Liver transplantation complicated by malpositioned transjugular intrahepatic portosystemic shunts

To report the surgical problems encountered during orthotopic liver transplantation as a result of a malpositioned transjugular intrahepatic portosystemic shunt (TIPS).

Three patients are described in whom TIPS stents were malpositioned in the following locations: extending into the main portal vein, extending into the suprahepatic inferior vena cava, and extending into the right atrium.

Malpositioning of TIPS stents altered and prolonged the operation in all of these patients by interfering with cross-clamping at the usual vascular sites during liver transplantation. Incorporation of the stents into the vascular wall prevented transcatheter retrieval and increased the difficulty of intraoperative removal.

Awareness of hepatic vascular anatomy is necessary in avoiding stent malpositioning. If malpositioning is identified, transcatheter approaches may be helpful in repositioning the stent. Otherwise, the transplant surgery team must be made aware of the problem for proper surgical planning prior to liver transplantation.