Transjugular Intrahepatic Portosystemic Shunt before and after Liver Transplantation

Abstract

The transjugular intrahepatic portosystemic shunt (TIPS) has long been referred to as a procedure performed as ?a bridge to transplantation? since, like many other portosystemic shunts, it decompresses the portal circulation and stabilizes patients but does not definitively treat portal hypertension. One of the major advantages of TIPS over surgically placed portosystemic shunts in the transplant era is that the TIPS is intrahepatic and is removed in situ with the native liver, and usually does not need additional surgery (unlike takedown/ligation of surgical shunts). There are several studies that evaluate TIPS before transplantation?not as a bridge/temporizing measure, but as a prelude to the transplant to decompress the portal circulation and reduce portosystemic engorgement and collaterals and thus, in theory, reduce intraoperative bleeding during liver transplantation. However, these studies, mostly in the transplant literature, have been equivocal from an intraoperative and posttransplant clinical outcome standpoint. TIPS creation in liver transplant recipients is another interesting aspect of TIPS. There has been a debate about whether or not liver transplantation adds additional technical difficulty to the TIPS procedure. Initially, many theories were proposed as to the technical difficulty of TIPS in a transplanted liver. However, recent opinions and published studies demonstrate that whole-graft liver transplantation does not pose a significant technical difficulty to TIPS. Moreover, there are several recent studies evaluating the outcomes of TIPS in liver transplant recipients, showing that outcomes are less favorable when compared with TIPS in nontransplanted patients. This article discusses the results of TIPS as a preoperative prelude to liver transplantation. In addition, it discusses the technical and clinical outcomes of TIPS in liver transplant recipients.

Consensus conference on TIPS management: Techniques, indications, contraindications

“…Votes in Favour: 100%. Comment: After LT portal hypertension and related complications may evolve because of allograft dysfunction/rejection, biliary complications, and recurrent disease [163,164,198,200,[204][205][206][207][208][209][210]. Peculiar indications to TIPS in liver transplanted patients refer to treatment of several vascular complications.…”

“…Because the number of treated patients is still very limited, TIPS placement for SSS should be considered in selected cases, when no other treatment options are available [163,164]. [198,204,210].…”

“…non-transplant patients (2b) [200,[204][205][206]208,210]. A 5.4c TIPS feasibility rates in partial graft and in kinked piggyback anastomoses are lower (4) [206].…”

“…Votes in Favour: 100%. Comment: TIPS placement can be difficult after LT [198,[204][205][206]208,210] particularly in split grafts, particularly for those derived from left liver lobe. This is related to the fact that almost all interventional radiologists are accustomed to performing the TIPS from a right or middle hepatic vein approach while targeting the right portal vein.…”

“…This is related to the fact that almost all interventional radiologists are accustomed to performing the TIPS from a right or middle hepatic vein approach while targeting the right portal vein. Real time ultrasound guidance or gun-site technique may be useful to place the TIPS in the left hepatic vein [210].…”