Hepatic Encephalopathy Unveiling Intracardiac Migration of a Transjugular Intrahepatic Portosystemic Shunt Stent: Successful Parallel Transjugular Intrahepatic Portosystemic Shunt with Conservative Management

Transjugular intrahepatic portosystemic shunt (TIPS) is a key therapy for portal hypertension complications in Budd–Chiari syndrome (BCS). Intracardiac stent migration is rare and typically presents with arrhythmia or tricuspid regurgitation rather than hepatic encephalopathy (HE). A 35-year-old female with BCS underwent TIPS (February 2025) and presented in August 2025 with West Haven Grade II HE. ECG and cardiac examination were normal. Transthoracic echocardiography demonstrated migration of the TIPS stent into the right atrium (RA). She improved with standard HE therapies. Interventional radiology performed a parallel TIPS, leaving the migrated stent in situ, given no cardiac sequelae and likely stent adherence. Postprocedure contrast-enhanced computed tomography confirmed the correct position and adequate flow through the new shunt. She remained asymptomatic at 1-month follow-up. To the best of our knowledge, this is among the first reported cases where HE was the sentinel event revealing intracardiac stent migration. HE may be the first clinical clue to TIPS migration. In selected, asymptomatic RA migrations, conservative retention of the intracardiac stent with parallel TIPS to restore portal decompression is feasible, supported by established HE and TIPS literature.