IMPACT OF TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT ON ORTHOTOPICLIVER-TRANSPLANTATION

Transjugular intrahepatic portosystemic shunt (TIPS) is being increasi ngly utilized prior to liver transplantation for portal hypertensive b leeding refractory to sclerotherapy or as initial management of varice al bleeding. The impact of TIPS on subsequent orthotopic liver transpl antation (OLT) is uncertain. The purpose of this study was to analyze the effect of TIPS on OLT in terms of operative transfusion requiremen ts, operative time, length of hospital stay, and graft and patient sur vival. The results in 17 patients undergoing TIPS for control of initi al or recurrent variceal bleeding prior to OLT between June 1991 and D ecember 1992 were compared to two other groups undergoing transplantat ion: 32 control patients with a history of variceal bleeding not treat ed by TIPS and 11 patients with a previous surgical portosystemic shun t. Compared with control and surgical shunt patients, patients who und erwent TIPS had less transfusion requirement for packed red blood cell s and fresh frozen plasma during OLT. The operative time and hospital stay of the TIPS patients were slightly, but not significantly, less. In contrast to patients having TIPS, the patients with a history of a previous surgical shunt had an increased requirement for packed red bl ood cells, longer operative time, and longer stay in the intensive car e unit and hospital. Two patients bed recurrent variceal bleeding afte r TIPS; one patient was found to have an occluded stent, and the other patient (with a patent stent) responded to sclerotherapy. Of the 14 p atients with ascites, 8 patients improved and 6 patients had complete resolution after TIPS. There were no major complications related to TI PS, although 3 patients had new or recurrent hepatic encephalopathy th at was easily manageable. Thus the preoperative performance of TIPS is associated with less operative transfusion requirement during OLT, pr esumably secondary to a reduction in portal hypertension. TIPS is pref erred to surgical shunt for pretransplant refractory variceal bleeding , as the latter is associated not only with significant morbidity and mortality but also increased transfusion requirements and prolonged op erative time and hospital stay.