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

The Management of Portal Vein Thrombosis after Adult Liver Transplantation: A Case Series and Review of the Literature

Background: Portal vein thrombosis (PVT) after adult liver transplantation (LT) is a rare but serious complication with no consensus on the ideal treatment. We report a case series and a comprehensive review of the literature on PVT after LT to discuss the therapeutic options. Methods: The clinical data of 360 adult patients (≥18 years of age) who underwent LT from January 2017 to January 2020 were reviewed, and a comprehensive search of PubMed and Web of Science was conducted. Patients diagnosed with PVT after LT were identified, and relevant risk factors and therapies were analyzed. Results: Among the 360 patients, 7 (1.94%) developed PVT after LT. Onset of PVT within one week after LT was found in six patients (85.71%). Four of the seven patients with PVT received systemic anticoagulation (low molecular weight heparin and warfarin) therapy. Minimally invasive interventional therapies combined with systemic anticoagulation (heparin and warfarin) were applied for three patients, two of whom died because of severe abdominal hemorrhage and liver failure. Of the 33 cases reported in the literature, minimally invasive interventional therapy combined with systematic anticoagulation or sclerotherapy were the most-used methods (20/33). Systemic anticoagulation was administered to four patients, and surgical operation (thrombectomy; portosystemic shunt and retransplantation) was performed for nine patients. Among these 33 patients, 4 eventually died. Conclusions: Interventional therapy combined with systemic anticoagulation is a good choice for the management of PVT after LT, and in our experience, systemic anticoagulation alone can also have a positive effect for early PVT patients.

Early Hepatic Artery Thrombosis After Pediatric Living Donor Liver Transplantation

AIM

Hepatic artery thrombosis is one of the major complications affecting patient and graft survival after liver transplantation. In this study, we analyzed the factors affecting the development of early hepatic artery thrombosis (eHAT) and its outcomes in pediatric liver transplantation.

METHODS

A total of 175 pediatric patients underwent living donor liver transplantation between January 2013 and November 2018. Factors affecting eHAT and its outcomes were examined.

RESULTS

Nine patients (5.1%) developed eHAT. In multivariate analysis, intraoperative hepatic artery revision and Roux-en-Y hepaticojejunostomy biliary reconstruction type were statistically significant (all, P < .05). Thrombectomy and reanastomosis was performed in 5 patients. Two of them were successful. In total, 3 retransplantations were performed and all of those patients are still alive.

CONCLUSION

The factors affecting eHAT are still a matter of debate. Intraoperative hepatic artery anastomosis revision and Roux-en-Y hepaticojejunostomy reconstruction were independent risk factors for development of eHAT. In the present study, the confidence interval of the variables is high, therefore exact determination of the risk factors may not be possible. Early detection and thrombectomy and reanastomosis may be the first treatment of choice to rescue the patient and graft. When it fails, retransplantation must be an alternative. The results of the present study state that at least once a day the vascular anastomosis must be examined by Doppler ultrasonography in the post-transplant first week. It must be repeated when liver enzymes increase. The patients under high risk for eHAT may be followed up closer.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study)

OBJECTIVES

Hepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.

METHODS

We retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.

RESULTS

The overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.

CONCLUSION

HA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study)

Objectives

Hepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.

Methods

We retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.

Results

The overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.

Conclusion

HA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

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Preoperative PVT was significant predictor of HA and/or PV complications.

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HA and/or PV complications especially early ones lead to significant poor outcome.

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Proper dealing with the risk factors like pre LT PVT improves outcome.

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The effective management of these complications is mandatory for improving outcome.

Current state of the art in management of vascular complications after pediatric liver transplantation

Vascular complications by compromising the blood flow to the allograft can have significant and sometimes life-threatening consequences after pediatric liver transplantation. High level of suspicion and aggressive utilization of diagnostic modalities can lead to early diagnosis and salvage of the allograft. This review will summarize the current trends in management of vascular complications after pediatric liver transplantation.

Concurrent hepatic artery and portal vein thrombosis after orthotopic liver transplantation with preserved allografts

In contrast to early HAT, late HAT has an insidious clinical presentation. Nevertheless, biliary and vascular reconstructions in this late setting are unlikely to improve outcome. Patent portal flow makes an important contribution to the viability of liver in case of late HAT while the allograft reconstitutes intrahepatic arterial flow through neovascularization. Concurrent HAT with PVT without immediate graft necrosis is extremely rare, and allograft and patient survival are seemingly impossible without retransplantation. In fact, hepatopetal arterial and portal venous neovascularization are known albeit obscure phenomena that can preserve posttransplant hepatic function under the extenuating circumstances of complete interruption of blood flow to the graft. We describe two such cases that developed combined HAT and PVT more than six months after OLT with perfect preservation of graft function. The survival of allografts in our cases was due to extensive hepatopetal arterial and portal venous collateralization. Simultaneous HAT and PVT after OLT are rare events and almost uniformly fatal, if they occur early. Due to paucity of such cases, however, underlying mechanisms and etiology remain elusive, and despite radiological diagnosis of these complications, there is no way to predict these events in the wake of stable graft function.

The long-term outcome of hepatic artery thrombosis after liver transplantation in children: role of urgent revascularization

Hepatic artery thrombosis (HAT), one of the most severe complications of pediatric orthotopic liver transplantation (OLT), often compromises graft and/or child survival. Of 590 OLT performed in 516 children over a 20-year period, 45 were complicated by early HAT, during the first 2 weeks after transplantation. Systematic Doppler ultrasonographic detection of HAT allowed successful surgical revascularization in 19 instances, resulting in a 20-year graft survival rate of 77% versus 24% of cases when revascularization was not attempted or failed. A combination of surgical emergency revascularization, biliary interventional radiology, biliary surgery and/or retransplantation resulted in an 80% 20-year patient survival rate, identical to that of transplanted children who did not experience early HAT. The majority of long-term survivors with their initial graft had normal liver tests, no biliary dilation on ultrasonography and minimal or moderate fibrosis on liver histology. A failed attempt at revascularization did not significantly alter patient survival. Despite these encouraging results, for the children and their parents to overcome the entire process in terms of reoperations, repeated radiological interventions, number of hospitalizations and emotional stress, remains an ordeal of such magnitude that it justifies renewed efforts to progress in the prevention of this complication.

