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Challenging TIPS in Liver Transplant Recipients: The Pull-Through Technique to Address Piggyback Anastomosis

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Abstract

Purpose

The hepatic vein access during transjugular intrahepatic portosystemic shunt (TIPS) can be challenging in liver transplant recipient patients, especially when piggyback anastomosis was performed. We described a modified technique and reviewed the clinical outcomes of TIPS in transplanted patients.

Materials and Methods

From 2015 to 2016, 8 patients with history of liver transplantation using a three-hepatic vein piggyback technique for venous anastomosis underwent a TIPS in our institution. Indications were refractory ascites (n = 7) or variceal bleeding (n = 1). When the hepatic vein access failed via the standard jugular route, a pull-through technique was used: After puncturing the right hepatic vein under ultrasound guidance, a guidewire and a vascular sheath were advanced, then the guidewire was snared in the inferior vena cava and retrieved though the jugular access, and the hepatic vein was catheterized along the guidewire. The safety and technical success rates of this technique and the clinical outcomes of the study population were retrospectively assessed.

Results

Seven of 8 patients (87.5%) required the pull-through technique to access a hepatic vein. No complications of the percutaneous access of the hepatic vein were found at the one-day and one-month ultrasound Doppler examinations. Among 7 patients who had refractory ascites, 3 had complete resolution of ascites (43%), and one had moderate improvement. One patient with refractory infected ascites on severe graft failure and one with massive bleeding died soon after the procedure.

Conclusion

A pull-through technique following percutaneous puncture of a hepatic vein is a safe technique for performing a TIPS in liver transplant recipients with piggyback anastomosis complicated by acute hepatic vein angulation.

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Abbreviations

TIPS:

Transjugular intrahepatic portosystemic shunt

OLT:

Orthotopic liver transplantation

IVC:

Inferior vena cava

US:

Ultrasound

mn:

Minutes

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Authors and Affiliations

  1. Department of Radiology, St-Eloi University Hospital, Montpellier, France

    Valentina Schembri, Christophe Cassinotto, Julien Delicque, Marie-Ange Pierredon, Lauranne Piron, Laure Escal & Boris Guiu

  2. Department of Surgery, St-Eloi University Hospital, Montpellier, France

    Fabrizio Panaro & Astrid Herrero

  3. Department of Hepatology, St-Eloi University Hospital, Montpellier, France

    José Ursic-Bedoya

Authors
  1. Valentina Schembri
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  2. Christophe Cassinotto
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  3. Fabrizio Panaro
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  4. Julien Delicque
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  5. Marie-Ange Pierredon
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  6. Lauranne Piron
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  7. Astrid Herrero
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  8. Laure Escal
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  9. José Ursic-Bedoya
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  10. Boris Guiu
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Corresponding author

Correspondence to Christophe Cassinotto.

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Conflicts of interest

The authors declare that they have no conflicts of interest.

Informed Consent

The institutional review board approved this study and waived the informed consent requirement because of the retrospective nature of the study.

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Schembri, V., Cassinotto, C., Panaro, F. et al. Challenging TIPS in Liver Transplant Recipients: The Pull-Through Technique to Address Piggyback Anastomosis. Cardiovasc Intervent Radiol 41, 804–810 (2018). https://doi.org/10.1007/s00270-018-1886-3

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  • DOI: https://doi.org/10.1007/s00270-018-1886-3

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