Liver transplantation in the presence of portal vein thrombosis: report from a single center

Portal vein thrombosis (PVT) is a frequent finding in liver transplantation, the management of which depends mainly on its extent. In cases of mild to moderate PVT, a low dissection of the portal trunk, a jump graft, or direct implantation of graft portal vein into large venous collaterals or thrombectomy offer alternatives. For severe PVT anecdotal reports suggest that cavoportal hemitransposition, portal arterialization, or combined liver and intestine transplantation may be attempted, although the results to date are not satisfactory. When extensive perivenous and venous inflammatory changes reach the infrapancreatic region, liver transplantation probably should not be performed due to the high mortality rate.     

Portal vein arterialization for liver transplantation with extensive portomesenteric vein thrombosis: a case report

We report herein a case of extensive thrombosis of portal venous system including mesenteric vein in a 70-year-old man who suffered from end-stage post-hepatitis C cirrhosis and who underwent orthotopic liver transplantation. There was no way to divert portal blood flow to the new liver because such an extensive thrombosis of portomesenteric venous system. There are some case reports of portocaval hemitransposition with some success but high mortality. We decided to arterialize the portal vein of the liver allograft with the recipient hepatic artery and the donor hepatic artery was anastomosed to the supraceliac aorta. He recovered slowly from the operation. At 1 year after the transplantation, he is doing well with perfect liver function tests. This case challenges our belief that portal blood flow is essential for the liver because of hepatotrophic factors.     

Successful percutaneous pulse spray thrombolysis of extensive acute portocaval hemitransposition thrombosis

We report a case of extensive acute thrombosis of portal vein and cava in a portocaval hemitransposition liver graft that was treated successfully with percutaneous pulse spray thrombolysis through a femoral vein access. The patient subsequently developed descending and sigmoid colon ischemic necrosis because of the venous thrombosis necessitating emergency colon resection. The patient had prolonged postoperative intensive care stay, but was eventually discharged in a good condition with normal liver function. Three month follow up demonstrated persistent normalization of hepatic function and normal duplex ultrasound.     

Liver transplant with portocaval hemitransposition: blood supply with only hepatic artery is possible?

We present herein a case of orthotopic liver transplantation (OLT) with portocaval hemitransposition. The patient underwent OLT for hepatocellular carcinoma with diffused portomesenteric vein thrombosis. The unique feature of this case was that 6 months after the operation, because of recurrent carcinoma, the hepatic vein was occluded and the portal vein became the drainage vein and the hepatic artery was the only vessel that supplied the liver. Yet the patient survived. Regarding the unique hemodynamic changes of the patient, could we let the portal vein alone in case of diffuse portomesenteric thrombosis in OLT?     

存在门静脉血栓及癌栓的肝癌患者的肝移植

目的　探讨存在门静脉血栓或癌栓的肝癌患者进行肝移植的处理要点。方法　对10例存在门静脉血栓或癌栓的肝癌患者施行原位肝移植术,术前常规准备供者的髂静脉,供肝保留较长的门静脉;术中注意取尽受者门静脉内的血栓或癌栓,门静脉壁存在水肿、增厚、变硬者,尽可能切除这段门静脉;9例行低位门静脉对端吻合,1例行门静脉下腔静脉的对端吻合;术后根据患者的凝血功能状态决定是否进行抗凝治疗。结果　1例术后第6 d发生门静脉血栓形成,溶栓术后因腹腔内出血、失血性休克死亡;另9例术后门静脉血流通畅,随访2~31个月,其中1例术后2个月死于感染,4例术后7、12、13、25个月肿瘤复发,其余4例无肿瘤复发。结论　术前存在门静脉血栓或癌栓的肝癌患者,只要处理得当,采用肝移植治疗可以取得较好结果。     

Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality

BACKGROUND: Splanchnic thrombosis is a surgical challenge in liver transplantation (LT). The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution. AIM: The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution. PATIENTS AND METHODS: Between 1999 and 2004, 366 liver transplants were performed in 335 patients. Forty-two patients [12.5%: portal vein thrombosis (PVT) group] had portal thrombosis at the time of LT. We analyzed the technical aspects and compared their evolution with a group of patients without portal thrombosis (n = 293; no-PVT group). Retransplantations were excluded. RESULTS: Of the 42 patients with thrombosis, 18 had partial thrombosis and 16 complete thrombosis [six included the proximal superior mesenteric vein (SMV) and in two the whole splanchnic system]. In 12 cases, usual T-T anastomosis was performed and in 16 cases a thrombectomy was carried out; there were five cases of anastomosis at confluence of the SMV, five cases of anastomosis to a collateral vein, three cases of venous graft, and one case of cavoportal hemitransposition. The operative time was higher in PVT group (417 +/- 103 min vs. 363 +/- 83; p = 0.0005), as RBC transfusion (2.4 +/- 3.1 vs. 1.9 +/- 2.3; p = 0.04), and hospital stay (20.9 +/- 14.9 d vs. 15.1 +/- 10.6; p = 0.002). However, there were no differences in hospital mortality (4% vs. 7.8%; p = 0.98), primary dysfunction (4.8% vs. 7.8%; p = 0.44), or three-yr-actuarial survival (75% vs. 77%; p = 0.95). The incidence of post-transplant thrombosis was higher in the PVT group (15% vs. 2.4%; p = 0.0005). CONCLUSIONS: Portal thrombosis is associated with greater operative complexity and rethrombosis, but has no influence on overall morbidity and mortality.     

肝移植术中门静脉血栓和瘤栓的处理

目的 探讨肝移植时门静脉血栓和瘤栓的处理方法和临床效果.方法 2000年8月至2004年底我院施行的150例肝移植患者中5例为肝硬化伴门静脉血栓形成,21例为肝癌伴门静脉瘤栓及/或血栓形成,共26例.这些病例在术中清除了门静脉内的栓子,3例又行门静脉壁部分切除及低位门静脉对端吻合术,1例行门腔静脉半转位吻合术.结果 26例中1例术后门静脉又再发血栓形成.21例肝癌合并门静脉瘤栓者,术后近期死亡3例,分别死于：门静脉继发性血栓形成,移植肝原发性无功能和多器官衰竭.18例得到长期随访,术后1、2、3年生存率分别为：66.7%,38.9%,27.8%.结论 肝移植时受体门静脉合并血栓/瘤栓者在清除栓子后再行肝移植仍然可取得较好的疗效.     

Successful Treatment of a Patient With Diffuse Portosplenomesenteric Thrombosis Using a Pericholedochal Varix for Portal Flow Reconstruction During Deceased Donor Liver Transplantation: A Case Report

Portal vein thrombosis remains a challenging issue in liver transplantation. When thrombectomy is not feasible due to diffuse portosplenomesenteric thrombosis, other modalities are adapted such as the use of a jump graft or portal tributaries or even multivisceral transplantation. For patients with diffuse thrombosis of the splanchnic venous system, a large pericholedochal varix can be a useful vessel for providing splanchnic blood flow to the graft and for relieving portal hypertension. We report our experience of successfully treating a patient with diffuse portosplenomesenteric thrombosis using a pericholedochal varix for portal flow reconstruction during deceased donor liver transplantation and eventually preventing unnecessary multivisceral transplantation. A 56-year-old man diagnosed with liver cirrhosis due to hepatitis B underwent deceased donor liver transplantation due to refractory ascites. Preoperative imaging revealed diffuse portosplenomesenteric thrombosis with large amount of ascites. During the operation, dissection of the main portal vein was not possible due to the development of multiple large pericholedochal varices and cavernous change of the main portal vein. After outflow reconstruction, portal inflow was restored by anastomosing the graft portal vein to a large pericholedochal varix. Postoperatively, although abdominal computed tomography scan showed stenosis of portal vein anastomosis site, liver function tests improved, and Doppler sonogram revealed no flow disturbance. During follow-up, the patient repeatedly developed hydrothorax and ascites. In addition, stenosis of the portal vein anastomosis and thrombosis of the portomesenteric system still remained. The patient underwent transhepatic portal vein stent insertion. After portal vein stent insertion, hydrothorax and ascites improved and the extent of thrombosis of the portomesenteric system decreased without anticoagulation therapy. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins can be a source of useful inflow to restore portal flow and decrease the extent of thrombosis, thereby preventing unnecessary multivisceral transplantation.     

