Beware of TIPS in liver transplant candidates

Transjugular intrahepatic portosystemic shunt (TIPS) reduce portal pressure and prevent bleeding from esophageal varices in cirrhotic patients. The method is often used in liver transplant candidates. Two cases of TIPS malpositioning in liver transplantation candidates are reported. In the first patient, the caudal end of the TIPS was situated distally in the portal trunk and during transplantation it was necessary to isolate the spleno-portal confluence in order to ensure anastomosis in an area of the wall without endothelial lesions. lit the second case, still on the waiting list, the cephalead end of the stent is situated in the right atrium and in this case a more complex trans-diaphragmatic and probably trans-atrial approach is foreseen to allow extraction of the stent. In cirrhotic patients who may be possible transplant candidates, shorter TIPS must be used and positioned with care intrahepatically. Careful radiological evaluation is recommended, together with a CT scan and possibly angiography, in patients with TIPS before liver transplantation is performed, to avoid surprises with detrimental effects during the transplant.