The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis

Abstract

The purpose of this research was to study the efficacy and outcomes of transjugular intrahepatic shunt (TIPS) in end-stage liver disease (ESLD) patients with portal vein thrombosis (PVT) eligible for orthotopic liver transplant. Nine consecutive patients with PVT underwent TIPS as a nonemergent elective outpatient procedure. The primary indication for TIPS was to maintain portal vein patency for optimal surgical outcome. Eight patients underwent contrast enhanced computed tomography (CT) and 1 magnetic resonance imaging diagnosing PVT. Shunt creation was determined by available targets at the time of TIPS and by prior imaging. Patients were followed with portography, ultrasound, CT, or magnetic resonance imaging, and the luminal occlusion was estimated before and after TIPS. Primary endpoints were transplantation, removal from the transplant list, or death. Stabilization, improvement, or complete resolution of thrombosis was considered successful therapy. Failures included propagation of thrombosis or vessel occlusion, and poor surgical anatomy due to PVT. Of 9 patients with PVT, TIPS was successfully placed in all patients without complication or TIPS-related mortality. Eight of 9 patients (88.8%) had improvement at follow-up. One patient failed therapy and re-thrombosed. Two patients (22.2%) were transplanted without complication and had no PVT at the time of transplant. Eight of 9 patients were listed for transplant at the time of their TIPS. Eight of 9 PVTs were nonocclusive. Four of 9 patients (44%) had evidence of cavernous transformation. Two patients expired during follow-up 42 and 44 months after TIPS. Three patients remain on the transplant list. One patient has not been listed due to nonprogression of disease. One patient has been removed from the transplant list because of comorbid disease. In conclusion, TIPS is safe and effective in patients with PVT and ESLD requiring transplant. Patients can be successfully transplanted with optimal surgical anatomy. Liver Transpl 12: 1544-1551, 2006.

Transjugular Intrahepatic Portosystemic Shunt with Thrombectomy for the Treatment of Portal Vein Thrombosis After Liver Transplantation

“…Previous case reports have validated the safety and efficacy of TIPS in recanalizing the PV system prior to OLT, mainly to allow for patent portal flow at the time of transplantation and reduce the need for intraoperative thrombectomy and risk of rethrombosis [5,[18][19][20][21][22]. Murad et al demonstrated that the degree of extension of thrombosis into the splanchnic venous bed directly correlated with decreased survival [20].…”

“…Although some reports have shown that transjugular intrahepatic portosystemic shunt (TIPS) may be an appropriate therapeutic option for patients with PVT, the data are limited [5][6][7]. Portal vein thrombosis typically occurs within weeks after orthotopic liver transplantation (OLT) and is uncommon, with a reported incidence of 1.2% [8].…”

Splanchnic and Extrasplanchnic Thrombosis in Cirrhosis: Prophylaxis vs Treatment

“…More recent studies, however, show a high procedural success rates of 73 to 100 %, a relatively low rate of TIPS dysfunction, with a final TIPS patency rate of 57-88 % [95][96][97][98]. Cavernomatous transformation [95][96][97][98], was found to cause increased technical difficulty. Likewise, older thrombi were associated with increased technical failure and a worse clinical outcome [99].…”

“…Two-year survival rates of about 80 % have been reported [96,97] Survival was better in patients with successful rather than failed TIPS placement [97]. Most available surveys had a retrospective design on patients where the indication for TIPS was not PVT but refractory complications of portal hypertension [95][96][97][98]. In another study [91], seven patients with PVT were treated with a TIPS due to a contraindication to anticoagulation or thrombus progression.…”

Degree of Portal Vein Thrombosis

“…In contrast, degree stratification is consistently involved in the studies about outcome of invasive therapies for PVT [5][6][7][8][9] due to its close associations with operability and prognosis. Herein, diverse classifications of PVT were listed in Table 2, except for simple classification into complete and partial thrombus.…”