Transjugular intrahepatic portosystemic shunts in liver transplant recipients

Abstract

Background: The aim of this study was to determine the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) in liver transplant (LT) recipients with refractory ascites/variceal bleeding and to compare the observed outcomes with those obtained in cirrhotic controls.

Methods: Clinical features of 14 LT recipients referred for TIPS placement between August 1985 and September 2006 were reviewed and compared with published series and 28 cirrhotic control patients undergoing TIPS.

Results: The median age of the 14 LT recipients was 52 years, 57% had chronic hepatitis C virus and the median time from LT to TIPS placement was 46 months. Portal vein thromboses in two patients and a procedural complication in another patient precluded TIPS deployment. Among the 11 patients who completed TIPS, the mean hepatic venous pressure gradient was significantly reduced post-TIPS (18.3 +/- 6.1 to 9.0 +/- 3.5 mmHg, P<0.01). However, only 50% of the patients with varices had no further bleeding and 57% of the refractory ascites patients required no further paracentesis. In addition to a single peri-procedural death and renal failure in three others, four patients (29%) developed infection and nine (82%) developed new onset or worsening encephalopathy at a median of 11 days post-TIPS. The 1-year patient survival of 14% was substantially lower than that observed in other series of LT recipients (57-67%) as well as the matched cirrhotic control group undergoing TIPS (58%).

Conclusion: The frequent morbidity noted in LT recipients undergoing TIPS, coupled with the low 1-year patient survival, demonstrates that portal decompression provides only marginal short-term benefit in the absence of retransplantation.