Routine Doppler ultrasound for the detection of clinically unsuspected vascular complications in the early postoperative phase after orthotopic liver transplantation

The Yield of Routine Post-Operative Doppler Ultrasound to Detect Early Post-Liver Transplantation Vascular Complications

Early detection of liver transplantation (LT) vascular complications enables timely management. Our aim was to assess if routine Doppler ultrasound (rDUS) improves the detection of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT) and hepatic venous outflow obstruction (HVOO). We retrospectively analysed timing and outcomes, number needed to diagnose one complication (NND) and positive predictive value (PPV) of rDUS on post-operative day (POD) 0,1 and 7 in 708 adult patients who underwent primary LT between 2010-2022. We showed that HAT developed in 7.1%, PVT in 8.2% and HVOO in 3.1% of patients. Most early complications were diagnosed on POD 0 (26.9%), 1 (17.3%) and 5 (17.3%). rDUS correctly detected 21 out of 26 vascular events during the protocol days. PPV of rDUS was 53.8%, detection rate 1.1% and NND was 90.5. Median time to diagnosis was 4 days for HAT and 47 days for PVT and 21 days for HVOO. After intervention, liver grafts were preserved in 57.1%. In conclusion, rDUS protocol helps to detect first week's vascular events, but with low PPV and a high number of ultrasounds needed.

Doppler ultrasonography is a useful tool for the diagnosis of hemodynamics in congestive graft injury due to heart failure after liver transplantation: A case report

Introduction

Patients with end-stage liver disease often have cardiac dysfunction, which can be worsened by hemodynamic instability in liver transplantation, causing congestive graft injury.

Presentation of case

A 28-year-old male with Wilson's disease underwent liver transplantation. The patient's history included cirrhotic cardiomyopathy and a preoperative ejection fraction of 37% on echocardiography. After liver transplantation, massive transfusion and acute renal failure led to increased central venous pressure. Doppler ultrasonography (US) showed an increase in positive components of the hepatic vein triphasic wave, followed by pulsatile changes in the portal vein waveforms and an eventual to-and-fro pattern. Laboratory data showed severe elevations of hepatocellular transaminase levels. Based on Doppler US findings, we determined liver damage was due to passive congestion caused by heart failure. Immediate initiation of continuous hemodiafiltration (CHDF) and intra-aortic balloon pumping (IABP) led to the patient's recovery from severe heart failure and graft injury.

Discussion

In our case, changes in the hepatic and portal vein waveforms and marked elevation of hepatocellular transaminases implied exacerbation of heart failure caused by hepatic congestion and injury. Worsening heart failure, in turn, led to progressive liver damage as the result of hepatic passive congestion. The patient's condition was successfully managed with early initiation of CHDF and IABP.

Conclusion

Doppler US can help diagnose congestive graft injury due to heart failure in liver transplant patients and should be performed during post-transplant management of patients with cardiac dysfunction.

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Cardiac dysfunction can worsen after liver transplantation, causing congestive graft injury.

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In the post-transplant period, it is often difficult to differentiate the cause of elevated liver transaminases.

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Doppler ultrasonography helps diagnose congestive graft injury due to heart failure.

Inferior Vena Cava Constriction After Liver Transplantation Is a Severe Complication Requiring Individually Adapted Treatment: Report of a Single-Center Experience

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.

Doppler ultrasound values after liver transplantation in children and their association with graft outcomes: a protocol for a systematic review and meta-analysis

INTRODUCTION

Liver graft and patient survival in children have improved substantially over the years; nevertheless, graft-related complications persist as the most important risk factor for mortality and graft loss. Doppler ultrasound evaluation is routinely used after liver transplantation; however, there is no consensus defining normal values, timing or frequency of Doppler ultrasound postoperative evaluation. Identification of patients who require an intervention or change in postoperative management is therefore challenging.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis to appraise and synthesise evidence describing Doppler ultrasound measurements and their association with graft complications in children who have received a liver transplant. We will search multiple databases: Ovid Medline, Embase, Wiley Cochrane Library, Web of Science-Science Citation Index Expanded, trial registry records and meeting abstracts using a combination of subject headings and keywords for liver transplantation, Doppler ultrasound and paediatric patients. All identified titles and abstracts of studies will be assessed for potential relevance. Selected studies will be retrieved and subjected to a second phase of screening, both selection phases will be done in duplicate by two independent reviewers, and discrepancies will be documented and resolved by a third reviewer. Data extraction will be done independently by two reviewers using a standardised data extraction form. Quality of evidence and risk of bias will be assessed, synthesised and pooled for meta-analysis if possible. We will perform a subgroup analysis if enough data are available.

