Fatty liver caused by portal vein thrombosis after living donor liver transplantation: a case report

Portal vein thrombosis (PVT) is a rare complication that occurs after liver transplantation: however, it cannot be ignored as a cause of graft loss and death. We herein report a pediatric case of PVT that caused a fatty change in the graft after living donor liver transplantation. The portal vein was successfully reconstructed using the left great saphenous vein of the same donor. Moreover, the fatty liver recovered after the operation. Our case suggests that the finding of fatty liver is an important marker of PVT and immediate portal reconstruction is performed.     

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.     

Successful Living Donor Liver Transplantation in Portomesenteric Thrombosis

Chronic portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to the risks involved and higher morbidity. In this report, we describe a surgical strategy for living donor liver transplant in patient with complete PVT using venovenous bypass from the inferior mesenteric vein (IMV) and then using a jump graft from the IMV for portal inflow into the graft. IMV is a potential source for portal inflow in orthotopic liver transplant.     

Successful minimally invasive management of late portal vein thrombosis after splenectomy due to splenic artery steal syndrome following liver transplantation: a case report

Portal vein thrombosis (PVT) after liver transplantation (OLT), which occurs in 1% to 2.7% of cases, can compromise patient and graft survival. Percutaneous transhepatic portal vein angioplasty offers an option to treat PVT, diminishing surgically related morbidity and the need for retransplantation. We describe a case of late PVT after OLT, which was successfully treated by a minimally invasive percutaneous transhepatic approach using both mechanical fragmentation and pharmacologic lysis of the thrombus followed by anticoagulation. The patient has had a good clinical course with normal graft function and patent portal blood flow at 6-month follow-up. This case report confirms the possibility of successful recanalization of the portal vein in a patient with late PVT after liver transplantation. Sustained anticoagulation/antiaggregation therapy for at least 6 months after the procedure is advisable.     

Accuracy of magnetic resonance imaging for preoperative detection of portal vein thrombosis in liver transplant candidates.

The detection of main portal vein thrombosis (PVT) on preoperative imaging of liver transplant candidates has important technical implications for the transplantation procedure. Data are scarce regarding the accuracy of magnetic resonance imaging (MRI) at detecting PVT. The aim of our study was to compare preoperative findings of the portal vein on MRI to operative findings at liver transplantation. Abdominal MRI and clinical records of 172 consecutive patients who received liver transplants between January 1999 and September 2004 were reviewed. Two radiologists independently evaluated the last abdominal magnetic resonance examinations obtained before liver transplantation, blinded to the original reading, operative findings, and clinical data. Findings on MRI were compared with intraoperative findings at transplantation. Main PVT was detected in 12 patients, in whom 8 were found to have thrombus at surgery, with 6 requiring a jump graft or thrombectomy. Sensitivity and specificity of MRI for detecting main PVT were 100% and 98%, respectively. The cause of discordance between findings on MRI and at transplantation in 2 cases was a diminutive caliber of the main portal vein that was interpreted as recanalized chronic thrombosis on MRI. In conclusion, in our study group MRI detected PVT in all liver transplant recipients requiring jump grafts at transplantation. The major reason for a false-positive MRI was a diminutive but patent portal vein.     

Long‐term outcomes of transmesenteric portal vein recanalization for the treatment of chronic portal vein thrombosis after pediatric liver transplantation

Portal vein thrombosis (PVT) may occur at any time following liver transplantation. We describe our experience with portal vein recanalization in cases of thrombosis after liver transplantation. Twenty‐eight children (5%) out of 566 liver transplant recipients underwent portal vein recanalization using a transmesenteric approach. All children received left hepatic segments, developed PVT, and had symptoms or signs of portal hypertension. Portal vein recanalization was performed via the transmesenteric route in all cases. Twenty‐two (78.6%) patients underwent successful recanalization and stent placement. They received oral anticoagulants after the procedure, and clinical symptoms subsided. Symptoms recurred due to portal vein restenosis/thrombosis in seven patients. On an intention‐to‐treat basis, the success rate of the proposed treatment was 60.7%. Only 17 out of 28 children with posttransplant chronic PVT retained stent patency (primary + assisted) at the end of the study period. In cases of portal vein obstruction, the transmesenteric approach via minilaparotomy is technically feasible with good clinical and hemodynamic results. It is an alternative procedure to reestablish the portal flow to the liver graft that can be performed in selected cases and a therapeutic addition to other treatment strategies currently used to treat chronic PVT.     

