Liver transplantation in patients with transjugular intrahepatic portosystemic shunts

In patients with intractable oesophageal variceal bleeding, transjugular intrahepatic portosystemic shunts (TIPSS) are being used increasingly as a bridge to orthotopic liver transplantation (OLTx). There is little information in the literature concerning variations in the operative techniques of OLTx required because of the presence of TIPSS.

A retrospective review of patients treated by TIPSS prior to OLTx was undertaken. The aims were to assess the effectiveness of TIPSS in bridging patients to OLTx and to examine whether TIPSS influence the operative management of OLTx.

Over a 4-year period eight adult patients underwent TIPSS insertion prior to OLTx in the Australian National Liver Transplant Unit (ANLTU). Transplantation was performed at a mean of 14.6 (0.3-53.8) months after TIPSS insertion. Prevention of major recurrent variceal haemorrhage prior to transplantation was achieved in six cases. In two patients the stents were predominantly intrahepatic and they did not interfere with OLTx. In five patients the stents extended into the portal vein, requiring removal during OLTx either by division of the stent with the recipient portal vein, followed by removal of the fractured stent wires from the portal veins (n = 3), or by 'endarterectomy' of the recipient portal vein, allowing removal of the intact stent (n = 2). In one case where the stent extended into the suprahepatic inferior vena cava, removal was achieved by traction without difficulty. All patients are alive at a mean of 24 (7-53) months post-transplant and none has portal vein abnormalities. When compared to 178 adult patients who had no TIPSS and underwent primary OLTx during the same study period, there was no difference in the length of operating time or the usage of blood products during OLTx.

Transjugular intrahepatic portosystemic shunts offer a bridge to OLTx by providing effective control of variceal haemorrhage. In the present series TIPSS did not increase surgical morbidity or mortality, but emphasis is placed upon the need for optimal TIPSS placement within the liver to facilitate subsequent OLTx.