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?     

肝移植后无症状性肝动脉血栓形成一例

目的 探讨导致移植肝动脉阻塞后无症状的可能原因。方法 通过肝功能监测、彩色多普勒超声、肝动脉造影、肝组织活检以及胆道造影等手段追踪观察肝动脉血栓形成的临床经过，综合分析导致“无症状”的各种可能因素。结果 肝移植术后第4d肝动脉吻合出现血栓形成，至20d肝动脉接近完全阻塞；肝组织学检查见肝内胆汁淤积、肝细胞水样变性、小胆管上皮细胞萎缩以及汇管区纤维化等病理学改变。肝功能检查提示除γ0谷氨本主酶和碱笥磷酸酶升高之外，肝功能恢复顺利。术后71d血管造影显示肝动脉完全阻塞，但有侧枝循环建立和门静脉代偿性扩张。术后患者始终未出现肝动脉阻塞所特有的临床症状。结论 侧枝循环的建立和门静脉的代偿，使移植肝得以存活；术后2周之内经常进行彩色多普勒超声检查对肝动脉血栓形成的早期诊断有帮助。     

Vascular Complications Following Adult Piggyback Liver Transplantation With End-to-Side Cavo-Cavostomy: A Single-Center Experience

Background

Vascular complications remain a significant cause of morbidity, graft loss, and mortality following orthotopic liver transplantation (OLT). These problems predominantly include hepatic artery and portal vein thrombosis or stenosis. Venous outflow obstruction may be specifically related to the technique of piggyback OLT.

Materials and Methods

Between February 2002 and February 2009, we performed 200 piggyback OLT in 190 recipients. A temporary portacaval shunt was created in 44 (22%) cases, whereas end-to-side cavo-cavostomy was routinely performed for graft implantation. Pre-existent partial portal or superior mesenteric vein thrombosis was present in 17 (12%) cirrhotics in whom we successfully performed eversion thrombectomy, which was followed by a typical end-to-end portal anastomosis. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft in 31 (16%) patients.

Results

The 14 (7%) vascular complications included hepatic artery thrombosis (n = 5), hepatic artery stenosis (n = 3), aortic/celiac trunk rupture (n = 2), portal vein stenosis (n = 2), and isolated left and middle hepatic venous outflow obstruction (n = 1). There was also 1 case of arterial steal syndrome via the splenic artery. No patient experienced portal or mesenteric vein thrombosis. Therapeutic modalities included re-OLT, arterial/aortic reconstruction and splenic artery ligation. Vascular complications resulted in death of 5 (36%) patients.

Conclusion

Our experience indicated that piggyback OLT with an end-to-side cavo-cavostomy showed a low risk of venous outflow obstruction. Partial portal or mesenteric vein thrombosis is no longer an obstacle to OLT; it can be successfully managed with the eversion thrombectomy technique.     

Rescue of Acute Portal Vein Thrombosis After Liver Transplantation Using a Cavoportal Shunt at Re-transplantation

BACKGROUND: Portal vein thrombosis is a rare but devastating complication following orthotopic liver transplantation. Fulminant liver failure ensues with acute portal vein thrombosis after transplantation limiting the treatment options. METHODS: We successfully re-transplanted a 46-year-old female patient who developed acute portal vein thrombosis 19 d after orthotopic liver transplantation. Vascular reconstruction included a cavoportal shunt to augment portal blood flow. RESULTS: Twelve months after re-transplantation this patient lives independently and enjoys excellent liver allograft function. CONCLUSIONS: Cavoportal shunt can augment portal blood flow in adult recipients of orthotopic liver transplants. This technique can be successfully employed during re-transplantation when portal blood flow is inadequate to maintain patency.     

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.     

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。     

Portal Vein Arterialization for Hepatic Artery Thrombosis in Liver Transplantation: A Case Report, Doppler-Ultrasound Aspects, and Review of the Literature

Portal vein arterialization (PVA) is a salvage procedure for insufficient hepatic arterial or portal vascularization. It plays a role in auxiliary and orthotopic liver transplantation (OLT). In OLT, current indications for PVA include hepatic artery thrombosis (HAT), pre-OLT or post-OLT extended splanchnic vein thrombosis, intraoperative low portal flow, and anatomic variations like the absence of portal and mesenteric veins. Out of the transplantation domain, PVA is used both in extensive surgery for malignancies of the liver, biliary tract, and pancreas and in the treatment of fulminant hepatic failure (FHF) due to intoxications. We describe a case of acute post-OLT HAT successfully treated with PVA as a short bridge to retransplantation. By Doppler ultrasound of clinical PVA we detected an increased intrahepatic portal flow velocity, with disappearance of the arterial spikes, a finding that needs further investigation. PVA represents a rare surgical procedure. In fact, it has been used most of all in urgent conditions or in case of abrupt vascular complications during surgery. According to the literature, PVA emerges as a salvage procedure for poor arterial or portal hepatic flow, both in OLT and in general abdominal surgery. The outcome of this procedure is unpredictable. The aim of the shunt is to gain time, awaiting the onset of collateral arterial vessels or the performance of definitive surgery. Its early thrombosis may be a catastrophic event, due to acute liver ischemia. In contrast, a late occlusion is often well tolerated. Strict surveillance is always useful because sometimes it is mandatory to embolize the arterioportal fistula to treat or to prevent the onset of portal hypertension.     

