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Semin intervent Radiol 2023; 40(01): 038-043
DOI: 10.1055/s-0043-1764409
Review Article

Portal Vein Recanalization–Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) Facilitates Liver Transplantation in Cirrhotic Patients with Occlusive Portal Vein Thrombosis

Adam Swersky
1   Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
,
Daniel Borja-Cacho
,
Zach Deitch
,
Bartley Thornburg
1   Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
,
Riad Salem
1   Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
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Abstract

Portal vein thrombosis (PVT) is a heterogeneous condition with multiple possible etiologies and to varying degrees has historically limited candidacy for liver transplant (LT) in the cirrhotic patient population due to resultant difficulties in constructing a robust portal vein anastomosis. While intraoperative approaches to managing PVT are well-described, methods which approximate normal portal physiology are not always feasible depending on the extent of PVT, and other nonphysiologic techniques are linked with substantial morbidity and poor long-term outcomes. Portal vein recanalization–transjugular intrahepatic portosystemic shunt (PVR-TIPS) creation is an efficacious method of restoring physiologic portal flow in cirrhotic patients prior to LT allowing for end-to-end PV anastomosis, and is the product of decades-long institutional expertise in TIPS/LT and the support of a multidisciplinary liver tumor board. To follow is a review of the pertinent pathophysiology of PVT in cirrhosis, the rationale leading to the development and subsequent evolution of the PVR-TIPS procedure, technical lessons learned, and a summary of outcomes to date.

Keywords

portal vein thrombosis - cirrhosis - liver transplant - portal vein recanalization - transjugular portosystemic intrahepatic shunt - interventional radiology


