LIVER-TRANSPLANTATION COMPLICATED BY MISPLACED TIPS IN THE PORTAL-VEIN

Objective The purpose of this study was to determine the incidence and complications related to transjugular intrahepatic portosystemic shun t (TIPS) stents found in the portal vein at the time of an orthotopic liver transplantation. Background Transjugular intrahepatic portosyste mic shunts are frequently used in patients with end-stage liver diseas e as a bridge to liver transplantation. The incidence of finding the m etal stent outside of the liver parenchyma al the time of transplantat ion is reported as high as 30%. Most cases that have been detailed inv olve stents misplaced in the vena cava with various outcomes. Almost n o data are available regarding stents misplaced into the portal vein. Methods and Results We report our experience with four patients with w hom a TIPS stent was found misplaced in the portal vein at the time of liver transplantation, including one patient with a stent extending i nto the superior mesenteric vein. This patient required extensive veno us reconstruction using a retropancreatic ''pant'' donor-iliac vein gr aft. The three other patients were transplanted without the need for e xtensive venous reconstruction. There was no significant difference in operative times for this group of patients, but there was a significa nt increase in the requirement for blood transfusion. In a follow-up p eriod ranging from 6 months to 2 years, ail patients remained alive an d had normal portal venous flow and functioning allografts. Most mispl aced stents were placed in patients with small cirrhotic livers and by radiologists with minimal experience with the procedure. Conclusions Misplaced TIPS in the portal vein before liver transplantation is a mo re frequent complication than previously reported; however, it does no t represent major technical difficulty if a clamp can be placed proxim ally on the portal vein. In the case of a stent extending below the sp leno-mesenteric confluence, interposition grafts such as a donor-iliac vein graft are necessary for venous reconstruction. The experience of the radiologist is critical to prevent this complication.