Favorable resolution of hepatic infarctions in transplanted liver after portal vein thrombosis treated by surgical thrombectomy: a case report

Portal vein thrombosis (PVT) after orthotopic liver transplantation (OLT) is a life-threatening complication associated with a high rate of graft loss and patient death, with reported incidence of 1% to 2% in adults. We report a case of an early PVT after OLT complicated by hepatic infarctions in the liver graft. After surgical thrombectomy and restoration of the portal inflow, hepatic infarctions resolved spontaneously within 6 months, which was confirmed by computed tomography.     

Recurrent Portal Vein Thrombosis In Liver Transplantation With Renoportal Anastomosis Caused by Spontaneous Reno-Caval Shunts: A Case Report

BackgroundOrthotopic liver transplantation (OLT) in patients with cirrhosis complicated by portal hypertension, portosystemic shunts, and chronic portal vein thrombosis (PVT) has long been challenging. Spontaneous spleno-renal shunts (SRS) allow new surgical techniques to restore portal vein patency and hepatopetal flow. Renoportal anastomosis (RPA) has emerged as an accepted method for transplanting these patients, with good long-term patient and graft survival. Orthotopic liver transplantation with RPA is known to be complicated by recurrent PVT, with few details discussed in the literature.Case ReportWe present a case of a 56-year-old woman with decompensated cirrhosis who underwent deceased donor whole graft OLT using RPA with iliac vein conduit. The postoperative course was complicated by occlusive thrombosis in the portal vein and iliac vein conduit. Venography revealed enlarged left gonadal and lumbar vein varices acting as reno-caval shunts with hepatofugal flow. Embolization of the varices re-established durable venous patency that was confirmed on post-transplant day 68 with no other hemodynamic complications.DiscussionThis showcases an interesting mechanism by which recurrent PVT may occur in patients undergoing OLT with RPA. Because durable portal vein patency can be achieved with Interventional Radiology embolization of reno-caval varices, assessing these communications is an important preoperative consideration for planned OLT with RPA.     

The Use of Recipient Superficial Femoral Vein as a Venous Graft for Portal Vein Reconstruction in Right Lobe Living Donor Liver Transplantation

In living donor liver transplantation (LDLT), portal vein thrombosis (PVT) in the recipient is frequently regarded as a contraindication. To reconstruct the PV of a right-lobe liver graft (RLG) using an interposition or jump graft from the splenomesenteric junction, various vein grafts and technical modifications have been introduced. The internal jugular, external iliac, or great saphenous veins have been utilized in such reconstructive procedures. However, the superficial femoral vein (SFV) is preferable to the autologous vein grafts in terms of caliber, wall thickness, and length. We employed the recipient SFV to reconstruct PVT among 40 adult LDLT using RLG. Thirty-three were reconstructed by single end-to-end anastomosis with the right or left recipient PV. Three patients were transplanted with a RLG using 2 separated PVs reconstructed by double anastomoses with both the right and left PVs of the recipient. The remaining 4 patients required venous grafting for portal reconstruction. We used the recipient SFV as an interposition or jump graft from the splenomesenteric junction to the graft PV. There were 2 cases of anastomotic PV stenosis; 1 in portal reconstruction without a venous graft and the other with a SFV graft. Both were treated successfully by balloon angioplasty. The recipient SFV is an excellent size match for the PV reconstruction as a long interposition or jump conduit when the venous system from the deceased donor is not available. The indication for LDLT in patients with complete PVT should be carefully decided before transplantation in terms of portal reconstruction.     

