Intraoperative transesophageal echocardiography guides liver transplant surgery in a patient with thrombosed transjugular intrahepatic portosystemic shunt.

Transjugular intrahepatic portosystemic shunt (TIPS) is common in patients presenting for orthotopic liver transplantation (OLT). More than 5,200 TIPS procedures were performed in the United States in 2008.* In our institution, 18% of adult OLT recipients during the past 2 yr presented with TIPS. Whereas TIPS mitigates symp-toms of portal hypertension, associated complications, such as thrombosis and migration, pose technical chal-lenges during OLT. 1–4 We present a case of OLT in a patient with known thrombosed TIPS. Intraoperative transesophageal echocardiography (TEE) revealed ceph-alad migration of the TIPS into the inferior vena cava (IVC) and an attached thrombus extending toward the cavoatrial junction. These findings necessitated a modifi-cation of surgical technique to safely remove the TIPS and prevent thromboembolism. We demonstrate that TEE may provide important clinical information for intraoperative management of OLT recipients with TIPS. A 47-yr-old Caucasian man with alcoholic cirrhosis complicated by hepatorenal syndrome presented for OLT. Eight weeks earlier, he underwent uneventful placement of a 10- (cid:2) 80-mm Viatorr

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