ANNALS OF SURGERYVol. 227, No. 3, 440-445C) 1998 Lippincott-Raven Publishers

Liver Transplantation Complicated by MisplacedTIPS in the Portal VeinPierre-Alain Clavien, MD, PhD, FACS,* Markus Selzner, MD,* J. E. Tuttle-Newhall, MD,* Robert C. Harland, MD,* andPaul Suhocki, MDt

From the Hepatobiliary Surgery and Liver Transplant Program, Department of Surgery* and Radiology, t Duke University MedicalCenter, Durham, North Carolina

ObjectiveThe purpose of this study was to determine the incidence andcomplications related to transjugular intrahepatic portosys-temic shunt (TIPS) stents found in the portal vein at the timeof an orthotopic liver transplantation.

BackgroundTransjugular intrahepatic portosystemic shunts are frequentlyused in patients with end-stage liver disease as a bridge toliver transplantation. The incidence of finding the metal stentoutside of the liver parenchyma at the time of transplantationis reported as high as 30%. Most cases that have been de-tailed involve stents misplaced in the vena cava with variousoutcomes. Almost no data are available regarding stents mis-placed into the portal vein.

Methods and ResultsWe report our experience with four patients with whom aTIPS stent was found misplaced in the portal vein at the timeof liver transplantation, including one patient with a stent ex-tending into the superior mesenteric vein. This patient re-

quired extensive venous reconstruction using a retropancre-atic "pant" donor-iliac vein graft. The three other patientswere transplanted without the need for extensive venous re-construction. There was no significant difference in operativetimes for this group of patients, but there was a significantincrease in the requirement for blood transfusion. In a fol-low-up period ranging from 6 months to 2 years, all patientsremained alive and had normal portal venous flow and func-tioning allografts. Most misplaced stents were placed in pa-tients with small cirrhotic livers and by radiologists with mini-mal experience with the procedure.

ConclusionsMisplaced TIPS in the portal vein before liver transplantation isa more frequent complication than previously reported; how-ever, it does not represent major technical difficulty if a clampcan be placed proximally on the portal vein. In the case of astent extending below the spleno-mesenteric confluence, in-terposition grafts such as a donor-iliac vein graft are neces-sary for venous reconstruction. The experience of the radiolo-gist is critical to prevent this complication.

The transjugular intrahepatic portosystemic shunt(TIPS) procedure was introduced for the management ofpatients with complications from portal hypertension in1989.' Currently, a common indication for TIPS place-ment is recurrent variceal bleeding or ascites refractory tomedical therapy in patients awaiting orthotopic livertransplantation (OLT).2'3 The intrahepatic location of thestent is critical in these patients to limit potential com-plications during the conduct of the transplant procedure.During placement, the stent can be deployed into the

suprahepatic cava or into the portal vein (PV) complicat-ing allograft revascularization at the time of OLT. Nu-merous cases of stents malpositioned in the vena cavahave been reported in the literature with various out-comes.4'5 However, there is little information regardingthe outcome of stents placed into the PV. Because of thelack of data on this complication and our recent involve-ment in several of these cases, we have reviewed ourinstitutional experience and the literature to date regard-ing TIPS found in the PV at the time of OLT.

METHODS AND RESULTSTransjugular intrahepatic portosystemic shunt was intro-

duced in our center as a standard procedure to control

440

Send correspondence and reprints to Pierre A. Clavien, MD, PhD, Depart-ment of Surgery, Duke University Medical Center, Box No: 3247,Durham NC 27710.

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variceal bleeding and ascites refractory to medical therapyin June 1992. A retrospective chart review was undertakento review all of the patients who had undergone OLT from1993 to 1996 to determine the number of stents placedbefore transplantation. Within the study period, 87 TIPSwere performed in our center. Twelve (9.4 %) of these TIPSwere placed in the 127 patients who received an OLT in ourcenter. Four (25%) of these 12 patients were found to havetheir stent inferiorly misplaced into the PV before or at thetime of OLT. In one case, the stent extended into thesuperior mesenteric vein (SMV). Each but one of thesestents were inserted by a radiologist who had previousexperience with less than 10 TIPS procedures. In contrast,all of the eight other patients had their TIPS stent placed bya single radiologist experienced with the procedure (p <0.02, Fisher's exact test). In addition, the only stent mis-placed by the experienced radiologist was located above theleft gastric vein allowing easy placement of the clampbelow the stent at the time of OLT (see case 4). Three of thefour misplaced stents were found in patients with very smallcirrhotic livers (<700g), while only half of the 12 patientswho received a TIPS before OLT had shrunken livers (p <0.04, Fisher's exact test). Only 1 (8%) of the 12 patients hadher stent extending in the suprahepatic vena cava as well,but this did not change the conduct of the transplant proce-dure (see case 3). Mean length of operative time was 6.5hours, not statistically different from the median time forpatients without TIPS. However, the mean transfusion re-quirement of 4.5 units of packed red cells was statisticallydifferent than our usual mean of 2.0 units (p < 0.03,Fisher's exact test). The following describes the four cases.

