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Hepatic encephalopathy (<jats:styled-content style=\"fixed-case\">HE<\/jats:styled-content>) remains a significant problem after <jats:styled-content style=\"fixed-case\">TIPS<\/jats:styled-content> placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for <jats:styled-content style=\"fixed-case\">TIPS<\/jats:styled-content> requires careful evaluation of risk factors for <jats:styled-content style=\"fixed-case\">HE<\/jats:styled-content>. <jats:styled-content style=\"fixed-case\">TIPS<\/jats:styled-content> procedure\u2010related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. 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