Publication History

Article published online:
04 May 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Ponziani FR, Zocco MA, Campanale C. et al. Portal vein thrombosis: insight into physiopathology, diagnosis, and treatment. World J Gastroenterol 2010; 16 (02) 143-155
    CrossrefPubMedGoogle Scholar
  • 2 Condat B, Valla D. Nonmalignant portal vein thrombosis in adults. Nat Clin Pract Gastroenterol Hepatol 2006; 3 (09) 505-515
    CrossrefPubMedGoogle Scholar
  • 3 Chawla Y, Duseja A, Dhiman RK. Review article: the modern management of portal vein thrombosis. Aliment Pharmacol Ther 2009; 30 (09) 881-894
    CrossrefPubMedGoogle Scholar
  • 4 Hoekstra J, Janssen HL. Vascular liver disorders (II): portal vein thrombosis. Neth J Med 2009; 67 (02) 46-53
    PubMedGoogle Scholar
  • 5 Zocco MA, Di Stasio E, De Cristofaro R. et al. Thrombotic risk factors in patients with liver cirrhosis: correlation with MELD scoring system and portal vein thrombosis development. J Hepatol 2009; 51 (04) 682-689
    CrossrefPubMedGoogle Scholar
  • 6 Stine JG, Wang J, Shah PM. et al. Decreased portal vein velocity is predictive of the development of portal vein thrombosis: a matched case-control study. Liver Int 2018; 38 (01) 94-101
    CrossrefPubMedGoogle Scholar
  • 7 Gatt A, Riddell A, Calvaruso V, Tuddenham EG, Makris M, Burroughs AK. Enhanced thrombin generation in patients with cirrhosis-induced coagulopathy. J Thromb Haemost 2010; 8 (09) 1994-2000
    CrossrefPubMedGoogle Scholar
  • 8 Kremers RMW, Kleinegris MC, Ninivaggi M. et al. Decreased prothrombin conversion and reduced thrombin inactivation explain rebalanced thrombin generation in liver cirrhosis. PLoS One 2017; 12 (05) e0177020
    CrossrefPubMedGoogle Scholar
  • 9 Sinegre T, Duron C, Lecompte T. et al. Increased factor VIII plays a significant role in plasma hypercoagulability phenotype of patients with cirrhosis. J Thromb Haemost 2018; 16 (06) 1132-1140
    CrossrefPubMedGoogle Scholar
  • 10 Tripodi A, Primignani M, Chantarangkul V. et al. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology 2009; 137 (06) 2105-2111
    CrossrefPubMedGoogle Scholar
  • 11 La Mura V, Tripodi A, Tosetti G. et al. Resistance to thrombomodulin is associated with de novo portal vein thrombosis and low survival in patients with cirrhosis. Liver Int 2016; 36 (09) 1322-1330
    CrossrefPubMedGoogle Scholar
  • 12 Ohnishi K, Saito M, Terabayashi H, Nomura F, Okuda K. Development of portal vein thrombosis complicating idiopathic portal hypertension. A case report. Gastroenterology 1985; 88 (04) 1034-1040
    CrossrefPubMedGoogle Scholar
  • 13 Chang CY, Yang PM, Hung SP. et al. Cavernous transformation of the portal vein: etiology determines the outcome. Hepatogastroenterology 2006; 53 (72) 892-897
    PubMedGoogle Scholar
  • 14 Molvar C, Amin P. Portal vein thrombosis in cirrhosis: interventional treatment options. Curr Gastroenterol Rep 2021; 23 (12) 24
    CrossrefPubMedGoogle Scholar
  • 15 Yerdel MA, Gunson B, Mirza D. et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation 2000; 69 (09) 1873-1881
    CrossrefPubMedGoogle Scholar
  • 16 Francoz C, Valla D, Durand F. Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 2012; 57 (01) 203-212
    CrossrefPubMedGoogle Scholar
  • 17 Nonami T, Yokoyama I, Iwatsuki S, Starzl TE. The incidence of portal vein thrombosis at liver transplantation. Hepatology 1992; 16 (05) 1195-1198
    CrossrefPubMedGoogle Scholar
  • 18 Garcia-Pagan JC, Valla DC. Portal vein thrombosis: a predictable milestone in cirrhosis?. J Hepatol 2009; 51 (04) 632-634
    CrossrefPubMedGoogle Scholar
  • 19 Lendoire J, Raffin G, Cejas N. et al. Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome. HPB (Oxford) 2007; 9 (05) 352-356
    CrossrefPubMedGoogle Scholar
  • 20 Rodríguez-Castro KI, Porte RJ, Nadal E, Germani G, Burra P, Senzolo M. Management of nonneoplastic portal vein thrombosis in the setting of liver transplantation: a systematic review. Transplantation 2012; 94 (11) 1145-1153
    CrossrefPubMedGoogle Scholar
  • 21 Englesbe MJ, Schaubel DE, Cai S, Guidinger MK, Merion RM. Portal vein thrombosis and liver transplant survival benefit. Liver Transpl 2010; 16 (08) 999-1005
    CrossrefPubMedGoogle Scholar
  • 22 Rana A, Hardy MA, Halazun KJ. et al. Survival outcomes following liver transplantation (SOFT) score: a novel method to predict patient survival following liver transplantation. Am J Transplant 2008; 8 (12) 2537-2546
    CrossrefPubMedGoogle Scholar
  • 23 Manzanet G, Sanjuán F, Orbis P. et al. Liver transplantation in patients with portal vein thrombosis. Liver Transpl 2001; 7 (02) 125-131
    CrossrefPubMedGoogle Scholar
  • 24 Bertelli R, Nardo B, Montalti R, Beltempo P, Puviani L, Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center. Transplant Proc 2005; 37 (02) 1119-1121
    CrossrefPubMedGoogle Scholar
  • 25 Dumortier J, Czyglik O, Poncet G. et al. Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant 2002; 2 (10) 934-938
    CrossrefPubMedGoogle Scholar
  • 26 Ravaioli M, Zanello M, Grazi GL. et al. Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg 2011; 253 (02) 378-384
    CrossrefPubMedGoogle Scholar
  • 27 Molmenti EP, Roodhouse TW, Molmenti H. et al. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg 2002; 235 (02) 292-296
    CrossrefPubMedGoogle Scholar