Single artery reconstruction in left liver transplantation

BACKGROUND

A left liver graft in living donor liver transplantation often has 2 arterial stumps. The indication for multiple arterial reconstructions remains controversial. The aim of this retrospective study was to investigate whether single anastomosis of a left liver graft affects the outcome of living donor liver transplantation.

METHODS

When a hepatic graft had 2 arterial stumps, the thicker (dominant) stump was reconstructed first. After the initial reconstruction, another reconstruction was performed only if no pulsating flow was observed from the remnant stump. A total of 134 left liver grafts were divided into 3 groups: Group 1 (n = 70), 1 arterial stump on a graft with 1 arterial reconstruction; Group 2 (n = 59), 2 stumps with 1 arterial reconstruction; Group 3 (n = 5), 2 stumps with 2 arterial reconstructions. The incidence of hepatic arterial thrombosis, biliary stenosis, and patient survival was compared between Groups 1 and 2.

RESULTS

The incidence of arterial thrombosis and biliary stenosis, and the patient survival curves, were equivalent between Groups 1 and 2.

CONCLUSION

When the criteria were satisfied, single arterial reconstruction in a left liver graft with 2 arterial stumps did not affect the patient survival or biliary complications.

Interventional radiologic procedures in the treatment of complications after liver transplantation

The aim of this study is to report our interventional radiologic procedures (IRP) in liver transplant (LTX) patients. These include procedures for biliary, arterial, venous, and portal complications, as well as the treatment of infected and non-infected fluid collections. This retrospective study covered 583 patients (mean age: 44 +/- 14 yr) in whom a total of 685 LTX were performed from August 1987 to April 2005. Overall, 182 LTX patients underwent a total of 428 IRP, including digital subtraction angiography (n = 152/35.51%), percutaneous transluminal angioplasty (PTA) (n = 4/0.93%) and PTA + stent (n = 7/1.63%) of arterial anastomosis, PTA + stent of the celiac trunk (n = 2/0.46%), transjugular intrahepatic portosystemic shunt (TIPS) (n = 2/0.46%), arterial lysis (n = 4/0.93%), venous lysis (n = 2/0.46%), inferior vena cava stenting (n = 2/0.46%), percutaneous biliary drainage (n = 34/7.94%), percutaneous transluminal dilatation (PTD) of the choledocho-enteric anastomosis (n = 16/3.73%), biliary stent (n = 5/1.16%), intrahepatic biliary flushing treatment, stone and cast biliary extraction (n = 27/6.30%), other interventions (e.g., embolization in other regions, transjugular liver biopsies, lymphangiographies) (n = 9/2.10%), and ultrasound- and computer tomography-guided biopsies and percutaneous drainage (n = 153/35.74%). The overall success rate was 85.7%. Technical improvements in LTX and interventional radiology permit vascular and biliary complications to be treated successfully by interventional radiology.

Portal vein complications after adult-to-adult living donor liver transplantation

Successful management of portal vein (PV) complications after liver transplantation is crucial to long-term success. Little information is available, however, regarding the incidence and treatment of PV complications after adult-to-adult living donor liver transplantation (LDLT). Between January 1996 and October 2006, 310 adult LDLTs were performed at our institution. PV thrombus was present in 54 patients at the time of LDLT. The incidence of PV complications, choice of therapeutic intervention, and outcomes were retrospectively analyzed. Among the 310 recipients, PV complications were identified in 28 (9%). Risk factors included smaller graft size, presence of PV thrombus at the time of LDLT, and use of jump or interposition cryo-preserved vein grafts for PV reconstruction. When divided into early (within 3 months, n = 11) and late (after 3 months, n = 17) complications, the use of vein grafts for PV reconstruction predisposed to the occurrence of late, but not early, PV complications. Portal vein thrombosis occurred more frequently in the early period (eight out of 11, 73%), whereas stenosis occurred more frequently in the later period (14 out of 17, 82%). Surgical interventions were favored in the earlier period, whereas interventional radiologic approaches were selected for later events. Overall 3- and 5-year survival rates were 81% and 77%, respectively, in patients with PV complications and 88% and 84%, respectively, in those without PV complications (P = 0.21, log-rank test). PV complications are a significant problem following LDLT with both early and late manifestations. Acceptable long-term results, however, are achievable with periodic ultrasonographic surveillance and timely conventional therapeutic interventions. The use of cryo-preserved vein grafts for reconstructing portal flow should be discouraged.

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.

Portal vein reconstruction in adult living donor liver transplantation using cryopreserved vein grafts

No data are available for the management of venous jump or interposition conduits for portal vein (PV) reconstruction in adult living donor liver transplantation (LDLT). The feasibility of using cryopreserved vein grafts as PV conduits was examined. Cryopreserved vein (n = 23) was used as a patch, interposition, or jump graft. The patency results were compared with those of anastomosis without vein patch (n = 217) or those with vein autografts (n = 10). The 5-yr primary and secondary patency rates of the cryopreserved vein grafts were 58% and 79%, respectively. In conclusion, our data indicate that the use of cryopreserved vein grafts should be limited as conduits in PV reconstruction in adult LDLT.