Introduction:

Transjugular intrahepatic portosystemic shunt (TIPS) has been commonly used as a bridge to liver transplantation (LT). However, TIPS diminishes collateral veins and may increase the risk of portal hyper-perfusion to liver grafts. Recent studies indicated portal hyper-perfusion plays an important role in small-for-size syndrome. The aim of the study is to assess the impact of pre-transplant TIPS in graft hemodynamics and outcomes.

Methods:

From 1/2004 to 10/2012, intra-operative portal venous flow (PVF) was measured in 85 whole and 12 partial LT for adult patients with TIPS at our institution. Intra-operative graft hemodynamics, risk factors for portal hyper-perfusion and post-operative outcomes were analyzed.

Results:

Post-reperfusion PVF was significantly higher in whole LT for patients with TIPS than without TIPS (1925 mL/min vs. 1699 mL/min, p=0.02). Low platelet count, large spleen, and uncontrolled ascites (Grade 2-3) after TIPS were associated with high PVF in the TIPS group, whereas indication of TIPS, sinusoidal pressure gradient at TIPS placement, and the duration between TIPS and LT were not.

In the 12 partial LT, 4 patients had uncontrolled ascites after TIPS and all of the 4 patients underwent portal inflow modulation. The mean PVF at the end of 12 partial LT was controlled well at 1402 mL/min. Although 2 patients had refractory ascites after partial LT, no patient experienced small-for-size syndrome. Three-year graft survival after partial LT was as favorable as whole LT with TIPS (83% vs. 78%, p=NS).

Conclusions:

Pre-transplant TIPS increases PVF to liver grafts, and uncontrolled ascites after TIPS is a risk factor for portal hyper-perfusion. Partial LT can be done for patients with TIPS using portal inflow modulation with favorable outcomes.

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