  • 28 Norrby J, Mjörnstedt L, Liden H, Friman S, Olausson M. Liver transplantation using cavoportal hemitransposition: a possibility in the presence of extensive portal vein thrombosis. Transplant Proc 2001; 33 (04) 2495-2496
    CrossrefPubMedGoogle Scholar
  • 29 Paskonis M, Jurgaitis J, Mehrabi A. et al. Surgical strategies for liver transplantation in the case of portal vein thrombosis -- current role of cavoportal hemitransposition and renoportal anastomosis. Clin Transplant 2006; 20 (05) 551-562
    CrossrefPubMedGoogle Scholar
  • 30 Bonnet S, Sauvanet A, Bruno O. et al. Long-term survival after portal vein arterialization for portal vein thrombosis in orthotopic liver transplantation. Gastroenterol Clin Biol 2010; 34 (01) 23-28
    CrossrefPubMedGoogle Scholar
  • 31 Chen H, Turon F, Hernández-Gea V. et al. Nontumoral portal vein thrombosis in patients awaiting liver transplantation. Liver Transpl 2016; 22 (03) 352-365
    CrossrefPubMedGoogle Scholar
  • 32 Hibi T, Nishida S, Levi DM. et al. When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg 2014; 259 (04) 760-766
    CrossrefPubMedGoogle Scholar
  • 33 Thornburg B, Desai K, Hickey R. et al. Portal vein recanalization and transjugular intrahepatic portosystemic shunt creation for chronic portal vein thrombosis: technical considerations. Tech Vasc Interv Radiol 2016; 19 (01) 52-60
    CrossrefPubMedGoogle Scholar
  • 34 Knight GM, Clark J, Boike JR. et al. TIPS for adults without cirrhosis with chronic mesenteric venous thrombosis and EHPVO refractory to standard-of-care therapy. Hepatology 2021; 74 (05) 2735-2744
    CrossrefPubMedGoogle Scholar
  • 35 Thornburg B, Riaz A, Salem R. Commentary on percutaneous trans-splenic balloon-assisted transjugular intrahepatic portosystemic shunt placement in patients with portal vein obliteration for portal vein recanalization: feasibility, safety and effectiveness. Cardiovasc Intervent Radiol 2022; 45 (05) 703-704
    CrossrefPubMedGoogle Scholar
  • 36 Chan T, DeGirolamo K, Chartier-Plante S, Buczkowski AK. Comparison of three caval reconstruction techniques in orthotopic liver transplantation: a retrospective review. Am J Surg 2017; 213 (05) 943-949
    CrossrefPubMedGoogle Scholar
  • 37 Entezari P, Riaz A, Thornburg B, Salem R. Percutaneous ultrasound-guided superior and inferior mesenteric vein access for portal vein recanalization-transjugular intrahepatic portosystemic shunt: a case series. Cardiovasc Intervent Radiol 2021; 44 (03) 496-499
    CrossrefPubMedGoogle Scholar
  • 38 Matsui O, Yoshikawa J, Kadoya M. et al. Transjugular intrahepatic portosystemic shunt after previous recanalization of a chronically thrombosed portal vein via a transmesenteric approach. Cardiovasc Intervent Radiol 1996; 19 (05) 352-355
    CrossrefPubMedGoogle Scholar
  • 39 Sabri SS, Caldwell SH, Kumer SC. et al. Combined transmesenteric and transhepatic recanalization of chronic portal and mesenteric vein occlusion to treat bleeding duodenal varices. J Vasc Interv Radiol 2014; 25 (08) 1295-1299
    CrossrefPubMedGoogle Scholar
  • 40 Salem R, Vouche M, Baker T. et al. Pretransplant portal vein recanalization-transjugular intrahepatic portosystemic shunt in patients with complete obliterative portal vein thrombosis. Transplantation 2015; 99 (11) 2347-2355
    CrossrefPubMedGoogle Scholar
  • 41 Habib A, Desai K, Hickey R. et al. Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis. J Vasc Interv Radiol 2015; 26 (04) 499-506
    CrossrefPubMedGoogle Scholar
  • 42 Thornburg B, Desai K, Hickey R. et al. Pretransplantation portal vein recanalization and transjugular intrahepatic portosystemic shunt creation for chronic portal vein thrombosis: final analysis of a 61-patient cohort. J Vasc Interv Radiol 2017; 28 (12) 1714-1721.e2
    CrossrefPubMedGoogle Scholar
  • 43 Talwar A, Varghese J, Knight GM. et al. Preoperative portal vein recanalization-transjugular intrahepatic portosystemic shunt for chronic obliterative portal vein thrombosis: outcomes following liver transplantation. Hepatol Commun 2022; 6 (07) 1803-1812
    CrossrefPubMedGoogle Scholar
  • 44 Alani M, Rowley M, Kang P, Chen S, Hirsch K, Seetharam A. Utility of transjugular intrahepatic portosystemic shunt placement for maintaining portal vein patency in candidates on wait lists who develop thrombus. Exp Clin Transplant 2020; 18 (07) 808-813
    CrossrefPubMedGoogle Scholar
  • 45 Bilbao JI, Elorz M, Vivas I, Martínez-Cuesta A, Bastarrika G, Benito A. Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients. Cardiovasc Intervent Radiol 2004; 27 (05) 474-480
    CrossrefPubMedGoogle Scholar
  • 46 Luca A, Miraglia R, Caruso S. et al. Short- and long-term effects of the transjugular intrahepatic portosystemic shunt on portal vein thrombosis in patients with cirrhosis. Gut 2011; 60 (06) 846-852
    CrossrefPubMedGoogle Scholar
  • 47 Arai H, Abe T, Takayama H. et al. Safety and efficacy of balloon-occluded transcatheter arterial chemoembolization using miriplatin for hepatocellular carcinoma. Hepatol Res 2015; 45 (06) 663-666
    CrossrefPubMedGoogle Scholar
  • 48 Wang Z, Jiang MS, Zhang HL. et al. Is post-TIPS anticoagulation therapy necessary in patients with cirrhosis and portal vein thrombosis? A randomized controlled trial. Radiology 2016; 279 (03) 943-951
    CrossrefPubMedGoogle Scholar