Patient 1

A 49-year old woman with cryptogenic cirrhosis wasreferred to our institution with ascites refractory to medicaltherapy, a large right pleural effusion, and an elevatedprothrombin time. After an evaluation, she was subse-quently listed for OLT. A TIPS was placed during her firsthospital admission but was complicated by deployment ofthe Wallstent (Schneider USA Inc, Minneapolis, MN) intothe proximal SMV. A second stent was placed craniad to thefirst but it did not decompress the portal system. Thus, athird intrahepatic stent was placed on the top of the twoother stents. This successfully decreased the portal pressuregradient across the shunt from 24 to 2 mmHg. The ascitesand the right pleural effusion dramatically improved afterthe procedure. The patient developed severe encephalopa-thy several months later, which required continuous hospi-talization. Serial doppler ultrasonography (US) and a tran-sjugular portal venogram before the transplantation showeda patent PV with unchanged location of the stents (Figure 1).An OLT was performed 5 months after the TIPS placement.

The transplant procedure started with the usual mobilization ofthe diseased liver including dissection of the porta hepatis. Thestent was easily palpable in the entire PV. The gastro-colic

Figure 1. Preoperative transhepatic venogram showing a transjugularintrahepatic portosystemic shunt (TIPS) (arrowheads) with two stentsand a third stent (arrow) extending into the superior mesenteric vein.SMV, super.or mesenteric vein; SV, splenic vein.

ligament was divided, and the inferior border of the pancreaswas identified. The splenic vein (SV) was freed of the pancre-atic attachments for about 3 cm by ligating several pancreaticvenous branches. The SMV was then identified and the stentwas found extending 2.5 cm below the confluence of thesplenic and superior mesenteric veins. The SV and the SMVwere clamped and divided about 1.5 cm away from the stent.The donor iliac vein graft was then used as a conduit forvascular reconstruction. An end-to-end anastomosis was per-formed between the internal and external iliac vein and SMVand SV, respectively. The common iliac vein was tunneledposteriorly to the pancreas and brought out in the porta hepatisarea (Figure 2). The hepatectomy was completed. The venacava was not preserved and the veno-venous bypass was notrequired. After the infra- and suprahepatic cava anastomoseswere performed, the donor PV was reanastomosed to the donoriliac vein of the pant graft. The duration of the anhepatic phasewas 57 minutes, rewarming time was 47 minutes, and thewhole operation was 8.5 hours. During the operation the pa-tient received two units of packed red blood cells, two units offresh frozen plasma, and one unit of platelets. The removedliver weighed 600 g. The postoperative course was uncompli-cated. The patient did experience one episode of acute rejectionwithin the immediate postoperative period. Serial postopera-tive doppler US examination of the liver up to 12 months afterthe OLT show an excellent flow in the iliac vein graft anddonor PV with homogeneous perfusion of the liver.

Patient 2

A 38-year old man underwent a TIPS procedure formedical refractory ascites while awaiting OLT for hepatitisC cirrhosis. A revision was required 6 months later becauseof an occlusion of the first stent. An OLT was performed 7months after the TIPS stent revision. The hepatectomy andpreparation of the portal triad was difficult because ofnumerous adhesions secondary to multiple laparotomies

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Figure 2. Intraoperative view (2A)and drawing (2B) showing the vascu-lar reconstruction after excision ofthe complete recipient portal vein in-cluding about 1.5 cm of splenic veinand 3 cm of superior mesentericvein. The donor iliac vein graft wasused as a conduit. An end-to-endanastomosis was performed be-tween the internal and external iliacveins and superior mesenteric veinand splenic vein, respectively (arrow-heads). The common iliac vein wasthen tunneled posteriorly to the pan-creas and anastomosed to the donorportal vein (arrow). P, pancreas; PV,portal vein; SV, splenic vein; andSMV, superior mesenteric vein.

Donor liver

sv

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after a motor vehicle crash 8 years before. The TIPS wasunexpectedly palpated in the PV up to the level of the leftgastric vein. Stent position was not commented on duringserial Doppler US performed before the surgery, and thusdiscovery of the stent into the PV was not anticipated. Aclamp could be placed below the stent at the confluence ofthe splenic and superior mesenteric veins, and the PV con-taining the stent was transected at the level of the PVbifurcation. After transecting the vein, the Wallstent waseasily removed. The hepatectomy was then completed in theusual fashion. Implantation of the allograft was performedwithout incident, and the donor PV anastomosed about 1 cmabove the lower limit of the removed misplaced stent. Thepatient received four units of packed red blood cells and twounits of fresh frozen plasma. The excised liver weighed690 g. Postoperative duplex US showed homogenous per-fusion of the liver with a patent PV. The patient has had nocomplications with an 8 month follow-up.

