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.     

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.     

Salvage procedure for unexpected portal vein thrombosis in living donor liver transplantation

Portal vein thrombosis (PVT) is considered a relative contraindication to living donor liver transplantation (LDLTx) due to technical difficulty and ethical considerations. So far, there have been a few reported cases of LDLTx with PVT, most of which were treated by thrombectomy with or without a venous conduit. We report a case of LDLTx in an unexpected recipient with grade 4 diffuse PVT, which was successfully managed using a variceal left gastric vein and a deceased donor iliac vein conduit to create a "de novo portal vein" for splanchnic inflow to the right lobe. The patient experienced an uneventful postoperative course with normal blood flow in the de novo portal vein at 1-year follow up. This report demonstrated that a variceal collateral vein can be used as appropriate alternative inflow for the right lobe in LDLTx cases in which an unexpected PVT is encountered.     

Simultaneous hepatic artery and portal vein thrombosis after living donor liver transplantation

Simultaneous hepatic artery and portal vein thrombosis rarely occurs after liver transplantation. The etiology is unknown. Of 213 patients (72 children and 141 adults) that underwent living donor liver transplantation (LDLT) from January 1996 to March 2003, 4 (2%) developed simultaneous thrombosis at 3 hours to 7 days (median, 4 days) after the operation. Emergent thrombectomy was performed in three patients; the remaining patient was registered in the Japan organ transplant network. All of the patients died due to hepatic failure (range, 18 hours to 6 days after the diagnosis; median, 2 days). Portal vein, hepatic artery, and hepatic vein velocity in the liver graft were measured every 12 hours by Doppler ultrasonography for 2 weeks after liver transplantation. These parameters were stable until just before the simultaneous thrombosis. These findings indicate that protocol Doppler ultrasonography can diagnose, but not predict, this fatal complication.     

术前门静脉血栓对活体肝移植预后的影响

目的 探讨术前门静脉血栓对活体肝移植的影响.方法 回顾性分析天津市第一中心医院2007至2011年完成的99例成人间活体肝移植患者,根据术前是否有门静脉血栓分为2组,血栓组26例,无血栓组73例.比较2组的术前危险因素及门静脉血栓对活体肝移植手术和术后患者预后的影响.结果 26例门静脉血栓患者Ⅰ级血栓23例,Ⅱ级血栓3例.肝移植术前的脾切除是发生门静脉血栓的独立危险因素(x2 =10.211,P=0.001).术前门静脉血栓会延长手术的无肝期(Z=-2.430,P=0.015),但2组患者术后并发症发生率(x2=0.326,P=0.568)及死亡率均无统计学差异,而且对患者的1年生存率和3年生存率均无影响(x2=0.505,P =0.477).结论 对于活体肝移植合并Ⅰ级或Ⅱ级门静脉血栓的患者,通过合理的术中处理及术后预防,门静脉血栓不会影响患者的预后.但门静脉血栓增加了一定的手术难度,需要详尽的术前评估和仔细的术中操作.     

Outcome of modified portal vein anastomosis for recipients with portal vein thrombosis or stenosis before living donor liver transplantation

Background

Portal vein thrombosis (PVT) or stenosis (PVS) often requires challenging techniques for reconstruction in living donor liver transplantation (LDLT).

Materials and Methods

A total of 57 LDLTs were performed between October 1996 and December 2010. There were 16 cases (28%) with PVT/PVS that underwent modified portal vein anastomosis (m-PVa). The m-PVa techniques were classified into 3 groups: patch graft (Type-1), interposition graft (Type-2), and using huge shunt vessels (Type-3). The reconstruction patterns were evaluated with regard to age, graft vessels, PV flow, and complication rate.

Results

The m-PVas were Type-1 in 10 cases, Type-2 in 3 cases, and Type-3 in 3 cases. The vessel graft in Type-1 was the inferior mesenteric vein (IMV) in 8 and the jugular vein in 2 cases, whereas the vessel graft in Type-2 was IMV in 2 and the saphenous vein in 1 case; in Type-3, the vessel grafts were renoportal, gonadal-portal, and coronary-portal anastomoses, respectively. The postoperative PV flow was sufficient in all types and slightly higher in Type-3. The postoperative complications occurred in 20% of the patients who underwent Type-1, in 33% who underwent Type-2, and in 0% who underwent Type-3.

Conclusion

The m-PVa was effective to overcome the surgical difficulty during transplantation. Pretransplant planning for the selection of the type of reconstruction is important for recipients with PVT/PVS.     

