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Gundlach JP, Günther R, Both M, Trentmann J, Schäfer JP, Cremer JT, Röcken C, Becker T, Braun F, Bernsmeier A. Inferior Vena Cava Constriction After Liver Transplantation Is a Severe Complication Requiring Individually Adapted Treatment: Report of a Single-Center Experience. Ann Transplant 2020; 25:e925194. [PMID: 32747619 PMCID: PMC7427346 DOI: 10.12659/aot.925194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Reports on vena cava occlusion after liver transplantation (LT) are rare, but this finding represents a severe complication in the early postoperative period. In the context of the complex presentation of a patient after LT, symptoms are often misinterpreted and can be subtle. Material/Methods In our cohort of 138 LTs performed between 2014 and 2017 at our University’s Transplantation Department, 117 transplantations were valid for further analysis after exclusion of pediatric transplantations and transplants with primary non-function grafts. In 101 cases (73%), patients received a deceased-donor full-size organ. Living-donor LT was performed in 8 patients (6.4%) and 8 patients (6.4%) received a split graft. We report on 6 patients who had inferior vena cava (IVC) occlusion and summarize the treatment choices. Results In our series, patients with positive findings (age 38–70 years) received an orthotopic full-size deceased-donor graft with end-to-end IVC anastomosis. In the subsequent period, imaging revealing IVC occlusion was done on a follow-up basis (n=2), due to dyspnea (n=1), and for progressive ascites (n=2). In 3 cases, a thrombus was found. We give detailed information on our treatment options from interventional treatment to transcardial thrombus removal and anastomosis augmentation. Conclusions IVC constriction and subsequent thrombosis are severe complications after LT that require individually adapted treatment in specialized centers. Since patients often present with subclinical symptoms, vascular diagnosis should be performed early to detect caval anastomosis pathologies. Despite regular ultrasonography, we favor CT and cavography for subsequent quantification. We also review the literature on IVC occlusion after LT.
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Affiliation(s)
- Jan-Paul Gundlach
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Rainer Günther
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Marcus Both
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jens Trentmann
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jost Philipp Schäfer
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jochen T Cremer
- Department of Cardiovascular Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Thomas Becker
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Alexander Bernsmeier
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
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Kamei H, Onishi Y, Ishigami M, Ishizu Y, Suzuki K, Ogura Y. Development of extensive inferior vena cava thrombosis due to the ligation of a large mesenteric-caval shunt during liver transplantation: A case report. Int J Surg Case Rep 2016; 29:211-214. [PMID: 27875796 PMCID: PMC5121213 DOI: 10.1016/j.ijscr.2016.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/10/2016] [Indexed: 11/16/2022] Open
Abstract
We report a case of IVC thrombosis caused by ligation of large mesenteric-caval shunt. This case serves as a note of caution when addressing a major portosystemic shunts in LT. The position of large collateral ligation should be carefully considered in LT.
Instruction Inferior vena cava (IVC) thrombosis can be a life-threatening complication after liver transplantation (LT). Although this complication is usually related to technical problems associated with vascular anastomosis, we report a case of IVC thrombosis which developed from a ligated large mesenteric-caval shunt. Presentation of case A 35-year-old man underwent LT from a brain-dead donor for primary sclerosing cholangitis. Enhanced computed tomography (CT) before LT showed a huge collateral vessel of the inferior mesenteric vein (IMV) draining into the infra-renal IVC directly. To obtain sufficient portal vein (PV) flow, the dilated IMV collateral was ligated. A routine Doppler ultrasound study on post-operative day 1 showed thrombus inside the infra-hepatic IVC. Enhanced CT showed that this thrombus originated from a ligated collateral vessel of the IMV and extended into the IVC. He was hemodynamically stable and liver function was consistently stable. The size of IVC thrombus slowly reduced and he is currently in good condition without any symptoms. Discussion To obtain adequate PV flow, ligation of a major PSS at the time of LT has been suggested. However, where it should be occluded has not been discussed. We should occlude a mesenteric-caval shunt not only at the upper side, but at the IVC side, based on findings from the current case. Conclusion To obtain appropriate PV flow toward a liver graft, occlusion of portosystemic shunts during LT is recommended. However, the position of ligation should be carefully considered to avoid extension of thrombus to major vessels.
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Affiliation(s)
- Hideya Kamei
- Departments of Transplantation Surgery, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan.
| | - Yasuharu Onishi
- Departments of Transplantation Surgery, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan.
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan.
| | - Yoji Ishizu
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan.
| | - Kojiro Suzuki
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan.
| | - Yasuhiro Ogura
- Departments of Transplantation Surgery, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan.