Patient 3

A 63-year old woman with primary biliary cirrhosis under-went a TIPS procedure to prevent recurrent esophagealvariceal bleeding before transplantation. Placement of the TIPSwas successful without further bleeding. The TIPS was revisedseveral times over the next 24 months for stenosis caused bypseudointimal hyperplasia. During liver transplantation theTIPS stent was found to extend into the main PV to 1 cm abovethe take off of the left gastric vein. After careful preparation,the PV could be clamped 2 cm below the lower limit of thestent. After mobilizing the liver, the stent also was found in thevena cava which extended about 2 cm above the right hepaticvein. However, a supra-hepatic clamp could be placed safelyproximal to the stent. The superior and inferior positioning hadnot been commented on during preoperative doppler scans.The hepatectomy and implantation of the graft were performedin the usual fashion. The patient received two units of packedred cells and one unit of fresh frozen plasma. The explantedliver was of normal size (1100 g). Except for one episode ofmild rejection, the patient had an uneventful course with doc-umented normal portal flow on doppler US after a 2-yearfollow-up.

Patient 4

A 53-year old woman received a TIPS because of intrac-table ascites because of cirrhosis secondary to hepatitis Cwhile awaiting transplantation. Her ascites resolved within6 weeks after the TIPS placement. A Doppler US performed3 months later revealed a patent stent without evidence ofstenosis. The patient concomitantly developed severe en-cephalopathy requiring continuous hospitalization. An OLTwas performed during that hospitalization, 7 months afterthe TIPS placement. At the time of surgery, the dissection ofthe porta hepatis was complicated by adhesions from apreviously open cholecystectomy. The liver appearedshrunken and the stent was palpable in the upper PV and

about 2 cm above the left gastric vein. The stent positionhad not been commented on during serial preoperativedoppler US. A clamp could be easily placed proximal to thestent and about 1 cm above the PV confluence. After achiev-ing total vascular exclusion, the PV was transsected acrossthe stent high in the porta hepatis. The residual stent in thePV could be removed safely by simple traction. The im-plantation was then performed in the usual fashion. Thepatient received 10 units of packed red blood cells, 10 unitsof fresh frozen plasma, and 1 adult-dose pack of platelets.The excised liver was small, weighing 595 g. Postoperativedoppler US with a 6 months follow-up demonstrated apatent PV with homogenous perfusion of the liver.

DISCUSSION

Currently, TIPS is recommended as a bridge to livertransplantation in patients who have failed other conven-tional modalities to control variceal bleeding and refractoryascites.23 This technique is particularly attractive in thispopulation because the stent is removed with the recipientliver at the time of OLT. However, improper positioning ofthe stent during the TIPS procedure can compromise sig-nificantly the transplant procedure. Because of the increas-ing use of this procedure in patients waiting for transplan-tation, potential complications of the TIPS must be reported.

There are few reports in the literature to date that regardthe incidence and risk of misplaced TIPS. Most reports havefocused on TIPS deployed too proximal in the suprahepaticvena cava, which complicates the placement of the uppercaval clamp or preservation of the recipient vena cava.3 5-7

To our knowledge, only eight patients from seven serieshave been reported with misplacement of the TIPS inferi-orly into the PV (Table ). 2,4,5,7-10 All of the cases weremanaged by transection of the PV either through or belowthe metallic stent after placement of a clamp below the stent.Direct anastomosis without venous graft interposition couldbe performed in each case between the donor and recipientPV. While three patients were treated similarly in our series,one required extensive vascular reconstruction using a or-thotopic pant iliac vein interposition graft to reconstruct themesenteric system connecting the recipient SV and SMV tothe donor PV.

