Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting

Abstract

Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.

Keywords: TIPS; bridge to transplant; liver transplantation; timing; transjugular intrahepatic portosystemic shunt.

Figure 1

Possible scenarios after second or further decompensation in patients with liver cirrhosis treated with medical therapy versus TIPS placement with a view to transplantation. Red boxes indicate possible negative events and the progression of liver diseases. Grey boxes indicate potential causes of a patient’s exclusion from transplantation or death. Patients with decompensated liver cirrhosis undergoing medical or endoscopic therapy may experience clinical improvement, but the natural history of the disease may progress to further deterioration and a need for transplantation. Patients with TIPS can often develop hepatic encephalopathy, which is frequently transient, and seldom ACLF or cardiac deterioration. Some patients after a TIPS may correct portal thrombosis, making liver transplants more feasible. TIPS, by improving portal hypertension-related complications, may increase transplant-free survival. HE, hepatic encephalopathy; TIPS, transjugular intrahepatic portosystemic shunt, PH, portal hypertension; ACLF, acute-on-chronic liver failure; PV, portal vein.

Figure 2

Clinical conditions that may occur in patients eligible for liver transplantation: impact and feasibility of TIPS. PVT, portal vein thrombosis; HCC, hepatocarcinoma; ACLF, acute-on-chronic liver failure; HRS, hepatorenal syndrome; HE, hepatic encephalopathy.