Does transjugular intrahepatic portosystemic shunting facilitate or complicate liver transplantation?

TECHNICALASPECTS

ELSEVIER

Does Transjugular lntrahepatic Portosystemic Complicate Liver Transplantation? M.S. Goldberg, A.G. Tzakis

D. Weppler,

F.A. Khan, W. DeFaria, R.T. Khan, M.G. Webb, J.R. Nery, A. Gyamfi, and

T

INTRAHEPATIC portosystemic RANSJUGULAR shunting (TIPS) has emerged as a valuable therapeutic option for treatment of complications related to portal hypertension. TIPS is effective in controlling variceal hemorrhage by reducing portal pressure. However, it is also associated with technical and physiologic complications such as misplacement, stenosis, occlusion, and encephalopathy.lm3 The aim of this study is to evaluate the rate and extent of technical complications related to previous TIPS placement in patients undergoing orthotopic liver transplantation (OLT). MATERIALS

AND

METHODS

Between June 1994 and August 15, 1996, 392 OLTs were performed on 357 patients at the University of Miami. Twenty-four patients had TIPS placed prior to OLT and are the focus of the study. Records were reviewed from initial presentation through OLT and during the postoperative course. The patients were divided into two groups: Group 1 (n = 8) consisted of patients who had technical complications related to TIPS, and Group 2 (n = 16) consisted of patients who did not. Technical complications were defined as surgical revisions made at the time of OLT due to previous TIPS placement. They were due to malposition of the stent and portal vein thrombosis. Patient and graft survival, blood product usage, and time from TIPS insertion to OLT were calculated for the two groups. Statistical analysis was performed using the single factor ANOVA. RESULTS

Twenty-one of the 24 patients had TIPS placed for control of variceal hemorrhage. The other three were placed for refractory ascites management. The mean age of the pa0 1997 by Elsevier Science Inc. 655 Avenue of the Americas,

Shunting Facilitate or

New York, NY 10010

tients was 50.6 years (range of 34 to 70). Initial diagnoses included hepatitis C (n = 15) Laennec’s cirrhosis (n = 12) hepatitis B (n = 2) primary biliary cirrhosis (n = 2) and cryptogenic cirrhosis (n = 1). Eight patients (33%) had complications during OLT surgery from previous TIPS placement (Group l), while 16 patients (67%) did not (Group 2). Patient survival was 62.5% (5 of 8) for Group 1 and 93.8% (15 of 16) for Group 2 (P = .06). Graft survival was 53.8% (7 of 13) for Group 1 and 88.9% (16 of 18) for Group 2 (P = .03). Two patients in Group 1 died from multisystem organ failure, while one died in a motor vehicle accident. One patient in Group 2 died from a sudden cardiac arrest. Retransplantation in Group 1 was due to hepatic artery thrombosis (n = 3, in two patients), primary nonfunction (n = l), and recurrent hepatitis C (n = 1). Retransplantation in Group 2 was due to primary nonfunction (n = 1) and chronic rejection (n = 1). There was no significant difference between the two groups with regards to UNOS status, time from TIPS placement to transplant (211 days for Group 1 vs 251 days for Group 2) or blood product usage. In Group 1 (see Table 1 and Figure l), four of the stents extended cephalad beyond the hepatic vein, one extended

From the University of Miami, School of Medicine, Department of Surgery, Division of Liver/G1 Transplantation (D.W., F.A.K., W.DeF., R.T.K., M.G.W., J.R.N., A.G., A.G.T.), and Department of Medicine, Division of Hepatology (M.S.G.), Miami, Florida. Address reprint requests to Deborah Weppler, Department of Surgery (M840), University of Miami School of Medicine, Division of Transplantation, P.O. Box 015809, Miami, FL 33101-5809.

0041-1345/97/$17.00 PII SOO41-1345(96)00265-5

557

Transplantation

Proceedings,

29, 557-559

(1997)

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GOLDBERG, Table 1. Complications From TIPS (Group 1)

Pt.

TIPS complication

Surgical intervention

1

Extended cephalad, embedded into wall of IVC and RA Extended cephalad, embedded into wall of IVC and RA Extended cephalad, embedded into wall of IVC Extended cephalad, loosely attached to IVC and RA Extended caudad into confluence of SMV and splenic vein

Extensive dissection into RA Extensive dissection into RA IVC reconstruction with donor patch Removed uneventfully

2 3 4 5

6 7

a

Extrahepatic portal vein thrombosis Extrahepatic portal vein thrombosis Extrahepatic portal vein thrombosis

Removal and reconstruction with venous interposition graft Removal of clot Removal of clot Clot removal and venous interposition graft

caudad into the confluence of the superior mesenteric and splenic veins, and three patients had normal stent placement with thrombosis of the extrahepatic portal vein. Of the four stents placed cephalad, two were embedded in the wall of the inferior vena cava (IVC) and right atrium (RA), requiring extensive dissection well within the pericardium. One case required reconstruction of the IVC with a donor patch, and one was loosely attached to the IVC and RA and was removed uneventfully. The one TIPS that was placed caudad required removal and use of a venous interposition graft for reconstruction of the portal vein. All three patients with portal vein thrombosis required removal of the clot, and one required a venous interposition graft.