Risk factors for intraoperative portal vein thrombosis in pediatric living donor liver transplantation

Pathologic changes of the recipient native portal venous system may cause thrombosis of the portal vein, especially in pediatric living donor liver transplantation (LDLT). This study assessed the utility of Doppler ultrasound (US) for the detection of intraoperative portal vein occlusion and identification of predisposing risk factors in the recipients. Seventy-three pediatric recipients who underwent LDLT at Chang Gung Memorial Hospital, Taiwan, from 1994 to 2002 were included. Preoperative and intraoperative Doppler US evaluation of the portal vein was performed. Age, body weight, native liver disease, type of graft, graft recipient weight ratio (GRWR), type of portal anastomosis, portal velocity, portal venous size and presence of portosystemic shunt were analyzed for statistical significance of predisposing risk factors. Eight episodes of intraoperative portal vein thrombosis, with typical findings of absent Doppler flow in portal vein and prominent hepatic artery with a resistant index lower than 0.5 (p < 0.001), were detected during transplantation, which was then corrected by thrombectomy and re-anastomosis. Children age < or =1 yr (p = 0.025), weight < or =10 kg (p = 0.024), low portal flow < or =7 cm/s (p = 0.021), portal venous size < or =4 mm (p = 0.001), and GRWR >3 (p < 0.017) were all risk factors for intraoperative portal vein thrombosis. Doppler US is essential in the preoperative evaluation, early detection and monitoring of outcome of the portal vein in liver transplant.     

Living donor liver transplantation for congenital absence of the portal vein in a child with cardiac failure

Congenital absence of the portal vein (CAPV) requires liver transplantation when encephalopathy develops. However, transplantation has technical difficulties because no collateral circulation exists except for the portosystemic shunt. Ligating the shunt will cause disastrous mesenteric venous congestion. We report a 19-month-old female infant with CAPV, who had portosystemic encephalopathy and cardiac failure, and underwent living donor liver transplantation with a partial clamp technique using a vein graft. This is the first case of successful liver transplantation for CAPV with cardiac failure.     

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.     

肝脏移植中门静脉机化血栓的外科对策

目的：探讨肝脏移植中门静脉机化皿栓的术中处理方法。方法：回顾分析我院41例肝移植门静脉机化血栓患者，22例在取栓后门静脉端端吻合，10例血栓段门静脉切除，8例门静脉与曲张内脏血管吻合，1例门腔半转位。结果：1例死于多脏器功能衰竭；1例死于肝动脉出血；1例术后门静脉血流不足，二次肝脏移植时缝扎分流的侧支后顺利康复；2例患者术后出现吻合口狭窄，均采用经皮肝穿刺门静脉支架置7、治愈，其余36例患者分别随访6～20个月，门静脉血流均保持通畅。结论：存在门静脉机化血栓的患者行肝脏移植，首选血栓段门静脉切除或取栓后门静脉重建，当不能进行时采用门静脉与曲张内脏静脉吻合可好效果。     

Acute portal vein thrombosis secondary to donor/recipient portal vein diameter mismatch after orthotopic liver transplantation: a case report

The incidence of portal vein thrombosis in end-stage liver disease is estimated as varying between 5% and 21%, whereas in candidates undergoing liver transplantation, this is 3-13%. Portal vein thrombosis occurring after liver transplantation can be managed surgically by thrombectomy, retransplantation, splenorenal shunt, or Wall-stent placement, or nonsurgically by angioplasty, local high-dose infusion of thrombolytic agents, combination of portal thrombolysis, or embolization of a pre-existing spontaneous splenorenal shunt. We report a case of portal vein thrombosis after liver transplantation diagnosed on postoperative day 1 in a 57-year-old patient who received a liver from an 8-year-old donor. The patient was successfully treated surgically with portal vein thrombectomy and systemic anticoagulation. Portal vein thrombosis, in this case, was considered to be secondary to size discrepancy between the donor and the recipient portal veins. Routine use of daily Doppler ultrasound was the key factor in early diagnosis.     

Outcomes of liver transplantation in candidates with portal vein thrombosis

Objective

The objective of the present study was to analyze the incidence of portal vein thrombosis (PVT), comparing morbidity and mortality rates among those affected with and those free of this complication. In the PVT group, we also analyzed mortality related to partial (PPVT) and total (TPVT) thrombosis.

