IS THE TRANSJUGULAR INTRAHEPATIC PORTACAVAL-SHUNT PROCEDURE BENEFICIAL FOR LIVER-TRANSPLANT RECIPIENTS

Recent reports document the efficacy of transjugular intrahepatic port ocaval shunts (TIPS) for the prevention of portal hypertensive bleedin g and have advocated its use as a bridge to liver transplantation. The re are no reports, however, analyzing liver transplant results for pat ients with indwelling TIPS. We reviewed the records of all adult prima ry recipients with a history of portal hypertensive bleeding or unmana geable ascites transplanted since the TIPS procedure became available in our institution in July 1991. Seven of 20 recipients underwent TIPS before transplant. There were no significant differences between pati ents with or without TIPS in age, United Network for Organ Sharing sta tus, Child-Pugh score, preoperative prothrombin time, operative time, operative blood product requirement, overall length of stay, and 6-mon th patient survival after transplant. We noted a trend toward less ope rative red cell (26.0+/-26.2 vs. 31.8+/-38.1 U, mean +/- SD) and autol ogous blood (4,762+/-3,335 vs. 113,355+/-20,460 ml) transfusion and im proved patient survival for those with a TIPS. Patients with a TIPS in place waited significantly longer for their transplant (282+/-113 vs. 149+/-113 days, P=0.014). There were 2 technical complications relate d to the TIPS, 1 in a patient who died after rupture of the suprahepat ic vena caval anastomosis where the device had traversed the caval/hep atic vein junction and weakened the tissues, and the other in a surviv or in whom the device extended into the right atrium and was extracted during the transplant procedure. Three patients with TIPS in place di ed of sepsis while waiting for a donor organ. We conclude that while t he TIPS offers benefits for the liver transplant recipient, placement of the device in small shrunken cirrhotic livers must be precise. Imme diate benefits for the transplant candidate may be offset by increased waiting time and technical complications at the transplant operation.