Transjugular intrahepatic portosystemic shunt to keep vein open

Abstract

Compared to a surgical shunt, a transjugular intrahepatic portosystemic shunt (TIPS) is a less invasive means of lowering portal venous pressure in patients with cirrhosis experiencing complications of portal hypertension, with relatively low procedure-related morbidity. Presently, the most common indications for TIPS placement are acute variceal bleeding and refractory ascites. The number of other indications is growing, but many are still controversial. We present a patient with partial portal vein thrombosis (PVT) who received TIPS to maintain portal vein patency when it was suspected that complete PVT was imminent. The TIPS was able to preserve the remaining portal flow until successful liver transplantation (LT) 3 months later. CASE REPORTWe evaluated a 58-year-old Caucasian male for LT who had end-stage liver disease secondary to cryptogenic cirrhosis. His medical history was notable for previous spontaneous bacterial peritonitis and ascites requiring frequent large-volume paracenteses. During transplant evaluation, he underwent contrast-enhanced computed tomography, which demonstrated nonoccluding thrombus in the portal vein ( Fig. 1) with extension into the right portal vein branch, superior mesenteric vein, and splenic vein (Fig. 2). To prevent complete PVT and improve his ascites, the patient underwent successful TIPS placement with a 10 mm ϫ 94 mm Wallstent, achieving a postshunt pressure gradient of 12 mm Hg. As an additional precaution, the patient was placed on warfarin, maintaining a therapeutic international normalized ratio between 2.6 and 2.9. Although his degree of hepatic encephalopathy increased after the procedure, his ascites improved, and he remained otherwise stable until transplantation 3 months later.At the time of LT, approximately 2 L of ascites was removed, and the patient had adhesions indicating recent spontaneous bacterial peritonitis. The portal vein was dissected beyond the bifurcation, and this revealed a thrombus in the portal vein completely occluding the left portal branch, extending into the right branch, and surrounding the TIPS in the main portal vein. However, the TIPS, which extended from the right portal vein branch into the main portal vein, and the associated segment of vein proximal to the TIPS were patent (Fig. 3). The thrombus had therefore extended since prior imaging, as it was now completely occluding the left branch of the portal vein. The operation was performed without complication, and the patient was transferred to a rehabilitation facility 2 weeks after LT and continues to do well. DISCUSSIONAlthough PVT is no longer an absolute contraindication to LT, its presence can have an impact on morbidity and mortality prior to and following LT. Besides contributing to the progression of portal hypertension and its sequelae before LT, PVT increases the complexity of LT itself. The operative time, rate of reoperation, requirement for red blood cell transfusion, and length of hospital stay are increased in patients with PVT.

Transjugular Intrahepatic Portosystemic Shunt for Maintenance of Portal Venous Patency in Liver Transplant Candidates

“…[7] The findings of these studies are further supported by report of at least one individual case describing use of TIPS to keep the portal vein open for liver transplantation. [8] Other large studies have confirmed the utility of TIPS in treating PVT in cirrhotic patients without specific intent as a bridge to liver transplantation. In 2011, Luca et al, described 87% patency improvement (complete recanalization in 57%) among 70 patients with nontumoral PVT who underwent TIPS.…”

Transjugular intrahepatic portosystemic shunt in the treatment of portal vein thrombosis: a critical review of literature

“…Despite advances in surgical techniques, some patients with endstage liver disease and concomitant extensive PVT are still precluded from the transplant list [91,92]. At some centers, [47,63,71,73]. However, the extension of a stent distally into the extrahepatic MPV or the SMV can potentially jeopardize the transplant surgery [93].…”