Use of Pericholedochal Plexus for Portal Flow Reconstruction in Diffuse Portal Vein Thrombosis: Case Report

Portal vein thrombosis (PVT) remains a challenging issue for liver transplantation surgeons. Most patients who have PVT undergo eversion thrombectomy. When thrombectomy is not successful due to diffuse PVT, other modalities are adapted, such as the use of a venous jump graft or portal tributaries. Here, we report our successful experience with reconstruction of portal flow using collateral plexus for a patient with grade 4 PVT. Thrombectomy did not restore portal flow. A pericholedochal plexus was found on the lateral wall of common bile duct. Direct end-to-end anastomosis was performed between the donor's portal vein and patient's choledochal plexus. Postoperative color Doppler ultrasound revealed normal portal flow.     

Thrombendvenectomy for Organized Portal Vein Thrombosis at the Time of Liver Transplantation

OBJECTIVE: To determine the efficacy of portal thrombendvenectomy in cases of portal vein thrombosis at the time of orthotopic liver transplantation. SUMMARY BACKGROUND DATA: Portal vein thrombosis (PVT) has been reported to have an incidence of 2% to 39% in end-stage liver disease. Multiple techniques have been suggested to treat this finding. Several reports have suggested suboptimal results after liver transplantation in recipients with PVT. METHODS: The authors prospectively collected data on 1,546 patients who underwent an initial orthotopic liver transplant at the authors' institution between December 1984 and October 1999. There were 820 male patients and 726 female patients. All recipients received either cyclosporine or tacrolimus immunosuppression. Intraoperative flows of the portal vein and hepatic artery were routinely measured. Duplex sonography was routinely performed on the first postoperative day and routinely 1, 2, 5, and 10 years after transplantation. Eighty-five patients underwent thrombendvenectomy for organized thrombus partially or completely occluding the portal vein. Postoperative treatment included low-molecular-weight dextran for 48 hours and daily aspirin for 3 months. There were 53 male patients and 32 female patients. The PVT group was compared with a control group consisting of transplant recipients without PVT. RESULTS: When compared with the control group, PVT patients were older at the time of transplantation and had a higher incidence of liver disease secondary to cryptogenic cirrhosis and Laennec's cirrhosis. There were no significant differences among both groups for 1-, 3-, and 6-year patient and graft survival rates. CONCLUSIONS: Thrombendvenectomy provides a rapid resolution of an otherwise complex problem. It is the authors' procedure of choice in cases of organized PVT at the time of transplantation. Operative time and length of stay in the intensive care unit are not prolonged, and patient and graft survival rates are not compromised.     

Portal Vein Thrombosis and Liver Transplantation: Long Term

Obstruction of the portal vein may be related to constriction by malignant tumors or thrombosis associated with liver disease. We herein have reported our experience with patients undergoing liver transplantation with portal vein thrombosis (PVT) whose diagnosis was made intraoperatively. From September 1991 to May 2009, we studied 27/419 (6.4%) patients with PVT who were evaluated according to the presence of esophagogastric varices, underlying disease, malignancy, and if there was previous surgery, review of medical records on data collected prospectively. We observed 24 (88.9%) patients with PVT grade 1, 2 (7.4%) with grade 2, and 1 (3.7%) with grade 3. The average age of the PVT patients was 47.5 years; the average model for End-Stage Liver Discase score was 18.3, and the predominant diagnosis, hepatitis C cirrhosis. Eighteen underwent a sclerotherapy/ligature. The sensitivity of ultrasound for grade 1 thrombosis was 39.1%; for grade 2, 50%; and for grade 3, 100%. Portal vein thrombectomy was performed in 24 patients. In other patients (grade 2), we performed an anastomosis of the donor portal vein to the recipient gastric vein or to a greater splanchnic collateral vein. In only 1 patient was the graft performed using the donor portal vein-donor iliac vein-recipient superior mesenteric vein. None of the patients displayed PVT in the immediate postoperative period. Actuarial survivals at the years 1, 3, and 5 were 85%, 74%, and 63%, respectively. We concluded that PVT cannot be considered to be a contraindication for liver transplantation.     

Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis

Kim S‐J, Kim D‐G, Park J‐H, Moon I‐S, Lee M‐D, Kim J‐I, Yoon Y‐C, Yoo Y‐K. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis.
Clin Transplant 2011: 25: 111–118. © 2010 John Wiley & Sons A/S. Abstract: The aim of this study was to improve outcomes in living donor liver transplantation (LDLT) patients with portal vein thrombosis (PVT). Of 246 adult patients who underwent LDLT with a right lobe graft between January 2000 and May 2007, PVT was diagnosed in 50 patients (20.3%), who were further subdivided into partial (n = 39, 78%) and complete (n = 11, 22%) types. Patients with PVT, especially complete PVT, showed high incidences of variceal bleeding (p = 0.021), operative RBC transfusion (p < 0.046) and a post‐transplantation complications related to bleeding (p = 0.058). We also classified PVT according to its location and the presence of collaterals: type I (n = 41, 82%): PVT localized above the confluence of the splenic and superior mesenteric veins (SMV); type II (n = 7, 14%): PVT extending below the confluence with a patent distal SMV; type III (n = 2, 4%): complete portal vein and SMV thrombosis except for a coronary vein. LDLT could be safely undertaken in patients with PVT without increased mortality. In our type II and III PVT, when thrombectomy fails, jump grafting using a cryopreserved vessel may serve as a reliable alternative method to restore portal flow.     

门静脉血栓与肝移植

门静脉血栓形成(PVT)是指门静脉主干以及门静脉属支内血栓形成。由于PVT常缺乏特征性表现，主要依赖于术前影像学检查发现，甚至在术中偶然发现PVT。随着我国肝移植事业的不断发展，移植过程中发现PVT的案例越来越多，PVT已不再是肝移植禁忌证。因此，针对PVT的诊断、治疗以及移植过程中的处理方法显得尤为重要。本文根据国内外最新研究进展及经典文献报道，对肝移植中PVT展开综述。     

Portal Vein Stent Placement in Living-donor Liver Transplantation: A Single-center Experience

IntroductionPortal vein thrombosis (PVT) and portal vein stenosis (PVS) are rare complications after liver transplantation that can lead to graft failure and patient death.Material and methodsThe aim of this study was to evaluate the effect of interventional treatment for PVT and PVS occlusion after liver transplantation. Follow-up data of 7 patients who underwent stent replacement for PVT and/or PVS were analyzed. The clinical success, complications, and portal vein patency were analyzed.ResultsClinical success was obtained in 6 of the 7 patients. No portal hypertension-related symptoms reoccurred in the 6 patients during the follow-up.ConclusionsInterventional radiologic treatment produced a high success rate and a favorable long-term outcome.     

Modified Cavoportal Hemitransposition for Severe Portal Vein Thrombosis Contributed to Long-term Survival After Deceased Donor Liver Transplantation—Insight Into Portal Modulation for Improving Survival: A Case Report

BackgroundSevere/massive portal vein thrombosis (PVT) deteriorates peri-liver transplantation outcomes. Cavoportal hemitransposition (CPHT) is a rescue procedure for severe PVT, and short-term outcomes have been well studied. However, CPHT is associated with some long-term issues caused by portal flow modulation via extraordinary reconstruction. We describe a patient with Yerdel grade 4 PVT who underwent a liver transplant and achieved long-term survival with CPHT and a portosystemic shunt.Case ReportA 50-year-old man with liver cirrhosis underwent a deceased donor liver transplant. Preoperative examinations indicated Yerdel grade 4 PVT; thus, we planned a CPHT. In liver transplant surgery, we confirmed diffusely complete PVT and removed them as possible. After placing a liver graft, we performed CPHT and confirmed that the graft received sufficient portal vein flow. However, the gastroepiploic vein pressure increased significantly. Therefore, we added a portosystemic shunt between the splenic vein and the inferior vena cava, and the pressure improved. The patient was discharged after an uneventful hospital stay, and he reported no unfavorable events for over 12 years.ConclusionsThis case study suggested that a modified CPHT with a portosystemic shunt for Grade 4 PVT was useful in preventing post–liver transplant PVT development and improved the outcome.     

