Portal vein recanalization and transjugular intrahepatic portosystemic shunt to improve transplant candidacy of patients with chronic portal vein thrombosis

Portal vein thrombosis (PVT) is common in cirrhotic patients and is a relative contraindication to transplantation at many centers. This is because of the risks known to be associated with the surgical techniques that are often required for transplant in the setting of PVT. The purpose of this study is to test our hypothesis that portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR TIPS) is an effective option for optimizing the transplant candidacy of patients with chronic PVT who are medically in need of liver transplantation. With IRB approval, 61 patients from 2009-2015 underwent PVR TIPS in order to improve transplant candidacy. Patients were medically in need of transplantation but had been denied listing due to the presence of chronic PVT. Patients were followed for post procedure portal vein and TIPS patency, overall survival and transplantation status. PVR TIPS was attempted in 61 patients and was technically successful in 60 (98%). Since transitioning to a trans-splenic approach to assist with recanalization, the procedure has been technically successful in 20/20 patients (100%). Median patient age was 58 years (range 22-75) and the most common etiology of cirrhosis was nonalcoholic steatohepatitis (18/61) followed by hepatitis C (13/61). Complete PVT was present in 35/61 patients (57%). In the 60 patients who successfully underwent PVR TIPS, the portal vein and TIPS remained patent during the course of follow up in 55 patients (92%) with a mean follow up time of 16.2 months. Following PVR TIPS, 23/60 patients (38%) have received liver transplants. Of these, 22/23 (96%) received physiologic end-to-end anastomoses. Five year overall survival after PVR TIPS is 83%. PVR TIPS should be considered in cirrhotic patients with portal vein thrombosis who are in need of liver transplantation. We believe that trans-splenic access simplifies the procedure and should therefore be the first line method for portal vein recanalization.