Extensive thrombosis of the portal vein and vena cava after orthotopic liver transplantation with cavoportal hemitransposition: a case report

We report herein a case of orthotopic liver transplantation (OLT) with cavoportal hemitransposition. The patient underwent OLT for hepatitis B virus-related cirrhosis with diffused portomesenteric vein thrombosis (PVT). The unique feature of this case was that 1 month after the operation, because of extensive thrombosis of the portal vein and vena cava in the allografted liver, the hepatic artery was the only vessel to supply the liver. Percutaneous pulse spray thrombolysis through a femoral vein access was incompletely successful with the result that the cavoportal anastomosis stoma occluded and the allografted liver was supplied only by the hepatic artery; the portal vein served no function. Yet the patient survived and was eventually discharged in good condition with normal liver and kidney functions. The patient is alive and well with persistent normalization of hepatic function during 1.5 years follow-up.     

Portomesenteric venous thrombosis associated with rectal venous malformations

Purpose

We report thrombosis of portal and mesenteric veins in patients with a pattern of rectal venous malformations (VMs) and ectatic major mesenteric veins.

Methods

Eight patients having rectal VMs with either ectatic mesenteric veins and/or evidence of portomesenteric venous thrombosis (PVT), evaluated from 1995-2009, were reviewed.

Results

Portomesenteric venous thrombosis was evident in 5 patients at presentation. Three had patent ectatic mesenteric veins, 2 with demonstrated reversal of flow, and 2 of whom went on to thrombosis during observation. Six patients developed portal hypertension. Five remain on long-term anticoagulation. After recognizing this pattern, one patient underwent preemptive proximal ligation of the inferior mesenteric vein (IMV) to enhance antegrade portal vein flow and prevent propagation or embolization of venous thrombus from the IMV to the portal vein.

Conclusion

Rectal VMs should be evaluated for associated ectatic mesenteric veins. The ectatic vein siphons flow from the portal vein down to the rectal VM, leading to stagnation of blood in the portal vein and resultant thrombosis. Primary thrombosis in the stagnant rectal VM and/or mesenteric vein can also predispose to embolization up into the portal vein. This pattern of rectal VM and ectatic mesenteric vein should be considered a risk factor for devastating PVT.     

Cavoportal hemitransposition: A successful way to overcome the problem of total portosplenomesenteric thrombosis in liver transplantation

Orthotopic liver transplantation (OLT) may be feasible even in the presence of diffuse portal vein thrombosis (PVT) in the recipient, providing hepatopetal portal flow to the graft can be ensured. Cavoportal hemitransposition was used in selected cases in which no other salvage solutions were technically possible. We report our experience of two patients with diffuse thrombosis of the entire portal system. One patient also had thrombosis of a previous portacaval shunt with a synthetic interposition graft. Portal pedicle dissection and native hepatectomy (with or without vena cava removal) appeared difficult. Bleeding from the exposed area was severe, and in one case, a new laparotomy was necessary to stop the abdominal hemorrhage. The postoperative course was complicated by severe ascites (with fluid infection and surgically drained suprahepatic abscess in one case), renal insufficiency (requiring dialysis in one case), esophagogastric variceal bleeding (needing several sessions of endoscopic treatment), and bronchopneumonic infections (in one case, superinfection with Aspergillus fumigatus despite amphotericin B lipid complex therapy led to the patient's death from multiorgan failure). Our experience was compared with 17 other cases in the literature. Etiologic factors, preoperative diagnostics, surgical problems, and postoperative complications are focused on and discussed. Diffuse PVT no longer appears to be an absolute contraindication to OLT, although cavoportal hemitransposition needs further experience and long-term follow-up. (Liver Transpl 2002;8:72-75.)     

门静脉和肠系膜上静脉血栓形成的CT、MRI诊断

目的探讨门静脉（PV）和肠系膜上静脉（SMV）血栓形成的CT、MRI征象及其诊断价值。方法回顾性分析25例经手术与病理证实的PV-SMV血栓形成病例CT和MRI检查资料。结果PV-SMV血栓形成的直接征象CT表现为PV-SMV血管内充盈缺损,PV周围呈轨道样增强;MRI表现为PV和SMV正常流空信号消失;急性、亚急性期血栓T1WI呈等或高信号,T2WI呈高信号;GD-DTPA增强扫描静脉期PV-SMV管腔内对比剂充盈缺损。PV-SMV血栓形成的间接征象包括肠腔扩张积液,肠管积血,肠壁增厚,肠黏膜水肿,薄纸样肠壁,缆绳征,肠系膜积液,肠壁积气,腹腔积液,门静脉海绵样变,肝脏异常灌注。结论CT、MRI是诊断PV-SMV血栓形成最有效的影像检查方法,MRI对PV-SMV血栓形成的定位、定量及血栓的分期优于CT。     

