To the Editor: 

Transjugular intrahepatic portosystemic shunt (TIPS) is common in patients presenting for orthotopic liver transplantation (OLT). More than 5,200 TIPS procedures were performed in the United States in 2008.*In our institution, 18% of adult OLT recipients during the past 2 yr presented with TIPS. Whereas TIPS mitigates symptoms of portal hypertension, associated complications, such as thrombosis and migration, pose technical challenges during OLT.1,,4We present a case of OLT in a patient with known thrombosed TIPS. Intraoperative transesophageal echocardiography (TEE) revealed cephalad migration of the TIPS into the inferior vena cava (IVC) and an attached thrombus extending toward the cavoatrial junction. These findings necessitated a modification of surgical technique to safely remove the TIPS and prevent thromboembolism. We demonstrate that TEE may provide important clinical information for intraoperative management of OLT recipients with TIPS.

A 47-yr-old Caucasian man with alcoholic cirrhosis complicated by hepatorenal syndrome presented for OLT. Eight weeks earlier, he underwent uneventful placement of a 10- × 80-mm Viatorr®(Gore, Flagstaff, AZ) coated stent for refractory ascites. Four weeks later he presented with massive ascites and acute renal failure (creatinine 2.9 mg/dl) requiring urgent hemodialysis for hyperkalemia (K 7.0 mM). Abdominal Doppler revealed occluded TIPS within right hepatic vein. Magnetic resonance imaging showed only that TIPS was in place. The patient remained hospitalized requiring hemodialysis.

On the day of OLT, the patient's Model for End-Stage Liver Disease score was 25. Intraoperative TEE (Acuson Sequoia, Oceanside, CA) confirmed absent flow within the TIPS but showed the superior end of the TIPS protruding into the IVC (fig. 1A, B) and a 2-cm thrombus extending from the TIPS into the IVC in proximity of the cavoatrial junction (fig. 1A). See video Supplemental Digital Content 1,, which shows the floating thrombus. Based on these findings, the surgeons modified the standard piggyback technique to prevent thromboembolization. The suprahepatic IVC was circumferentially dissected into the pericardium and clamped above the thrombus, whereas the TIPS was pulled caudad. The infrahepatic IVC was clamped, completely isolating the hepatic veins, which were then divided, allowing the liver to be removed with the TIPS and associated thrombus intact (fig. 1C). A clamp was placed across the orifice of the hepatic veins, and flow was reestablished in the IVC. Surgery was completed uneventfully. No blood products were given. The patient was discharged home 2 weeks later.

Fig. 1. Two-dimensional view of the inferior vena cava (IVC). Proximal end of transjugular intrahepatic portocaval shunt (TIPS, thin arrow ) protrudes into the IVC. The attached thrombus (thick arrow ) extends toward the cavoatrial junction (A ). Color Doppler demonstrates flow in the IVC but no Doppler signal in the TIPS (B ). In situ  TIPS and protruding thrombus (arrow ) in the excised liver (C ).

Fig. 1. Two-dimensional view of the inferior vena cava (IVC). Proximal end of transjugular intrahepatic portocaval shunt (TIPS, thin arrow ) protrudes into the IVC. The attached thrombus (thick arrow ) extends toward the cavoatrial junction (A ). Color Doppler demonstrates flow in the IVC but no Doppler signal in the TIPS (B ). In situ  TIPS and protruding thrombus (arrow ) in the excised liver (C ).

Because TIPS is common in OLT recipients, perioperative physicians should be aware of associated complications and look for them systematically. Thrombosis, misplacement, and TIPS migration have been reported.2,,5In particular, intraoperative TIPS migration with serious consequences has been reported,6but intraoperative TEE in assessing the TIPS and guiding surgical management has not been used. In our case, intraoperative TEE, but not preoperative imaging, revealed that the superior end of the TIPS had migrated into the IVC. The migration may have occurred preoperatively or even intraoperatively because of surgical manipulation of the liver. In addition to assessing positioning, TEE was key in detecting free-floating thrombus, prompting altered surgical management.

No specific guidelines for the use of TEE in OLT exist, but experts support its use in the monitoring of hemodynamics and regional wall motion.7,,9In our experience, TEE is useful in assessing position and patency of TIPS in OLT recipients. Visualization of hepatic veins, IVC, and the cavoatrial junction is not a standard view.10In transgastric position, the probe is rotated right, toward the liver, and the omniplane angle is adjusted to 0–50 degrees to visualize the hepatic veins entering the IVC. Upon withdrawal of the probe, the cavoatrial junction is seen.†Systematic interrogation of IVC and TIPS should start before liver mobilization. The risks and benefits of placing a TEE probe into an individual OLT recipient should be considered. Direct placement of an ultrasound transducer on the hepatic vessels, an approach analogous to epiaortic ultrasound examination,11may be a safe alternative that should be considered.

This case report emphasizes the utility of TEE in OLT beyond its known applications. In this patient, TEE provided timely critical information not otherwise obtainable. The anesthesiologist should recognize that OLT recipients with TIPS may present with complications for which TEE is a uniquely useful diagnostic tool.


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