 1000 micrograms of subcutaneous cyanocobalamin once, ferrous sulfate supplementation 3 times a day, and continuing folic acid supplementation. Currently, there is no specific standardized approach for managing post-TIPS hemoperitoneum; however, we can learn to manage these complications by taking a look at current guidelines for trauma-induced coagulopathy. In these cases, the primary concern is hypofibrinogenemia [13,14]. During active bleeding, fibrinogen is the first coagulation factor to be depleted and evidence suggests that restoring fibrinogen levels in bleeding patients can improve clot formation and clot strength, effectively controlling hemorrhage [15]. Low fibrinogen levels have been associated with poor patient outcomes and increased mortality [13]. Additionally, factor XIII has been found to play a crucial role in clot strength. It does so by stabilizing and crosslinking fibrin [13]. Postoperative levels of factor XIII below 60% have been identified as an independent risk factor for postoperative intracerebral hemorrhage [13]. However, current bleeding management for trauma-induced coagulopathy does not include routine supplementation of factor XIII. In our case, 1 unit of cryoprecipitate per 10 kg of body weight was suggested for minor bleeding, while for major bleeding, 1 unit of cryoprecipitate per 5 kg of body weight was recommended. This offered to replenish both fibrinogen and FXIII. Supplement platelets are added in trauma-induced coagulopathy when platelet counts are lower than 50,000/uL similar to suggestions by our hematology team [13]. Prothrombin complex concentrate (PCC) has been suggested as a first-line therapy in bleeding diathesis; however, limited evidence exists suggesting its use in this setting.

Conclusion

Inadvertent puncture of the liver capsule during the TIPS procedure is a recognized occurrence, but there is limited literature on the management of resulting intraperitoneal hemorrhage. However, interventional radiologists can draw upon existing guidelines for trauma-induced coagulopathy and postliver biopsy intraperitoneal hemorrhage to guide their management of hemoperitoneum resulting from underlying coagulopathy following TIPS. By adapting and applying these guidelines, interventional radiologists can customize their approach to each patient, leading to improved outcomes.

Patient consent

Informed consent was obtained from the patient before writing up this case study.