Percutaneous transhepatic treatment of symptomatic mesenteric venous thrombosis

Three patients were seen with acute mesenteric venous thrombosis. With a transhepatic access, percutaneous pharmacologic thrombolysis was performed in one patient with extensive thrombosis of the portal and mesenteric veins, resulting in complete thrombolysis of the portal vein and partial thrombolysis of the superior mesenteric vein. In two patients with focal thrombosis, the use of mechanical devices achieved complete thrombolysis. Percutaneous thrombolysis of portal and mesenteric veins with a transhepatic approach, followed by coil embolization, is a promising endovascular technique for treatment of symptomatic acute mesenteric venous thrombosis.     

Eversion thromboendovenectomy for organized portal vein thrombosis encountered during liver transplantation

INTRODUCTION: Due to the technical experience acquired in the field of liver transplantation portal vein thrombosis is no longer considered a contraindication for transplantation. Nevertheless, the results obtained in patients with portal vein thrombosis are at times suboptimal, and there is no consensus on the appropriate surgical technique. PATIENTS AND METHODS: Among the 455 liver transplants performed between May 1988 and December 2001, 32 (7%) presented with portal vein thrombosis. Twenty (62%) were type Ib, seven (22%) type II/III, and five (16%) type IV. Twenty-two were men (69%), with a mean age of 50 years (range: 30-70 years); the thrombosis in all cases developed in a cirrhotic liver. The surgical method in all cases consisted of an eversion thromboendovenectomy under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. RESULTS: Among the 32 cases undergoing thrombectomy, 31 (96%) were successful with a failure in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis rethrombosed. The 5-year survival rate of the patients in the series was 69%. Only two patients died from causes related to the thrombosis, both showing type IV thrombosis. CONCLUSION: The ideal treatment for portal thrombosis during liver transplantation depends on its extension and on the experience of the surgeon. In our experience, eversion thromboendovenectomy resolves most thromboses (types I, II, and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal hemitransposition.     

细胞间粘附因子-1在门静脉高压患者脾静脉的表达及意义

目的 探讨细胞间粘附因子—1(ICAM—1)在门静脉高压患者脾静脉的表达及其在贲门周围血管离断术后门静脉血栓形成的意义。方法 对34例门静脉高压患者和34例单纯脾破裂患者的脾静脉行苏木素—伊红染色观察形态学变化；行ICAM—1原位杂交并行定量分析，术后观察门静脉血栓的发生，对两者的关系进行研究。结果 门静脉高压患者脾静脉中膜平滑肌增生，内膜增厚，门静脉高压组和脾破裂组之间脾静脉内皮细胞ICAM—1mRNA表达差异有非常显著性(P＜0．01)；脾破裂组术后无门静脉血栓形成，门静脉高压组有8例门静脉血栓形成；门静脉高压组内有无门静脉血栓形成病例之间脾静脉内皮细胞ICAM—1mRNA表达差异有显著性(P＜0．05)。结论 门静脉高压性血管病变及其内皮细胞ICAM—1mRNA过度表达可能是门静脉高压患者门静脉血栓形成重要原因。     

The significance of portal vein thrombosis after distal splenorenal shunt

The aims of this study were to determine the incidence of portal vein thrombosis after the distal splenorenal shunt, to identify any predictive factors, and to assess the clinical significance of this complication. Preoperative and postoperative angiograms and clinical evaluation were reviewed in 124 patients who underwent distal splenorenal shunts. Total and partial portal vein thrombosis were seen on 13 (10.5%) and 22 (17.7%) postoperative angiograms, respectively. The only preoperative variable correlating with development of portal vein thrombosis was portal venous perfusion, which was significantly lower in patients with than in those without portal vein thrombosis. In six of 10 patients with postoperative pancreatitis, portal vein thrombosis developed. The frequency of early postoperative complications was significantly greater in patients with total portal vein thrombosis than in those with partial or no thrombosis. Long-term follow-up has shown no significant effects of portal vein thrombosis on late ascites, encephalopathy, or survival.     