ETHICS AND DISSEMINATION

Strategies to disseminate our review include presenting in liver transplant review sessions, publishing in high-impact peer-reviewed medical journals, and presenting at national and international paediatric radiology and liver transplant meetings, conference presentations, events, courses and plain-language summaries. This knowledge will allow easier identification of patients with a higher risk of developing graft-related complications and could potentially improve patient and graft outcomes. We wish to disseminate our results to discover potential areas for future research and drive improved future practices and policies. Our target audience includes researchers, institutions, healthcare professionals, health system decision-makers, policy-makers and research funders community.

TRIAL REGISTRATION NUMBER

CRD42019119986.

The effect of Doppler ultrasound on early vascular interventions and clinical outcomes after liver transplantation

BACKGROUND

During the immediate postoperative period after liver transplantation (LT), postoperative bleeding and vascular complications (stenosis, thrombosis) are the two most common complications that require therapeutic decisions. Doppler ultrasound (DUS) is the established method for screening vascular patency after LT during the immediate postoperative period. The objective of our study was to evaluate the impact of DUS performed on postoperative days (POD) 1 and 2 on early vascular interventions.

METHODS

We studied 200 patients who had undergone living donor or deceased donor liver transplantation between January 2011 and March 2012. Postoperative liver DUS findings of up to POD 14, including patency of hepatic artery, portal vein, and hepatic vein, were retrieved. Patients with normal DUS findings on POD 1 and POD 2 were classified as the normal early DUS group. Patients with abnormal DUS findings at POD1 or POD2 were classified as the abnormal early DUS group. Frequency of vascular interventions was compared between the two groups. Risk factors that predict vascular interventions also were assessed.

RESULTS

On POD 1 and 2, 81.5 % (163/200) had normal DUS findings and management was not altered by subsequent DUS findings. Two patients in the normal group were found to have hepatic artery dissection and hepatic vein thrombosis on routine CT on POD 7 and received vascular intervention. DUS results in the two patients were normal until POD 6, but DUS performed after the CT on POD 7 were consistent with the CT findings. Of the 37 recipients who showed abnormal DUS findings on POD 1 or 2, the DUS findings were normalized or unchanged thereafter in 33 patients and no vascular interventions were performed. Two patients underwent hepatic artery thrombectomy on POD 2, one patient required a portal vein thrombectomy on POD 1, and one patient died on POD 3 due to bleeding. The overall incidence of vascular complication requiring vascular interventions was 2.5 %. Logistic regression identified abnormal DUS findings on POD 1 or 2 as an independent risk factor of vascular complications requiring intervention.

CONCLUSIONS

In LT recipients who demonstrate normal DUS findings in the first 2 postoperative days, additional DUS screening may have value only when clinically indicated.

UltraFast Doppler ultrasonography for hepatic vessels of liver recipients: preliminary experiences

Purpose:

The purpose of this study was to investigate the value of UltraFast Doppler ultrasonography (US) for evaluating hepatic vessels in liver recipients.

Methods:

Thirty-nine liver Doppler US sessions were conducted in 20 liver recipients. Each session consisted of UltraFast and conventional liver Doppler US in a random order. We compared the velocities and phasicities of the hepatic vessels, duration of each Doppler study, occurrence of technical failures, and differences in clinical decisions.

Results:

The velocities and resistive index values of hepatic vessels showed a strong positive correlation between the two Doppler studies (mean R=0.806; range, 0.710 to 0.924). The phasicities of the hepatic vessels were the same in both Doppler US exams. With respect to the duration of the Doppler US exam, there was no significant difference between the UltraFast (251±99 seconds) and conventional (231±117 seconds) Doppler studies (P=0.306). In five poor breath-holders, in whom the duration of conventional Doppler US was longer, UltraFast Doppler US (272±157 seconds) required a shorter time than conventional Doppler US (381±133 seconds; P=0.005). There was no difference between the two techniques with respect to technical failures and clinical decisions.

Conclusion:

UltraFast Doppler US is clinically equivalent to conventional Doppler US with advantages for poor breath-holders during the post-liver transplantation work-up.

Postoperative complications in patients with portal vein thrombosis after liver transplantation: Evaluation with Doppler ultrasonography

AIM: To study the postoperative complications in patients with preoperative portal vein thrombosis (PVT) undergoing liver transplantation (LT) and to evaluate the complications with Doppler ultrasonography.

METHODS: Retrospective studies were performed on 284 patients undergoing LT (286 LT) with respect to pre- and postoperative clinical data and Doppler ultrasonography. According to the presence and grade of preoperative PVT, 286 LTs were divided into three groups: complete PVT (c-PVT), partial PVT (p-PVT) and non-PVT, with 22, 30 and 234 LTs, respectively. Analyses were carried out to compare the incidence of early postoperative complications.

