Liver transplantation has come a long way over the past 50 years, becoming the mainstay definitive treatment of most types of liver failure. Advancements in both operative techniques for enhanced recovery and pharmacologic management have greatly increased survival rates in recipients1. The disparity between available donors and waitlisted patients is still a great challenge. Of the 317 patients on Mexico’s 2019 liver transplant waiting list, only 223 received a graft, accounting for just 70% of the patients in need2. This seemingly universal barrier is also present in the developed world. The United Kingdom reported that the discrepancy leads to the death of ∼9% of patients listed for transplant, before a donor organ becomes available. The United States reports that waitlist mortality varies geographically, ranging from 6.5 to 37.4 deaths per 100 waitlist-years3,4.

Medical therapy has evolved and been optimized for the treatment of patients with liver failure, as have procedures designed to aid and restore the physiologic baseline. Procedures, such as transjugular intrahepatic portosystemic shunt (TIPS) and portocaval shunt placement, aim to reduce the systemic vascular complications of portal hypertension5. Rapid normalization leads to mesenteric venous decongestion, increased effective arterial blood volume, and increased response to pharmacologic management6,7 that clinically translates to a lower incidence of variceal bleeding, decreased bacterial translocation, and improved renal function8. Current indications for TIPS placement include refractory esophageal varices or early interventions for patients with a high risk of treatment failure, Budd-Chiari syndrome, and treatment-refractory ascites, showing superior control, increased survival, and better glomerular filtration rates, when compared with paracentesis8,9. However, the benefits of TIPS placement come at the cost of worsening liver function. Decreased perfusion shows increased international normalized ratio and bilirubin values, reduced albumin, and an increased risk of developing pulmonary hypertension, due to cardiac overload, and higher rates of encephalopathy, due to the shunting of unfiltered blood10–12. Risks for complications are also associated with the procedure. They include vascular injuries to the carotid arteries or right atrium, bleeding, portal or caval perforations, and biliary duct injury. The incidence of those complications, along with TIPS infection, have been reported at less than 1%13. Thus, TIPS can be a safe “bridging” therapy that enables the treatment of refractory symptoms until transplantation becomes available14. The aim of the present study was to compare operative time, operative bleeding, transfusions, intensive care unit (ICU) stay, and short-term survival in patients with TIPS prior to orthotopic liver transplantation (OLT) versus patients that only underwent OLT (OLT-only group).

We performed our study at a low-volume TIPS and OLT center.

A retrospective review was conducted on patients that underwent liver transplantation at the Hospital San José Tec de Monterrey, since the program first began in 1999 until February 2020. Records for hospitalization, operative notes, and clinical data were reviewed for all patients. A total patient population of 92 was reviewed, of which 9 (9.8%) underwent TIPS prior to receiving the transplant. Clearance from the hospital ethics committee and patient consent were obtained for this study.

Transplants were distributed, according to the Mexican General Health Law, Article 336, which states that organ allocation is dependent on the receptor’s status, transplant opportunity, expected benefits, compatibility, and hospital location. Organs were recovered from donors after brain death in all cases and rapid extraction procurement with 4C in-situ portal and arterial preservation solution was carried out, followed by standard cold storage (Starzl). Wisconsin solution was used in the first 12 cases and histidine-tryptophan-ketoglutarate for all the remaining transplants. Whole liver transplantation was performed in all patients. The classic technique, with the aid of a venovenous bypass, was carried out in only one case, whereas a vena cava preservation technique was employed in the others. Biliary reconstruction was achieved via duct-to-duct anastomosis. All 9 TIPS placements were performed by the same interventional radiologist. Procedures were carried out under general anesthesia, with ultrasound-assisted right internal jugular vein puncture. Guidewires were navigated to achieve selective hepatic vein catheterization and pre-shunt measures were obtained for portal, hepatic, and inferior vena cava vessels. Portograms were analyzed for circulation aberrations. Balloon dilation was performed before stent placement, changes in portosystemic pressures were recorded, and shunt patency was verified.

After the initial analysis, 1:3 propensity score (PS) matching was performed through a multiple stepwise regression of age, smoking status, and Child-Pugh grade. The resulting PSs for complications and mortality were used to select control cases from the OLT-only patient pool, using a nearest neighbor algorithm with a .05 clamp.