Effect of TIPS insertion on waitlist mortality and access to liver transplantation in Budd-Chiari syndrome

The impact of TIPS on waitlist mortality and liver transplantation (LT) urgency in patients with Budd-Chiari syndrome (BCS) remains unclear. We analyzed patients with BCS listed for LT in the UNOS database (2002-2024) to assess TIPS's impact on waitlist mortality and LT access through competing-risk analysis. We compared trends across 2 phases: phase 1 (2002-2011) and phase 2 (2012-2024). Of 815 patients with BCS, 263 (32.3%) received TIPS at listing. TIPS group had lower MELD-Na scores (20 vs. 22, p < 0.01), milder ascites ( p = 0.01), and fewer Status 1 patients (those at risk of imminent death while awaiting LT) (2.7% vs. 8.3%, p < 0.01) at listing compared to those without TIPS. TIPS patients had lower LT rates (43.3% vs. 56.5%, p < 0.01) and longer waitlist times (350 vs. 113 d, p < 0.01). TIPS use increased in phase 2 (64.3% vs. 35.7%, p < 0.01). Of 426 patients who underwent transplantation, 134 (31.5%) received TIPS, showing lower MELD-Na scores (24 vs. 27, p < 0.01) and better medical conditions (intensive care unit: 14.9% vs. 21.9%, p < 0.01) at LT. Status 1 patients were fewer (3.7% vs. 12.3%, p < 0.01), with longer waiting days (97 vs. 26 d, p < 0.01) in the TIPS group. TIPS use at listing increased from phase 1 (25.6%) to phase 2 (37.7%). From phase 1 to phase 2, ascites severity improved, re-LT cases decreased (phase 1: 9.8% vs. phase 2: 2.2%, p < 0.01), and cold ischemic time slightly decreased (phase 1: 7.0 vs. phase 2: 6.4 h, p = 0.14). Median donor body mass index significantly increased. No significant differences were identified in patient/graft survival at 1-/5-/10-year intervals between phases or TIPS/non-TIPS patients. While 90-day waitlist mortality showed no significant difference ( p = 0.11), TIPS trended toward lower mortality (subhazard ratio [sHR]: 0.70 [0.45-1.08]). Multivariable analysis indicated that TIPS was a significant factor in decreasing mortality (sHR: 0.45 [0.27-0.77], p < 0.01). TIPS group also showed significantly lower LT access (sHR: 0.65 [0.53-0.81], p < 0.01). Multivariable analysis showed that TIPS was a significant factor in decreasing access to LT (sHR: 0.60 [0.46-0.77], p < 0.01). Subgroup analysis excluding Status 1 or HCC showed similar trends. TIPS in patients with BCS listed for LT reduces waitlist mortality and LT access, supporting its bridging role.