RESULTS: PVT, inferior vena cava (IVC) thrombosis, hepatic artery thrombosis (HAT) and biliary complications were found postoperatively. All complications were detected by routine Doppler ultrasonography and diagnoses made by ultrasound were confirmed by clinical data or/and other imaging studies. Nine out of 286 LTs had postoperative PVT. The incidence of the c-PVT group was 22.7%, which was higher than that of the p-PVT group (3.3%, P < 0.05) and non-PVT group (1.3%, P < 0.005). No difference was found between the p-PVT and non-PVT groups (P > 0.25). Of the 9 cases with postoperative PVT, recanalizations were achieved in 7 cases after anticoagulation under the guidance of ultrasound, 1 case received portal vein thrombectomy and 1 case died of acute injection. Ten LTs had postoperative IVC thrombosis. The c-PVT group had a higher incidence of IVC thrombosis than the non-PVT group (9.1% vs 2.6%, P < 0.05); no significant difference was found between either the c-PVT and p-PVT groups (9.1% vs 6.7%, P > 0.5) or between the p-PVT and non-PVT groups (P > 0.25). Nine cases with IVC thrombosis were cured by anticoagulation under the guidance of ultrasound, and 1 case gained natural cure without any medical treatment after 2 mo. HAT was found in 2 non-PVT cases, giving a rate of 0.7% among 286 LTs. Biliary complications were seen in 12 LTs. The incidence of biliary complications in the c-PVT, p-PVT and non-PVT groups was 9.1%, 3.3% and 4.3%, respectively (P > 0.25 for all), among which 2 stenosis led retransplantations and others were controlled by relative therapy.

CONCLUSION: C-PVT patients tend to have a higher incidence of PVT and IVC thrombosis than non-PVT patients after LT. The incidence of postoperative complications in p-PVT patients does not differ from that of non-PVT patients. A relatively low incidence of HAT was seen in our study. Doppler ultrasonography is a convenient and efficient method for detecting posttransplant complications and plays an important role in guiding treatment.

End-to-side caval anastomosis in adult piggyback liver transplantation

No consensus exists regarding the optimal reconstruction of the cavo-caval anastomosis in piggyback orthotopic liver transplantation (PB-LT). The aim of this study was to analyze our experience with end-to-side (ES) cavo-cavostomy. Outcome parameters were patient and graft survival and surgical complications. During the period 1995-2002 146 full-size PB-LT in 137 adult patients were performed with ES cavo-cavostomy without the routine use of temporary portocaval shunt (TPCS). In 12 patients (8%) this technique was used for implantation of second or third grafts. Veno-venous bypass was not used in any case and TPCS was performed only in eight patients (6%). One-, three- and five-yr patient and graft survival were 84%, 79% and 75%, and 81%, 74% and 69%, respectively. The median number of intraoperative transfusion of packed red blood cells (RBC) was 2.0 (range 0-33) and 30% of the patients (n = 43) did not require any RBC transfusion. Surgical complications of various types were observed after 49 LT (34%) and none of the complications was specifically related to the technique of ES cavo-cavostomy. Our experience indicates that PB-LT with ES cavo-cavostomy is a safe procedure, can safely be performed without the routine use of a TPCS, has a very low risk of venous outflow obstruction and can also be used effectively during retransplantations.

Complications of arterial reconstruction in living donor liver transplantation: a single-center experience

PURPOSE

Microsurgical reconstruction of the fine hepatic arteries (HA) reduces the chance of complications in living donor liver transplantation (LDLT). We reviewed HA reconstructions and analyzed their complications and treatment in a single center.

METHODS

Between August 1996 and September 2004, we performed LDLT on 71 adults and 19 children. Patients received a lateral segment graft (n = 16), a left lobe graft (n = 11), an extended left lobe graft (n = 12), or a right lobe graft (n = 51).

RESULTS

Hepatic artery reconstruction was performed by end-to-end anastomosis under an operating microscope in all except five adults who received right lobe grafts with loupe magnification. Arterial complications developed in 5 (5.6%) of the 90 patients. Three patients required reanastomosis during their primary operation because of HA thrombosis, anastomotic kinking, and stenosis, respectively. There were three postoperative complications: an anastomotic stenosis, revised by percutaneous transluminal angioplasty; rupture of an HA pseudoaneurysm, treated by embolization; and anastomotic kinking, revised by reanastomosis. The patient with the pseudoaneurysm died of arterial complications. Multivariate analysis of cases before (4/13, 30.8%) and after 2000 (1/77, 1.3%) revealed that surgical experience was the only significant factor in reducing the incidence of HA complications (P = 0.007).