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.     

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.     

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.)     

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.     

Outcome of extra-anatomic vascular reconstruction in orthotopic liver transplantation

BACKGROUND: Portal venous and hepatic arterial reconstruction are critical to successful outcomes in orthotopic liver transplantation (OLT). With portal vein thrombosis or inadequate hepatic arterial inflow, extra-anatomic vascular reconstruction is required. However, the clinical outcomes following extra-anatomic vascular reconstruction are largely unknown. METHODS: To determine the outcomes associated with extra-anatomic vascular reconstruction, we performed a retrospective review of 205 OLT recipients transplanted between 1995 and 2000. RESULTS: Extra-anatomic portal venous inflow was based upon the recipient superior mesenteric vein using donor iliac vein graft in a retrogastric position (n = 12). Extra-anatomic arterial inflow was based on recipient infrarenal aorta using donor iliac artery graft through the transverse mesocolon (n = 25). OLT with routine anatomic vascular construction served as control (n = 168). Extra-anatomic vascular reconstruction was not associated with increased morbidity, mortality, operating room time, length of stay, or thrombosis. CONCLUSION: We conclude that extra-anatomic vascular conduits are associated with excellent long-term outcomes and provide acceptable alternatives for vascular reconstruction in OLT.     

Polyarteritis nodosa, presenting as life-threatening gastrointestinal hemorrhage in a liver transplant recipient.

This unique case reports the first recorded episode in the medical literature of vasculitis post-liver transplantation, presenting as life-threatening gastrointestinal hemorrhage. A 52-year-old Caucasian woman underwent orthotopic liver transplantation (OLT) for autoimmune cirrhosis complicated by hepatoma and portal vein thrombosis. Late hepatic artery thrombosis led to a second liver graft. Following recovery from an episode of acute rejection, the patient presented with large volume hematemesis, melena, and hemochezia (passage of fresh blood from the rectum). Following upper and lower gastrointestinal endoscopy and surgery, angiography illustrated the presence of polyarteritis nodosa (PAN), which was successfully treated with high-dose steroid therapy. Gastrointestinal hemorrhage is an unusual presentation of vasculitis, especially PAN. The occurrence of this phenomenon post-OLT, in the presence of immunosuppression is previously unreported.     

彩色多普勒超声对肝移植术后11例血管并发症的诊断

目的评价彩色多普勒超声对肝移植术后血管并发症的诊断意义。方法回顾性分析和总结11例肝移植术后血管并发症的彩色多普勒超声检查资料,检测指标包括肝动脉及左右分支的峰值速度、阻力指数、加速度及加速时间,门静脉平均流速。结果5例经手术或造影证实为动脉并发症(血栓形成2例,肝动脉狭窄2例,肝动脉痉挛1例),彩色多普勒超声表现有肝动脉狭窄处的高速高阻血流并伴有湍流,而狭窄远端肝内动脉峰值速度<40cm/s,阻力指数<0.5,加速时间>0.08s,加速度<300cm/s2,2例肝动脉血栓形成肝门部无动脉血流信号;6例为门静脉并发症(3例门静脉狭窄,3例门静脉血栓形成)。结论彩色多普勒超声对肝移植术后血管并发症的诊断具有重要的指导意义。     

Liver transplantation for PNH with Budd-Chiari syndrome

A 54-year-old male patient with end-stage liver failure from Budd-Chiari syndrome due to paroxysmal nocturnal hemoglobinuria (PNH) underwent liver transplantation (OLT) in 1989. Retransplantation became necessary 1 year later when thrombotic occlusion of the portal vein and common hepatic artery led to graft loss after withdrawal of anticoagulation therapy because of several gastrointestinal bleeding episodes. The patient is now alive 3 years after the first OLT. To the best of our knowledge and according to the literature, this is, to date, the longest that any PNH patient has survived after liver transplantation. Although the course of this patient was complicated in a way similar to that reported for other cases in the literature, patients with PNH should not, in principle, be excluded from liver transplantation. Lifelong anticoagulation with coumarin and the use of steroids together with cyclosporin reduce the risk of recurrent thrombosis and PNH crises.     

A Novel Technique for Auxiliary Partial Liver Transplantation With Reno-Portal Anastomosis and Avoidance of the Hepatoduodenal Ligament

Auxiliary liver transplantation (ALT) is a treatment for acute liver failure when regeneration of the native liver is possible or for metabolic disorders. In selected cases ALT and orthotopic liver transplantation (OLT) have similar survival when ALT is performed in the orthotopic position (auxiliary partial orthotopic liver transplantation, APOLT). Drawback of ALT with portal vein to portal vein anastomosis is the frequent occurrence of thrombosis, compromising both graft and native liver, and the necessity of a significant resection. To avoid division of portal flow we performed ALT with an end-to-end anastomosis between the graft portal vein and the left renal vein of the recipient (reno-portal ALT, REPALT). The hepatic artery was anastomosed to the aorta using an iliac arterial graft conduit. The bile duct was anastomosed to the stomach. In the two cases presented here excellent immediate graft function occurred with rapid regeneration of the graft and without early vascular complications.     