Acute pancreatitis following segmental pancreatic resection associated with portal vein thrombosis and aneurysm of the spleno-mesenteric venous confluence

Vascular abnormalities associated with acute pancreatitis are well-known and reported in the literature in up to 50% of the patients with acute necrotizing pancreatitis. Most reported vascular abnormalities are superior mesenteric and/or portal vein thromboses and arterial pseudo-aneurysms. Portal vein aneurysm and/or spleno-mesenteric venous aneurysm are rare entities. Furthermore, portal vein aneurysm can be complicated by portal vein thrombosis. We report a case of spleno-mesenteric vein aneurysm that unusually followed portal vein thrombosis and was secondary to postoperative pancreatitis following segmental pancreatic resection for a well-differentiated endocrine carcinoma. The patient was treated successfully with conservative treatment, although he developed a hepatic abscess two months after his treatment.     

Caval inflow to the graft: a successful way to overcome diffuse portal system thrombosis in liver transplantation

Portal vein thrombosis was considered to be a major contraindication to liver transplantation before the introduction of vessel grafts from the recipient's area of confluence of the splenic and superior mesenteric veins, behind the neck of the pancreas, to the graft's portal vein. Refinement in surgical technique has given rise to a large number of possibilities to overcome portal vein thrombosis in OLT recipients, ranging from portal vein thrombectomy to several different venous graft jump reconstructions. All these reconstructions require the presence of a patent vein of the portal system. When neither splanchnic veins nor sufficiently large venous collaterals are available, liver transplantation has been considered impossible. Salvage solutions include arterialization of the portal vein with the associated risk of liver damage in the longterm, a combined liver and bowel transplantation has been proposed but not yet reported (and in any case the results of combined liver and bowel transplants are not as good as those of liver transplantation alone) and finally the use of blood inflow from the inferior vena cava as first reported by Tzakis and coworkers. Portal flow from the inferior vena cava may be performed as a last resort. Although the consequences of severe pretransplantation portal hypertension remain and should be treated before, during, and after transplantation, liver function is normal in the short and midterm. With this new procedure, diffuse portal vein thrombosis is no longer an absolute contraindication to liver transplantation. But this needs to be confirmed in light of further experience and longterm followup.     

Portal vein thrombus after pediatric proctocolectomy with ileoanal anastomosis

In adults, mesenteric venous thrombosis with extension into the portal system is a known complication of total proctocolectomy with pouch ileoanal anastomosis. Although frequently reported in adults, this complication is rare in pediatric patients undergoing this operation. We report 2 cases of adolescent patients with ulcerative colitis who experienced portal vein thrombosis after this procedure. Both were treated with systemic anticoagulation therapy with complete resolution of their clots. We recommend that mesenteric/portal venous thrombosis be considered in the differential diagnosis in any child presenting with fever, abdominal pain, and leukocytosis after restorative proctocolectomy with ileal pouch anastomosis and that imaging obtained to evaluate abdominal complaints in this population be directed toward ruling out this complication.     

Single center experience of 39 patients with preoperative portal vein thrombosis among 404 adult living donor liver transplantations.

Living donor liver transplantation (LDLT) for patients with portal vein thrombosis (PVT) involves technical difficulty. The aim of this research was to analyze their preoperative diagnosis of PVT, operative procedures, and postoperative courses of patients with preoperative PVT. Thirty-nine patients of 404 adult patients (9.7%) undergoing LDLT in our hospital from 1996 June to 2004 December had PVT at their transplantation. Twenty-nine patients had intractable ascites, 21 had gastrointestinal bleeding, and 18 had encephalopathy. The thrombus was located in the portal trunk in 23, in the portal trunk and superior mesenteric vein (SMV) in 7, and developed into the SMV and the splenic vein in 8. The occlusive grade was partial in 29, and complete in 10 patients. The thrombus was removed by a simple technique, and eversion and/or incision technique, or total removal of the portal vein (PV). The PV was reconstructed with the thrombectomized native PV, with an interposed vein graft, or porto-caval hemitransposition. Advanced PVT had a significant impact on blood loss and hospital mortality. Three out of 10 patients with residual PVT required radiological and/or surgical intervention after transplantation. In conclusion, thorough planning is essential for a successful LDLT outcome for patients with preexisting PVT.