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.     

Intraoperative stent placement in the portal vein during or after liver transplantation.

The purpose of this research was to evaluate the intermediate effectiveness of intraoperative portal vein stent placement for portal venous stenosis in liver transplantation. We attempted intraoperative portal vein stent placement in 44 portal venous anastomotic stenoses in 36 patients. All patients underwent stent placement via either the inferior or superior mesenteric vein. A total of 22 patients underwent portal vein stent placement simultaneously with liver transplantation, and 14 patients underwent stent placement 1-25 days (mean 5.93 days) after liver transplantation. Of the 22 patients, there was portal vein occlusion in 3 patients and small portal vein (<6 mm) in 10 patients (2.5-5.7 mm; mean size 3.9 mm). Patient follow-up included clinical and laboratory data collection, Doppler ultrasonography (US), and computed tomography (CT). Intraoperative portal vein stent placement was technically successful in all of our study patients, even in 6 patients with total occlusion of the portal vein. A total of 10 study patients underwent thrombectomy of the portal vein, 1 underwent patient portosystemic shunt ligation, and 7 patients had both procedures simultaneously. Portal venous patency has been maintained for 0-56 months (mean 16 months) in 42 (95%) of the 44 stent placements. In conclusion, intraoperative portal vein stent placement is an effective and long lasting treatment modality for treat portal venous stenosis, especially in patients with portal vein occlusion or small sized portal vein.     

Diagnosis and treatment of pediatric patients with late-onset portal vein stenosis after living donor liver transplantation

Portal vein stenosis (PVS) after living donor liver transplantation (LDLT) is a serious complication that can lead to graft failure. Few studies of the diagnosis and treatment of late-onset (≥3 months after liver transplantation) PVS have been reported. One hundred thirty-three pediatric (median age 7.6 years, range 1.3–26.8 years) LDLT recipients were studied. The patients were followed by Doppler ultrasound (every 3 months) and multidetector helical computed tomography (once a year). Twelve patients were diagnosed with late-onset PVS 0.5–6.9 years after LDLT. All cases were successfully treated with balloon dilatation. Five cases required multiple treatments. Early diagnosis of late-onset PVS and interventional radiology therapy treatment may prevent graft loss.     

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.     

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.     

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.     

Risk factors for portal vein complications in pediatric living donor liver transplantation

Shibasaki S, Taniguchi M, Shimamura T, Suzuki T, Yamashita K, Wakayama K, Hirokata G, Ohta M, Kamiyama T, Matsushita M, Furukawa H, Todo S. Risk factors for portal vein complications in pediatric living donor liver transplantation.
Clin Transplant 2010: 24: 550–556.
© 2009 John Wiley & Sons A/S. Abstract: Background: Portal vein (PV) complications in pediatric living donor liver transplantation (LDLT) are often asymptomatic in the early stages after transplantation and can be serious enough to lead to graft failure. There have been few reports on risk factors for PV complications in LDLT. The aim of this study is to investigate the influence of hepatic inflow upon PV complications and to predict patients at risk for these complications. Material/method: From 1997 to 2008, 46 pediatric patients underwent LDLT at our center. Portal venous and hepatic arterial flows and PV diameter were analyzed. Results: PV complications were identified in seven patients (15.2%) and occurred at a younger age and lower weight. As a result of appropriate treatment, none of the patients suffered graft failure. Analysis of the 46 patients and 27 patients under two yr of age indentified smaller PV diameter in recipient and larger discrepancy of PV diameter as risk factors. Portal venous flow tended to be low, in contrast to hepatic arterial flow, which tended to be high. Conclusion: PV size strongly influences PV complications. Other factors such as younger age, low portal venous flow, and high hepatic arterial flow may be risk factors for PV complications.     

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.     

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.     

Intra-operative management of low portal vein flow in pediatric living donor liver transplantation

For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of 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.     

Percutaneous mechanical fragmentation and stent placement for the treatment of early posttransplantation portal vein thrombosis.

BACKGROUND: Early portal vein thrombosis is a rare but severe complication of liver transplantation requiring retransplantation or at least surgical thrombectomy, both hampered by high morbidity and mortality. METHODS: We describe of a case of successful long-term recanalization of early posttransplantation portal vein thrombosis by a minimally invasive percutaneous transhepatic angiographic approach using both mechanical fragmentation and pharmacological lysis of the thrombus followed by stent placement. RESULTS: Mechanical fragmentation and contemporaneous local urokinase administration resulted in complete removal of the clot; the use of a vascular stent after balloon dilatation allowed restoration of normal blood flow to the liver after 9 months of follow-up. CONCLUSIONS: This case report confirms the possibility of successful recanalization of the portal vein after early posttransplantation thrombosis by a minimally invasive angiographic approach. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis.     