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Urahashi T, Mizuta K, Ihara Y, Sanada Y, Wakiya T, Yamada N, Okada N. Impact of post-transplant flow cytometric panel-reactive antibodies on late-onset hepatic venous outflow obstruction following pediatric living donor liver transplantation. Transpl Int 2014; 27:322-9. [DOI: 10.1111/tri.12255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 04/30/2013] [Accepted: 11/28/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Taizen Urahashi
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Koichi Mizuta
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Yoshiyuki Ihara
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Yukihiro Sanada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Taiichi Wakiya
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Naoya Yamada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Noriki Okada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
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Huber TJ, Hammer S, Loss M, Müller-Wille R, Schreyer AG, Stroszczynski C, Wohlgemuth WA, Uller W. Primary Stent Angioplasty of the Inferior Vena Cava After Liver Transplantation and Liver Resection. Cardiovasc Intervent Radiol 2013; 37:949-57. [DOI: 10.1007/s00270-013-0745-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 08/27/2013] [Indexed: 11/30/2022]
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Tasse J, Borge M, Pierce K, Brems J. Safe and Effective Treatment of Early Suprahepatic Inferior Vena Caval Outflow Compromise Following Orthotopic Liver Transplantation Using Percutaneous Transluminal Angioplasty and Stent Placement. Angiology 2010; 62:46-8. [DOI: 10.1177/0003319710369795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jordan Tasse
- Department of Radiology, Loyola University Medical Center,
Maywood, IL, USA
| | - Marc Borge
- Department of Radiology, Loyola University Medical Center,
Maywood, IL, USA,
| | - Kenneth Pierce
- Department of Radiology, Loyola University Medical Center,
Maywood, IL, USA
| | - John Brems
- Department of Surgery, Loyola University Medical Center,
Maywood, IL, USA
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Darcy MD. Management of venous outflow complications after liver transplantation. Tech Vasc Interv Radiol 2008; 10:240-5. [PMID: 18086429 DOI: 10.1053/j.tvir.2007.09.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Liver transplantation can be complicated by stenosis of the hepatic venous or inferior vena cava outflow. Venous outflow stenosis occurs at rates of 1 to 6% depending on the type of anastomosis. Stenoses can develop acutely as a result of technical problems or can present much later after the transplant due to intimal hyperplasia or perianastomotic fibrosis. Common clinical presentations include hepatic dysfunction, liver engorgement, ascites, abdominal pain, and occasionally variceal bleeding. Treatment can generally be accomplished via a transjugular approach, but percutaneous transhepatic access may be needed when the anastomosis cannot be catheterized from the jugular access. Angioplasty can achieve technical success in restoring anastomotic patency in close to 100% of cases, but restenosis is frequent. Repeat angioplasties may be needed. In adults and pediatric patients with adult sized hepatic veins, stenting may be a better option. Resolution of clinical signs and symptoms is seen in 73 to 100% of cases. Major complications are uncommon, with stent migration being one of the more difficult complications to manage.
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Affiliation(s)
- Michael D Darcy
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University, St Louis, MO 63110, USA.
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7
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Power-Pulse Thrombolysis and Stent Recanalization for Acute Post-Liver Transplant Iliocaval Venous Thrombosis. Cardiovasc Intervent Radiol 2008; 31 Suppl 2:S166-70. [DOI: 10.1007/s00270-007-9261-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 11/22/2007] [Accepted: 11/28/2007] [Indexed: 11/26/2022]
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8
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Randi ML, Sartori MT, Luzzatto G, Ruzzon E, Boccagni P, Ragazzi R, Girolami A. Thrombocytosis and recurrent hepatic outflow obstruction (Budd-Chiari syndrome) after successful thrombolysis: case report and literature review. Clin Appl Thromb Hemost 2002; 8:369-74. [PMID: 12516687 DOI: 10.1177/107602960200800409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Approximately two thirds of cases of hepatic flow obstruction are due to myeloproliferative disorders. Restoration of hepatic blood flow is the essential goal of treatment. Thrombolytic therapy seems to achieve good results at least in selected cases. A 32-year-old woman is presented, with an intermittent increase in platelet count (526-725 x 10(9)/L), two previous spontaneous abortions and acute symptomatic occlusion of hepatic veins, and in whom a diagnosis of essential thrombocythemia was initially carried out in agreement with the polycythemia vera study group criteria. She received recombinant tissue plasminogen activator followed by heparin with restoration of normal hepatic outflow. Asymptomatic re-occlusion of the hepatic veins was observed 1 year later, despite adequate continuous warfarin treatment. Angiography showed marked narrowing of the intrahepatic cava vein due to extrinsic compression by an enlarged liver, not due to a new thrombosis so that no specific intervention could be performed. In the presence of a dearly documented hepatic vein thrombosis, thrombolytic therapy should be considered. The patient was given low-molecular-weight heparin with a dramatic reduction in previously elevated fibrinogen level and a good control of the hepatic function.
