Large Pleural Effusion After Transjugular Intrahepatic Portosystemic Shunt, a Rare but Deadly Complication

Cirrhosis affects more than 630,000 adults globally and can lead to development of ascites. Transjugular intrahepatic portosystemic shunt (TIPS) is an alternative option for refractory ascites in patients who are ineligible or are waiting for liver transplants. However, this procedure can have serious complications. We present a case that highlights the development of a complex pleural effusion complicated by hemorrhagic shock and disseminated intravascular coagulation after TIPS in a 54-year-old man. Our case is the first to report such a complication and aims to provide awareness.


Introduction
Cirrhosis, also known as end-stage liver disease, affectsmore than630,000 adultsglobally [1].It results from scarring caused by chronic liver damage leading to permanent loss of liver function. As the liver loses function and scars, portal venous pressure is increased because blood cannot as easily transverse the liver parenchyma. This results in transudate accumulating within the peritoneal cavity [2]. As more fluid accumulates within the peritoneal cavity, patients may developspontaneous bacterial peritonitis, a condition witha17-32% mortality rate [2,3].
Definitive treatmentfor cirrhosis-induced ascitesis liver transplantation. However, only approximately half of all eligiblepatients onlivertransplantwaitlistslaterreceivea transplant due to the low supply of donor livers [4]. Transjugularintrahepatic portosystemic shunt (TIPS) is an alternative option forrefractory ascites in such patients.TIPS is an artificial tract created under X-ray imaging within the liver to bypass the scarred liver tissue, thereby reducing the amount of back pressure and resulting ascites. However, TIPS can be associated with a variety of complications including bleeding, infection, and hepatic encephalopathy [4]. Other complications can be rare but still occur.Our casedescribes one such complication in a patient who underwentTIPS and subsequently developed pleural effusions.

Chemistry
Ourpatient was nota candidate forliver transplantduetoactiveIV druguse, so he elected to proceed with TIPS (Figures 1,2).During the procedure, afirm, cirrhotic liver was noted, causing difficulties for anastomosiscreationbetween right hepatic and portal veins. Anastomosis was eventually createdwitha 2 cm/6 cmViatorr10 mm TIPS stent and a 10 mm x 59 mm covered Viabahn extension, resulting in aportal venous gradientdecreasefrom 11 to 1 mmHgwithminimalblood loss.    Figure 3).Portalsystemicanastomosis was patent.Cardiac ultrasound showedahyperdynamic left ventricle withoutright ventricular strain.The patient was subsequently intubated.CT angiography did not show definite areas of extravasation.

FIGURE 4: Development ofovernight effusion.
Alternatively,traumatotheinternal jugular veinorcarotid arteryduringtheprocedurecould havecontributed tothe hemothorax.Aslowlybleeding vesselmay notbeimmediatelyapparenton imagingbut may collect in the pleural space over time. A right internal jugular vein approach was used; while traversing from the internal jugularveintotheliver,any vessels in the vicinitycould be injuredand bleed into pleural spaceifacommunication exists [9]. Contrary to this theory,no hematoma or acute venous bleeding was noted during the procedure.
The risk of damage to intraperitoneal vasculature or traversal of the liver capsuleoccurring increases when multiple passes are made throughtheliver for TIPS and can cause hemothorax. Excessive blood loss can also result from extrahepatic puncture of the main portal vein, causing massive hemoperitoneum after balloon dilation. These etiologies areless likelybecause only 100 mL of blood loss was recorded intraoperatively and correct portosystemic shunt placement was documented. Right upper quadrant ultrasound 24 hours postprocedure also showed stable ascites with no hematoma or collection at the porta hepatis. Finally, flash malignant pleural effusion is unlikely ascomputed tomography (CT) chest, CT abdomen and pelvis, and bronchoscopy within the month prior to admission did not showany potentialsources of malignancy.

Conclusions
This case seeks tohighlighta rare, yet serious, complication of TIPSso thatpreventative and supportive measures can be taken.While treating these patients, vasopressors, IV fluids, and blood infusions are essential for maintaining patient's hemodynamic stability. Close-interval chest X-ray follow-up is also important to monitor patient's pleural effusions' sizes and need for a thoracentesis and chest tubes. In our case, angiography was not conducted to definitely determine the cause of bleeding due to patient instability. However,giventhe knowledge of the procedure and anatomy,wecan hypothesize that the source of bleeding was likely from bloody peritoneal fluid from the procedure, damage to the jugular vein or other blood vessels, or damage to the liver capsule. Future studies would benefit from emergent angiogram if the patient is stable enough to identify a definite source of bleeding.

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.