Conventional Liver Retransplantation with Caval Replacement for Suprahepatic Inferior Vena Cava Stenosis Secondary to a Malpositioned TIPS: A Case Report.

INTRODUCTION: Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established bridging therapy for the management of severe complications of portal hypertension. However, the impact of long-standing malpositioned TIPS on liver transplantation remains scarcely reported CASE REPORT: A 64-year-old male with alcoholic cirrhosis and refractory hepatic hydrothorax underwent TIPS placement with sustained clinical benefit for nearly 8 years. He later developed refractory ascites and recurrent hepatic encephalopathy and was listed for liver transplantation. He subsequently underwent the procedure using the piggyback technique, requiring venoplasty of the lateral wall of the inferior vena cava due to extensive pericaval fibrosis associated with a long-standing malpositioned TIPS, which was markedly protruded into the right atrium. Within 48 hours, the patient developed primary non-function and required emergent retransplantation. Intraoperatively, pressure measurements demonstrated a gradient between the infrahepatic and suprahepatic vena cava (16 and 9 mmHg, respectively), consistent with significant hepatic venous outflow obstruction. Extensive residual fibrosis near the suprahepatic inferior vena cava was also observed. The conventional technique with caval replacement was used, allowing resection of the stenotic suprahepatic inferior vena cava segment affected by fibrosis secondary to the malpositioned TIPS. At the end of the procedure, venous pressures were equalized between the suprahepatic and infra-renal inferior vena cava (10 mm Hg). The patient recovered uneventfully and is currently under outpatient follow-up.

CONCLUSION: Long-term TIPS-related anatomical alterations, particularly in the setting of malposition, may increase surgical complexity during liver transplantation and require tailored operative strategies. Awareness of these challenges by the transplant team is essential to optimize outcomes in this unique patient population.