Right posterior portal vein stenosis developed after living donor liver transplantation using a modified right lobe graft with a type 2 portal vein: a case report

Portal vein complications after liver transplantation (LT) can lead to graft liver failure. In this living donor liver transplantation case a stenosis developed in the right posterior branch of the portal vein of the graft liver from a living donor with type 2 portal vein variation. A 61-year-old woman diagnosed with hepatocellular carcinoma due to hepatitis B received a liver graft revealing a single lumen divided by a septum. The portal vein was anastomosed to the recipient portal vein without venoplasty. Postoperative Doppler sonogram revealed poor flow in the right posterior portal vein with compensatory arterial hyperperfusion. The postoperative computed tomography (CT) scan revealed narrowing of the proximal part of the right posterior portal vein with periportal tracking. Without intervention, the liver enzyme and bilirubin levels decreased to normal and the follow-up CT scan showed decreased periportal tracking. The patient was discharged without major complications. We believe that the posterior portal vein stenosis resulted from the direct anastomosis of the portal vein without a further venoplasty. Although there was no major complication due to the posterior portal vein stenosis in our patient, we suggest a venoplasty to prevent portal vein stenosis when using right lobe grafts with a type 2 portal vein, even if a single lumen is present and there is a margin for a direct anastomosis.     

Anatomical variations of donor portal vein in right lobe living donor liver transplantation: the safe use of variant portal veins

In right lobe (RL) living donor liver transplantation (LDLT), portal vein (PV) variations are of immense clinical significance. In this study, we describe in detail our PV reconstruction techniques in RL grafts with variant PV anatomy and evaluate the impact of accompanying biliary variations on the recipient outcomes. In a total of 386 RL LDLTs performed between July 2004 and July 2012, the clinical data on 52 (13%) transplants using RL grafts with variant PV anatomy were retrospectively analyzed. Portal vein anatomy was classified as type 2 in 20 patients, type 3 in 24 patients, and type 4 in eight patients. The PV reconstruction techniques utilized included back‐wall plasty (n = 21), back‐wall plasty with saphenous vein graft interposition (n = 6), saphenous vein graft interposition (n = 5), cryopreserved iliac vein Y‐graft interposition (n = 6), and quiltplasty (n = 3). There was no donor mortality. In a median follow‐up of 29 months, none of the recipients had vascular complications. Anomalous PV anatomy was associated with a high (54%) incidence of biliary variations; however, these variations did not result in increased biliary complication rate. Overall, the 1‐ and 3‐year patient survival rates of recipients were 91% and 81%, respectively. Vascular and biliary variations in RL grafts render LDLT technically more challenging. By employing appropriate reconstruction techniques, it is possible to successfully use RL grafts with PV variations without endangering recipient and donor safety.     

Clinical application of arterialization of portal vein in living related donor partial liver transplantation

Arterialization of the portal vein was employed during hepatic arterial reconstruction in our first few clinical experiences of partial liver transplantation using liver grafts obtained from living related donors. This procedure reduced the time required for revascularization of the grafts to about 25 min, and could in fact reduce the ischemic phase of the grafts. Repeated practice of the clinical transplantation technique has shortened the time needed to complete vascular reconstruction, eliminating the need for this procedure in most of our subsequent cases. In many clinical cases, however, there may be emergency situations which require vascular reconstruction, resulting in a prolongation of ischemic phase and the deterioration of the cellular viability of the graft. In such situations, arterialization of the portal vein can be a useful way to prevent the prolongation of the ischemic phase and to rescue the graft.     

Hepatic vein reconstruction in living donor liver transplantation

INTRODUCTION: Living donor liver transplantation has emerged as a response to the cadaveric graft shortage, especially for adult recipients. Both right and left liver grafts are widely used, although some technical problems remain unresolved. Herein we describe our technique for reconstruction of the venous outflow in living donor liver transplantation. METHODS: From April 1986 to September 2004, 1012 liver transplantations were performed including 30 living donor liver transplantations between April 1995 and September 2004. We have selected the first 28 cases to ensure a mean follow-up of 21.07 +/- 13.11 months. We transplanted 18 right lobe grafts, 7 left lobe grafts, and 3 left lateral segment grafts. A surgical technique is described herein. RESULTS: No venous outflow obstruction developed among living donor liver transplantation recipients. CONCLUSION: We recommend reconstruction of the hepatic veins in living donor liver transplantation including joining together the three hepatic veins in the recipient to avoid venous outflow obstruction.