CONCLUSION

Case number-dependent anastomotic reliability using microsurgical techniques is important for safer arterial reconstruction.

Analysis of differences in outcome of two European liver transplant centers

Authors analyzed the differences in the outcome of two European liver transplant centers differing in case volume and experience. The first was the Transplantation and Surgical Clinic, Semmelweis University, Budapest, Hungary (SEB) and the second the University Medical Center Groningen, Groningen, The Netherlands (UMCG). We investigated if such differences could be explained. The 1-, 3- and 5-year patient survival in the UMCG was 86%, 80%, and 77% compared with 65%, 56%, and 55% in SEB. Graft survival at the same time points was 79%, 71%, and 66% in the UMCG and 62%, 55%, and 53% in SEB. Significant differences were present regarding the donor and recipient age, diagnosis mix, disease severity and operation variables, per-operative transfusion rate, vascular complications, postoperative infection rate, and need for renal replacement. To determine factors correlating with survival, a separate uni- and multivariate analysis was performed in each center individually, between study parameters and patient survival. In both centers, peri-operative red blood cell (RBC) transfusion rate was a significant predictor for patient survival. The difference in blood loss can be explained by different operation techniques and shorter operation time in SEB, with consequently less time spent on hemostasis. It was jointly concluded that measures to reduce blood loss by adapting the operation technique might lead to improved survival and reduced morbidity.

Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation

Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child-Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0-18.8 l) in the re-intervention group compared with 1.5 l (range 0-13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.

Eversion thromboendovenectomy in organized portal vein thrombosis during liver transplantation

Portal thrombosis is no longer considered a contraindication for transplantation because of the technical experience acquired in the field of liver transplantation and the development of various surgical techniques. All the same, the results obtained in portal thrombosis patients are at times suboptimal, and the surgical technique used (thromboendovenectomy or veno-venous bypass) is also controversial. Between May 1988 and December 2001, 455 liver transplants were performed, of which 32 (7%) presented portal vein thrombosis. Of these, eight belonged to the first 227 transplants (group I), and 24 to the other 228 (group II). Of the 32 cases with portal thrombosis, 20 (62%) were type Ib, seven (22%) type II/III and five (16%) type IV. Twenty-two were males (69%), with a mean age of 50 yr (range: 30-70 yr); the thrombosis in all cases developed over a cirrhotic liver: 15 cases of an ethanolic origin, 11 because of hepatitis C virus, two cases of autoimmune aetiology, one case of primary biliary cirrhosis, one case because of hepatitis B virus and two cases of a cryptogenic origin. Five cases had a history of surgical treatment for portal hypertension. The surgical method in all cases consisted of an eversion thromboendovenectomy (ETEV) under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. Once re-canalization was achieved, we performed local heparinization and end-to-end portal anastomosis. In no case was systemic post-operative heparinization performed. In the 32 cases in which thrombectomy was attempted it was achieved in 31 of them (96%), failing only in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis re-thrombosed. The 5-yr survival rate of the patients in the series was 69%, with 10 patients dying, of whom only two from causes related to the thrombosis and the thrombosis treatment, both with type IV thrombosis. The ideal treatment for portal thrombosis during liver transplantation is controversial and depends on its extension and the experience of the surgeon. In our experience, ETEV resolves most thromboses (types I, II and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal haemitransposition.

Endoscopic ultrasound is a sensitive and specific test to diagnose portal venous system thrombosis (PVST)

OBJECTIVES

Thrombosis of the portal venous system (PVS) may complicate cirrhosis, pancreatitis, malignancies, and hypercoagulable states. Computed tomography (CT) scanning can diagnose thrombi present in the lumen of the PVS, but is probably insensitive. Endoscopic ultrasound (EUS) may be a more sensitive test for diagnosing PVS thrombosis (PVST). We sought to determine the accuracy of EUS for the diagnosis of PVST.

METHODS

Using a retrospective analysis of patients' studies retrieved from a database at Massachusetts General Hospital, we determined the sensitivity and specificity of EUS in 16 patients with PVST and 29 without PVST as proven by surgery and/or CT scanning. All patients underwent a linear EUS exam of the PVS and the results of the EUS report were used as the basis of the study.

RESULTS

The sensitivity of EUS for the finding of PVST was 81% in 13 of 16 patients and the specificity was 93% in 27 of 29 patients with an overall accuracy of 89% (40/45). In an additional group of 11 patients, EUS demonstrated the presence of a PVST that was not detected by CT scanning.

CONCLUSION

Linear EUS is a highly sensitive and specific test for PVST.