Orthotopic liver transplantation in case of TIPS stent dislocation

Transjugular intrahepatic portosystemic shunts (TIPS) are indicated in patients with liver cirrhosis and portal hypertension for treatment of variceal bleeding or refractory ascites. Additionally implantation of stents may lead to stent dislocation or thrombosis in up to 20 % of cases. Detailed information about stent dislocation and its impact on subsequent orthotopic liver transplantation (OLT) is rare regarding the literature. We report on a patient suffering from ethyltoxic liver cirrhosis in which OLT was technically complicated by a thrombosed TIPS stent, dislocated in the portal vein. This stent was implanted prior to OLT due to refractory ascites and partial portal vein thrombosis. We conclude that TIPS stent insertion, especially in liver transplant candidates, should only be performed by radiologists in centers with expertise and experience.     

A single-center experience with retrograde reperfusion in liver transplantation

Poor graft function secondary to injury by ischemia and reperfusion remains a major problem with regard to morbidity and mortality in clinical liver transplantation (LTX). Up to one fifth of patients suffer from poor initial liver function due to severe damage to hepatocytes. This situation leads either to primary nonfunction described in approximately 6% of LTX or to slow recovery. We present a new method of reperfusion during LTX. From July 1998 to July 2002, 42 LTX in 39 recipients, (10 female, 52 years old (26–70) were performed. LTX was carried out in piggy-back technique. After completing the piggy-back anastomosis, the caval vein was declamped immediately, and retrograde low pressure reperfusion of the graft with low oxygenated venous blood was established. Portal anastomosis was performed using a running suture. In order to provide optimal retrograde liver perfusion, no clamping of the donor portal vein was done. After completing portal anastomosis, the recipient portal vein was declamped immediately. During arterial anastomosis, the transplanted liver was antegradely perfused via the portal vein. After completing hepatic artery anastomosis, declamping of the hepatic artery was done and arterial perfusion started. No backtable or in-situ-flushing except the described reperfusion technique was performed. Forty-two LTX in 39 recipients using piggy-back technique and retrograde reperfusion via the caval vein followed by antegrade reperfusion via the portal vein were performed; 38 out of 39 patients (97.44%) were alive and well at day 8 after LTX. One patient (2.56%) died of a pre-existing portal vein thrombosis on day 2 after LTX. Three patients had to undergo retransplantation for hepatic artery thrombosis (7.14%). Liver enzymes, bilirubine, prothrombine time and AT III on day 1, 3, 5 and 8 after LTX showed favourable values. Median aspartate aminotransferase (ASAT) was 219 U/l on day 1 after LTX. One-month survival rate was 95.23%, and 1-year survival rate 87.88%. Two patients died of liver-associated causes (5.12%). One patient died of a late hepatic artery thrombosis, and one more of rejection. No other severe case of rejection appeared. We can conclude that retrograde reperfusion might be highly sufficient method of removing perfusion fluid from the transplanted liver. Low pressure perfusion with low oxygenated blood might reduce the production of free oxygen radicals. Retrograde reperfusion via the caval vein and antegrade reperfusion via the portal vein seemed to lower postoperative liver enzyme values and to improve initial liver function after LTX.     

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。     

Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center

INTRODUCTION: Although portal vein thrombosis (PVT) is no longer considered a contraindication for liver transplantation (OLT), it is still considered a high risk because of the complexity of the surgical procedure. The aim of this study was to evaluate the impact of PVT in the recipient during OLT on intra- and perioperative management and outcome. PATIENTS AND METHODS: Between April 1986 and October 2003, 721 primary OLT included 64 patients (8.8%) with PVT. The underlying liver disease was postnecrotic cirrhosis in most cases (n = 37). Intraoperative (length of surgery, packed red blood cells (PRBC) transfusion requirements, ischemia time, complications) and postoperative parameters (ICU stay and hospitalization time, complications, actuarial graft and patient survival at 1 month and 1 and 5 years) were compared with a control group of patients submitted to OLT without PVT (n = 657). RESULTS: Portal flow was reestablished in 56 patients with thromboendovenectomy, in seven patients with a venous graft from the superior mesenteric vein, and with cavoportal hemitransposition in one case. The average ICU and hospital stay as well as the 1-month and 1- and 5-year patient survivals were not significantly different in the PVT versus the control group. We observed slightly more PRBC transfusions and longer surgery procedures in the PVT group. CONCLUSIONS: Our experience suggests that thromboendovenectomy is the procedure of choice for PVT. The results are good in terms of survival rates and postoperative complications, although the presence of PVT may lead to more technical problems during surgery.