Fig. 1.

WEPPLER, KHAN ET AL

DISCUSSION

TIPS has emerged as a valuable modality in the treatment of complications from portal hypertension, due to its ability to gain immediate control of variceal hemorrhage. Numerous reports and a recent consensus conference have shown that TIPS is effective in stopping acute variceal hemorrhage that cannot be successfully controlled with sclerotherapy, as well as recurrent variceal bleeding which is refractory to pharmacologic therapy and sclerotherapy.lm3 Additionally, TIPS has also become an option for the treatment of ascites refractory to medical treatment.‘-’ Despite the use of TIPS in many patients to control variceal hemorrhage or refractory ascites, TIPS placement is not without complications. Minor complications include puncture site hematoma, pain, transient arrhythmias, hypotension, and fever. Severe life-threatening complications, which occur in 1% to 2% of the patients, include hemoperitoneum, hemobilia, acute hepatic ischemia, cardiac puncture, pulmonary edema, and septicemia. There are several chronic complications related to TIPS placement. Hepatic encephalopathy has been reported in 15% to 30% of patients and shunt stenosis in 33% to 66% of patients. Portal or splenic vein thrombosis is seen in 1% to 15% and chronic hemolytic anemia in 1% to 3% of patients.‘-“X8X9 Mills et al”’ previously reviewed surgical complications in 23 patients who had a TIPS prior to transplant. Four patients had misplacement of the stent, two caudad and two cephalad. A fifth patient had a bile duct perforation during stent placement causing bile peritonitis. They found no difference in operative time or blood loss between complicated and uncomplicated TIPS patients, or the remaining patients who underwent transplant without previous TIPS placement. Wilson et al” reported on three patients with surgical complications secondary to TIPS placement: one extending into the extrahepatic portal vein, one in the RA, and one in the suprahepatic vena cava. These malpositioned stents prolonged the operation in all of these patients by interfering with cross-clamping at the usual vascular sites. We compared two groups of patients who had a previous TIPS and underwent liver transplantation at our center during the study period. Group 1 had technical complications requiring correction at the time of liver transplantation and Group 2 did not. The two groups were comparable with regards to UNOS status, time from TIPS placement to transplant, and blood product usage during OLT. In Group 1, which comprised 33% of the patients, graft and patient survival was markedly reduced. Two of the mortalities occurred after the patient’s discharge (one in each group) and were not related, at least directly, to the liver transplant; however, the other two patients who died in Group 1 did not leave the hospital after the surgery. There was no difference in complications in TIPS done at our institution vs those done elsewhere. In time, some of these complications, particularly malplacement of the stent,

PORTOSYSTEMIC

SHUNTING

IN LIVER TRANSPLANTATION

may be decreased as more experience with the TIPS procedure is obtained. In conclusion, TIPS can be a life-saving procedure because it is very effective in controlling variceal hemorrhage and can serve as a bridge to OLT. However, it has significant potential to complicate a liver transplant. Therefore, judicious use of it is recommended if OLT is anticipated. REFERENCES

1. Schiffman ML, Jeffers L, Hoofnagle JH, et al: Hepatology 22:1591, 1995 2. LaVerge JM, Ring EJ, Gordon RL, et al: Radiology 187:413, 1993 3. Roessle M, Haag K, Ochs A, et al: N Eng J Med 330:165,1994

4. Ochs A, Rossle M, Haag K, et al. N Eng J Med 332:1192,1995 5. Somberg KA, Lake JR, Tomlanovich SJ, et al. Hepatology 21:709, 1995 6. Wong F, Sniderman K Liu P, et al: Ann Intern Med 122:816, 1995 7. Quiroga J, Sangro B, Nunez M, et al: Hepatology 21:986,1995 8. Sanyal AJ, Freedman AM, Shiffman ML, et al: Hepatology 20:46, 1994 9. Somberg KA, Riegler JL, LaBerge JM, et al: Am J Gastroenter01 90:549, 1995 10. Mills M, Imagawa D, Olthoff K: Transplant Proc 27:1252, 1995 11. Wilson MW, Gordon RL, LaBerge JM, et al: J Vast Intetv Radio1 6:695, 1995