Liver transplantation in a patient with diffuse portal venous system thrombosis

Modified Cavoportal Hemitransposition for Severe Portal Vein Thrombosis Contributed to Long-term Survival After Deceased Donor Liver Transplantation-Insight Into Portal Modulation for Improving Survival: A Case Report

BACKGROUND

Severe/massive portal vein thrombosis (PVT) deteriorates peri-liver transplantation outcomes. Cavoportal hemitransposition (CPHT) is a rescue procedure for severe PVT, and short-term outcomes have been well studied. However, CPHT is associated with some long-term issues caused by portal flow modulation via extraordinary reconstruction. We describe a patient with Yerdel grade 4 PVT who underwent a liver transplant and achieved long-term survival with CPHT and a portosystemic shunt.

CASE REPORT

A 50-year-old man with liver cirrhosis underwent a deceased donor liver transplant. Preoperative examinations indicated Yerdel grade 4 PVT; thus, we planned a CPHT. In liver transplant surgery, we confirmed diffusely complete PVT and removed them as possible. After placing a liver graft, we performed CPHT and confirmed that the graft received sufficient portal vein flow. However, the gastroepiploic vein pressure increased significantly. Therefore, we added a portosystemic shunt between the splenic vein and the inferior vena cava, and the pressure improved. The patient was discharged after an uneventful hospital stay, and he reported no unfavorable events for over 12 years.

CONCLUSIONS

This case study suggested that a modified CPHT with a portosystemic shunt for Grade 4 PVT was useful in preventing post-liver transplant PVT development and improved the outcome.

Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation

Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.

Caval inflow to the graft for liver transplantation in patients with diffuse portal vein thrombosis: a 12-year experience

OBJECTIVE

To analyze the short- and long-term results of cavoportal anastomosis (CPA) and renoportal anastomosis (RPA) in 20 consecutive liver transplantation (LT) candidates with diffuse portal vein thrombosis (PVT).

SUMMARY BACKGROUND DATA

Caval inflow to the graft (CIG) by CPA or RPA has been the most commonly used salvage technique to overcome the absolute contraindication for LT in case of diffuse PVT.

METHODS

From 1996 to 2009, 3 patients (15%) underwent CPA and 17 patients (85%) had an RPA during LT. In addition to routine follow-up, patients were specifically evaluated for signs of portal hypertension (PHT) and for patency of the anastomoses. The follow-up ranged from 3 months to 12 years (median of 4.5 years).

RESULTS

: Caval inflow to the graft was feasible in all attempted cases. In the short term (<6 months), 35% of patients had residual PHT-related complications (massive ascites and variceal bleeding). These resolved spontaneously or with endoscopic management. Three deaths occurred; none was related to PHT or shunt thrombosis. In the long term (>6 months), 1 death occurred because of recurrent variceal bleeding after RPA thrombosis. At last follow-up, all living patients [n = 13 (65%)] had normal liver function, no signs of PHT and patent anastomoses. There were no retransplantations. Graft and patient survival at 1, 3, and 5 years were 83%, 75%, and 60%, respectively.

CONCLUSIONS

Caval inflow to the graft is an efficacious salvage technique with satisfactory long-term results, considering the spontaneous outcome in patients denied LT because of diffuse PVT. Adequate preoperative management of PHT and its associated complications is vital in obtaining good results. In the long term, residual PHT resolves and the liver function returns to normal.

Long-term survival after portal vein arterialization for portal vein thrombosis in orthotopic liver transplantation

Portal vein thrombosis is a relatively common finding during liver transplantation. The management of portal vein thrombosis during liver transplantation is technically demanding and ensures adequate portal flow to the liver graft. Eversion thromboendovenectomy and bypass using a patent splanchnic vein and cavoportal hemitransposition are the most often used procedures to treat portal vein thrombosis. There have been anecdotal reports of portal vein arterialization. We report a case of portal vein arterialization during orthotopic liver transplantation for decompensated cirrhosis. When thromboendovenectomy failed to restore sufficient portal flow and completion of arterial anastomosis between the recipient hepatic artery and the donor celiac trunk, a calibrated end-to-side anastomosis between the donor splenic artery and the donor portal vein was performed. With a 6-year follow-up, there are no symptoms related to portal hypertension, liver function is normal. However, an aneurismal dilatation of the portal branches has progressively developed. Calibrated portal vein arterialization is a possible option for portal vein thrombosis in liver transplantation, allowing long-term patient and graft survival.