Methods

We undertook a retrospective study of orthotopic liver transplantations from deceased donors in 617 recipients from January 1991 until October 2008. Recipients were classified according to whether they had PVT. In all cases, we considered age, sex, Model for End-stage Liver Disease score, Child-Pugh score, indication for transplantation, type of thrombosis, surgical technique blood product transfusion, and survival rate.

Results

There were 48 patients with PVT (7.78%) among 670 transplantations in 617 recipients in our institution. Concerning the type of thrombosis, 28 (58.3%) were partial and 20 (41.7%) total with complete occlusion of the portal vein lumen.

Conclusion

PVT in liver transplant candidates is a rare event (7.8%) that entails greater difficulty in the procedure, expressed as a longer operative time, greater consumption of blood products, and complex surgical techniques. The prognosis for these patients depends on the type of thrombosis: patients with TPVT showed a higher mortality, whereas those with PPVT had survival rates comparable to those of candidates with a permeable portal vein.     

Outcome of patients with pre-existing portal vein thrombosis undergoing arterialization of the portal vein during liver transplantation

Arterialization of the portal vein is being propagated as a technical possibility in liver transplant recipients with pre-existing portal vein thrombosis. In our own small series, portal vein arterialization (PVA) was carried out in four patients undergoing orthotopic liver transplantation. In three of these cases, the portal vein was anastomosed to the aorta via an interposed iliac artery, and in one case, directly to the hepatic artery. After PVA, all transplants showed regular initial function. Two patients died postoperatively after 19 and 50 days, of intra-abdominal haemorrhage and liver necrosis with thrombosis of the portal vein, respectively. A further patient had previously developed fibrosis of the liver, which led to the death of the patient 11 months after PVA. In the remaining patient, chronic rejection requiring re-transplantation developed 24 months after PVA had been performed. These unfavourable results prompt the conclusion that PVA cannot be recommended as a standard clinical procedure.     

门静脉血栓的肝移植术中处理

目的 探讨门静脉血栓(PVT)的肝移植术中外科处理方法及其效果.方法 肝移植患者2508例,共行肝移植2614次,其中253例术前并发PVT.并发PVT者的Yerdel分级为,Ⅰ级者104例,Ⅱ级者114例,Ⅲ级者29例,Ⅳ级者6例.根据具体情况对并发Ⅰ、Ⅱ级PVT者施行静脉血栓切除术、外翻血栓切除术或外翻式门静脉内膜剥脱切除术;并发Ⅲ级PVT者,18例行外翻式门静脉内膜剥脱切除术,11例行外翻血栓切除术;并发Ⅳ级PVT者行外翻式门静脉内膜剥脱切除术.结果 218例并发Ⅰ、Ⅱ级PVT者中,32例行静脉血栓切除术,52例行外翻血栓切除术,134例行外翻式门静脉内膜剥脱切除术,均获得成功.29例并发Ⅲ级PVT者中,18例行外翻式门静脉内膜剥脱切除术,均获得成功;11例行外翻血栓切除术,其中5例获得成功,6例失败.6例并发Ⅳ级PVT者中,3例行外翻式门静脉内膜剥脱切除术,获得成功,3例取栓失败.253例并发PVT者肝移植术后6个月的存活率为93.7%,与同期无PVT的肝移植患者相比较(94.4%),差异无统计学意义(P>0.05).结论 并发PVT者可接受肝移植,术中应根据PVT的Yerdel分级情况,采取适合的外科处理方式.     

肝移植中门静脉-内脏曲张静脉吻合在门静脉机化血栓患者的应用

目的:探讨门静脉-内脏曲张静脉吻合在门静脉机化血栓患者肝移植中的应用。方法:对门静脉和肠系膜上静脉均完全被机化血栓阻塞的7例患者实施肝移植,其中3例供体门静脉-曲张冠状静脉吻合;2例髂静脉搭桥供体门静脉和脾门旁曲张的静脉吻合;1例采用供体门静脉-胆总管前曲张静脉吻合;1例供体门静脉—曲张的胃网膜右静脉吻合。结果:7例手术全部成功。1例术后7d死于多脏器功能衰竭,但是门静脉血流一直通畅。1例术后6个月发现吻合口狭窄,术后9个月采用经皮肝穿刺门静脉支架置入治愈;其余患者分别随访12～22个月,门静脉血流均通畅,无狭窄或血栓形成,肝、肾功能正常。结论:肝移植中对门静脉和肠系膜上静脉均完全被机化血栓阻塞的患者,行供体门静脉-曲张内脏静脉吻合可取得良好疗效。