Orthotopic liver transplantation with a suprahepatic vena caval anastomosis over a transjugular intrahepatic portosystemic shunt

Meyer, C; Odeh, M; Herrera, Juan J.; Resende, Alexandre; Perarnau, Jean–Marc; Ellero, B.; Jaegle, M; Boudjéma, Karim; Jaeck, Daniel; Wolf, Philippe

doi:10.1016/s1072-7515(98)00117-3

Cited by 15 publications

(12 citation statements)

References 4 publications

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“…This was to the larger suprahepatic caval anastomosis and detailed partial inclusion of vein and stent in the circumference of the recipient vein. 9 Our report shows that it is technically possible and, in the short term at least, a safe procedure in the smaller caliber portal vein. Although portal vein thrombosis occurs only rarely after liver transplantation, this patient would be at a greater risk for this complication because of a preexisting portal vein abnormality.…”

Section: Discussionmentioning

confidence: 58%

Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: A new method for portal anastomosis?a surgical salvage procedure

et al. 2000

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A transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly used method of treating variceal bleeding from portal hypertension. Many patients are subsequently listed for transplantation, which may be complicated by malposition of the inferior end of the TIPS stent. This report details such a case and offers a surgical technique to salvage this situation. Copyright 2000 by the American Association for the Study of Liver DiseasesA transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for variceal bleeding from portal hypertension. 1 Although most series have reported that TIPSs are a safe bridge to transplantation in selected patients, 2-4 there have been recent warnings to transplant surgeons regarding the specific complications of stent migration and malposition. 5,6 A TIPS may necessitate modification of the surgical procedure, but this is generally a surmountable problem. 7 We report a case of a malpositioned, impacted TIPS extending in the caudal direction that rendered a patient unsuitable for transplantation except by direct anastomosis onto the TIPS-portal vein complex. Case ReportA 43-year-old woman with hepatitis C and alcoholic cirrhosis underwent TIPS placement after 3 variceal bleeds, reducing her portal pressure from 34 to 30 mm Hg. She self-referred 7 months later, after having been lost to follow-up, with recurrent bleeding, lethargy, and worsening ascites, at which time a TIPSogram showed an occluded stent with an associated proximal thrombus that proved resistant to balloon dilatation. A second stent was introduced by the same approach through the initial TIPS and extended inferiorly down the portal vein in an attempt to displace the thrombus. This was successful, with a reduction in portal pressure from 28 to 17 mm Hg, but it was noted that the inferior end of the stent was lying at the portal vein origin. She was then listed for transplantation. A computed tomographic scan of her abdomen confirmed the second TIPS lying at the junction of her splenic and superior mesenteric veins, and angiography suggested extension of the TIPS into the superior mesenteric vein (Fig. 1). Her TIPS was dilated electively 6 months later, with portal pressure reduced from 28 to 21 mm Hg. She was admitted for transplantation, having had her original TIPS in situ for 16 months.At surgery, the initial TIPS stent was seen protruding through the portal vein wall, with the lower stent palpable throughout the length of the portal vein. The lower stent continued to be palpable through the base of the transverse mesocolon into the superior mesenteric vein in the infracolic compartment. The stent was associated with intense thickening of surrounding tissues.The patient was placed on venovenous bypass for the period of caval clamping. Once the recipient portal vein had been opened through the TIPS, it was found that removal of the stent was impossible because of embedding. However, no bare metal was exposed in the lumen, which had reendothelialized over the mesh metal. An anastomosis was ...

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Section: Discussionmentioning

confidence: 58%

Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: A new method for portal anastomosis?a surgical salvage procedure

et al. 2000

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“…Misplacement and migration of these stents are rare complications that occur during TIPS placement, in addition to other complications such as perforation of the liver capsule, hemoperitoneum, bile duct or gallbladder perforation, hemobilia, cardiac perforation, or hepatic artery injury 6, 21, 22. Our patient underwent several revisions and dilations of his primary TIPS.…”

Section: Discussionmentioning

confidence: 88%

“…As a result, an increasing proportion of patients undergoing DDLT have had previous TIPSs, which may influence vascular reconstruction in these cases. Both the perioperative management of these patients and the rate of complications of TIPS during DDLT are not clearly defined 6, 7, 15–20…”

Section: Discussionmentioning

confidence: 99%

“…Careful deployment of the stent is central to avoiding complications. In addition, the extremity of the prosthesis should ideally be placed less than 5 mm below the hepatic vein / cava junction and should not extend more than 1 cm into the main portal vein 6. Thus, the size and caliber of the stent should be carefully determined.…”

Section: Discussionmentioning

confidence: 99%

“…Complications of TIPSs include misplacement or migration of the stent to distant locations 3–5. Extraction of TIPSs has been described as a challenging maneuver during liver transplantation (LT) 6, 7. TIPS misplacement may even preclude transplantation due to proximal or distal vascular involvement.…”

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confidence: 99%

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