Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting

Abstract

Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS “towards transplant” can offer advantages in terms of ameliorating a patient’s clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.

Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhosis

“…In patients awaiting transplants with a diagnosis of HCC, TIPS placement is considered in order to treat significant portal hypertension and allow bridge percutaneous procedures. Studies investigating the feasibility and safety of radiofrequency ablation (RFTA), radioembolization (TARE), and chemoembolization demonstrated that, in patients with compensated liver function, the results are similar to patients without TIPS [27].…”

“…Refractory ascites and/or refractory hydrothorax; • Treatment of gastroesophageal varices as secondary prophylaxis of variceal bleeding or as rescue therapy for uncontrolled bleeding; • Bridge in patients awaiting liver transplantation, particularly in patients with portal hypertension complications. No significative difference was reported in the recent literature on the post-transplant outcome, comparing patients with TIPS and no TIPS, regarding postoperative complications, transfusion requirement, length of stay, and re-transplantation rate [27].…”