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.     

Using Pericholedochal Varix Inflow for Complete Portal Vein Thrombosis in Living Donor Liver Transplantation: A Case Report

One of the crucial steps of liver transplantation is to provide the portal inflow. Portal vein thrombosis is the most challenging factor to achieve. Using a pericholedochal varix for portal inflow in a patient with complete portal vein thrombosis in living donor liver transplantation (LDLT) is a rare technique. We present our experience of a LDLT with PVT.     

终末期肝病合并门静脉血栓患者的肝移植术(附四例报告)

目的 探讨终末期肝病合并门静脉血栓(PVT)患者的肝移植术。方法 对准备肝移植的受者常规应用CT和彩色多普勒检查，发现共有4例受者伴有PVT。此4例受者进行了原位肝移植术和门静脉血栓摘除治疗。术中对残留有附壁血栓的1例受者，在肠系膜上静脉分支处插入一带有肝素帽的导管，术后用于注入尿激酶进行溶栓治疗。术后所有受者均应用了低分子肝素、华法令和前列腺素E1等抗凝治疗。结果 术中一次性取尽血栓3例；1例受者PVT延及脾静脉人口和门脉左右支，术后门静脉残留有血栓，经溶栓和抗凝治疗，术后28d血栓消失。有3例受者在术后2个月内痊愈出院，随访至今情况良好；1例受者因胸腔穿刺并发出血，后发生多房性积液和肺部感染，于术后48d死亡。结论(1)PVT不是肝移植的绝对禁忌证；(2)外科摘除血栓、溶栓和抗凝治疗能对PVT进行根治；(3)出血是肝移植门静脉血栓治疗后的主要并发症，要加强预防和治疗。     

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??Management of portal vein thrombosis during the perioperative period of orthotopic liver transplantation WU Gang, LIU Yong-feng,CHENG Dong-hua??et al. Department of General Surgery, the First Affiliated Hospital,China Medical University,Shenyang 110001,China Corresponding auther: LIU Yong-feng, E-mial: yfliu@mail.cmu. edu.cn Abstract Objective To analyze the managements of portal vein thrombosis(PVT) during the perioperative period of orthotopic liver transplantation.Methods Between May 1995 to June 2008,194 orthotopic liver transplantation were performed in our institute,of which 24 presented portal vein thrombosis .12 were grade ??,9 grade ??,2 grade ?? and 1 grade ?? . The management of PVT depended mainly on its extent.Ligation of the collateral circulation,especially spontaneous or surgical splenorenal shunt,was made as approaches to improve portal flow. Heparin or low-molecule-weight heparin as a prophylactic anticoagulation therapy was maintained during and after operation if prothrombin time is less than eighteensonds. Follow-up Doppler ultrasonography was used daily in the early postoperative period.Results After a follow-up of 6-104 months, overall incidence of portal vein thrombosis was 2.58%(5/194).Surgical thrombectomy and revascularization was carried out in 1 case. Percutanous thrombolysis ,balloon angioplasty, or stent placement via portal vein were performed in 3 cases.No treatment was given in 1 patient without hepatic dysfunction. Mortality related to portal vein thrombosis was 0.Conclusion PVT might be avoid by performing a ideal technique for managing PVT as often as possible,by ligation of portosystemic shunt during surgery, and by postoperative anticoagulation.Close follow-up by Doppler ultrasonography may make a prompt diagnosis and reduce PVT-derived loss of grafts.