Vascular reconstruction of the PV during liver transplan-tation is often used in cases of portal venous thrombosiswith reported reoccurrence of thrombosis in 20% to 30% ofthe patients.'1-15 Recently Pina et al.'4 have described apatient with extensive PV thrombosis in whom the donoriliac vein graft was used as a conduit between the PV andtwo jejunal veins of the SMV. They labeled this graft "pantjump graft." Similarly, Kirsch et al." reported a series ofseven patients with PV thrombosis discovered at the time ofOLT. A donor iliac venous conduit between the PV andSMV was used in each case. The interposition graft wasplaced orthotopically behind the pancreas in two patientsand through the transverse mesocolon in the other five. In

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Table 1. LITERATURE REVIEW OF TIPS FOUND IN THE PORTAL VEINAT THE TIME OF OLT

DislocationNumber of Known Before

Authors Patients Management During OLT OLT Complications Follow-up

Wilson et al.4 1 Clamping below the stent, transection No No NAacross the stent

Lerut et al.5 1 Clamping below the stent, transection NA PV aneurysm NAacross the stent

Jabbour et al.10 1 NA NA Partial PV thrombosis NASuc et al.7 1 NA NA No NALa Berge et al.2 1 Clamping and transection below the stent NA No NAWoodle et al.8 1 Stent moved intrahepatically NA No PV patentMillis et al.9 2 Clamping and transection below the stent NA PV thrombosis NACurrent study 4 (1) Pant iliac vein reconstruction Yes No PV patent

(2) Clamping and transection below the No No PV patentstent

(1) Clamping below the stent, Transection No No PV patentacross the stent

NA = not available; PV =portal vein.

the present series, a pant graft technique was also used inone patient for orthotopic reconstruction of the hepaticvenous supply. The retropancreatic position of the iliac veingraft combined with complete removal of the native PVcontaining the stent was probably important in preventingkinking and compression of the iliac graft, which may haveimpaired the portal blood flow. The orthotopic techniquemight be more suitable here than in the situation of PVthrombosis because of the absence of elevated portal hyper-tension. In case of severe portal hypertension, kinking, orextrinsic compression of the PV are rarely symptomaticafter OLT. Complete vascular reconstruction of the portalvenous system is also technically easier in the patient witha previously placed TIPS than in presence of PV thrombo-sis, where numerous collaterals and varices are present. Inthe patients currently presented, the portal system recon-struction was performed without major intraoperative com-plications. However, the amount of blood transfused duringsurgery was significantly greater than in other patients.The incidence of stent dislocation in the PV after the

TIPS procedure appears to be underreported. In our series of127 OLT recently performed at Duke University MedicalCenter, four (25%) of 12 TIPS placed before surgery werefound inferiorly misplaced in the portal venous system,while only one extended into the suprahepatic vena cava.This discrepancy can be explained by the increased aware-ness by the interventional radiologist regarding the impli-cations of a stent in the vena cava. On the other hand, theimplications of stents located in the portal vein are un-known, and therefore there are no guidelines available. Theaberrant location of the stent remained unknown until thetime of surgery in three patients despite multiple preopera-tive doppler US, a finding similar to the other reports (Table1). In the fourth patient whose stent was demonstrated in the

SMV before surgery, performing a transjugular portalvenogram just before OLT was important to identify theexact location of the stent; this allowed advanced prepara-tion and an adequate strategy for vascular reconstruction.Because of the potentially increased risk of intraoperativecomplications including increased need for transfusion andthe inability to place a cannula in the PV if a veno-venousbypass is to be used, recognition of misplaced stents in thePV prior to OLT is important. Preoperative Doppler USwith special attention for the stent location is recommendedin every case. If doppler US does not clearly show theintrahepatic stent location, a transjugular portal venogrammust be performed before transplantation. Moulin et al.'6reported a percutaneous transjugular removal during a TIPSprocedure of a stent extending into the SMV. We did notretrieve the stent in our patient because of the fear of PVperforation and bleeding.The risk factors for misplaced TIPS in the PV remain

elusive. Two statistically significant risk factors were iden-tified in our series: the size of the cirrhotic liver and theexperience of the radiologist with the TIPS procedure. Inour patients, an inferiorly positioned stent was found sig-nificantly more frequently in small cirrhotic livers (< 700g)than in normal or increased size livers. Now stents areavailable in many lengths and diameters. Use of a shorterstent in smaller livers can prevent too inferior extension ofthe stent into the PV. Wallstents shorten significantly duringtheir deployment, making accurate positioning of the stentdifficult. This may explain the association found in thisstudy between the incidence of stent misplacement and theexperience of the radiologist with the TIPS procedure.These findings may lead to the recommendation to haveTIPS placed only by experienced radiologists, particularlyin patients with small livers.

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In conclusion, although a TIPS stent placed too low in thePV does not constitute a contraindication for transplantationeven in presence of severe stent dislocation, it can representmajor intraoperative challenges. Small cirrhotic livers ap-pear to be at greater risk for a low positing of the stent, andonly experienced radiologists should perform the TIPS pro-cedure in these patients. Recognition of stent location beforeOLT is important for planning a strategy for stent removalor vascular reconstruction during OLT.

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3. Roessle M, Haag K, Ochs A, et al. The transjugular intrahepaticportosystemic stent - shunt procedure for variceal bleeding. N EnglJ Med 1994;330:165-171.

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