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Affiliation(s)
- Maria Luigia Randi
- Department of Medical and Surgical Sciences, University of Padua Medical School, Padua, Italy.
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Angle JF, Matsumoto AH, Al Shammari M, Hagspiel KD, Spinosa DJ, Humphries JE. Transcatheter regional urokinase therapy in the management of inferior vena cava thrombosis. J Vasc Interv Radiol 1998; 9:917-25. [PMID: 9840035 DOI: 10.1016/s1051-0443(98)70422-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To study the efficacy of local infusion of urokinase (UK) in the treatment of symptomatic inferior vena cava (IVC) thrombosis. MATERIALS AND METHODS Eight patients (five men and three women) who ranged in age from 19 years to 75 years (mean, 56 years) with symptomatic IVC thrombosis underwent local catheter-directed infusion of UK with use of up to three access sites. Infrarenal IVC thrombus and iliac vein thrombus was identified in all patients. Four patients had extension of thrombus proximal to the renal veins. Seven of eight patients had at least one risk factor for IVC thrombosis: hypercoagulable state (n = 3), IVC filter (n = 3), malignancy (n = 2), recent surgery (n = 2), and oral contraceptive use (n = 1). No serious procedure-related complications were encountered, although one patient died 5 days after UK therapy of pulmonary failure due to advanced lung cancer. UK was infused for an average of 79 hours (range, 24-140 hours) and a mean total dose of 7.4 million U of UK (range, 2.9-14.4 million U). Adjunctive balloon angioplasty was performed in three patients. No vascular stents were placed. Clinical and/or radiographic follow-up was obtained in all eight patients. RESULTS Thrombolysis was successful in seven of eight (88%) IVCs with no or minimal residual thrombus. The remaining seven patients had no lower extremity swelling 2-24 months (mean, 11 months) after the procedure. Three of seven patients had computed tomographic or venographic follow-up (mean, 9 months; range, 1.5-15 months), demonstrating unchanged or improved IVC patency. CONCLUSIONS Transcatheter regional infusion of UK for re-establishing venous patency in acute IVC thrombosis appears to be effective with good short-term and mid-term clinical benefit.
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Affiliation(s)
- J F Angle
- University of Virginia, Health Sciences Center, Charlottesville 22908, USA
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Sharafuddin MJ, Hicks ME. Current status of percutaneous mechanical thrombectomy. Part III. Present and future applications. J Vasc Interv Radiol 1998; 9:209-24. [PMID: 9540903 DOI: 10.1016/s1051-0443(98)70260-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- M J Sharafuddin
- Section of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis, MO 63110, USA
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11
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Mazzaferro V, Regalia E, Pulvirenti A, Baratti D, Montagnino G, Bozzetti F. Renal-splenic shunt for intrahepatic caval occlusion after piggy-back liver transplantation. Transpl Int 1997. [DOI: 10.1111/j.1432-2277.1997.tb00935.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Frank JW, Kamath PS, Stanson AW. Budd-Chiari syndrome: early intervention with angioplasty and thrombolytic therapy. Mayo Clin Proc 1994; 69:877-81. [PMID: 8065191 DOI: 10.1016/s0025-6196(12)61791-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We present a complex case of the Budd-Chiari syndrome due to thrombosis of the hepatic veins in the presence of stenosis of the left hepatic vein and membranous obstruction of the inferior vena cava. The acute thrombosis occurred after laparoscopic surgical removal of the gallbladder. Because we strongly suspected the Budd-Chiari syndrome, hepatic venography was performed. The hepatic venous outflow obstruction was relieved by angioplasty and thrombolytic therapy with use of local infusions of urokinase into the clot. We propose that angiography be performed in patients in whom the Budd-Chiari syndrome is suspected and that angioplasty and thrombolytic therapy be initiated early.
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Affiliation(s)
- J W Frank
- Division of Gastroenterology and Internal Medicine, Mayo Clinic Rochester, Minnesota 55905
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Hansen ME, Miller GL, Starks KC. Pulse-spray thrombolysis of inferior vena cava thrombosis complicating filter placement. Cardiovasc Intervent Radiol 1994. [DOI: 10.1007/bf00197914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Hansen ME, Miller GL, Starks KC. Pulse-spray thrombolysis of inferior vena cava thrombosis complicating filter placement. Cardiovasc Intervent Radiol 1994; 17:38-40. [PMID: 8187132 DOI: 10.1007/bf01102071] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Inferior vena cava thrombosis is an uncommon but potentially serious complication of caval filter placement. A 34-year-old man with symptomatic caval thrombosis, which occurred 6 weeks after filter placement, was successfully treated with a combination of pulse-spray and local infusion of urokinase.
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Affiliation(s)
- M E Hansen
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas 75235
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