Preoperative transjugular intrahepatic portosystemic shunt (TIPS) -guided portal flow modulation in resection and...

We report the case of a patient with cirrhosis with significant portal hypertension who underwent a Resection and Partial Liver Segment 2/3 Transplantation with Delayed Total Hepatectomy procedure using a hypersmall left liver graft with a graft-to-recipient weight ratio of 0.29. To reduce the risk of small-for-size syndrome and modulate portal inflow, a preoperative transjugular intrahepatic portosystemic shunt (TIPS) was placed, decreasing the portosystemic gradient from 15 to 8 mmHg. After transplantation, the TIPS was calibrated and then occluded once sufficient graft hypertrophy was confirmed. This dynamic portal modulation allowed for a safe extended left hepatectomy in the recipient and supported effective graft regeneration. The native liver was explanted after the graft volume reached 1441 mL and accounted for >75% of total liver function. Notably, no small-for-size syndrome occurred. This case suggests that a preoperative TIPS can be considered as part of an individualized, stepwise strategy for portal inflow modulation in selected patients with portal hypertension undergoing RAPID transplantation with hypersmall grafts. Although this report describes a single experience, this strategy represents a promising approach to explore for optimizing portal flow modulation in this context. Further studies are needed to confirm its reproducibility, safety, and potential benefit.