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

Intraoperative portal vein stenting through umbilical vein approach: An innovative salvage procedure for portal vein thrombosis in pediatric liver transplant

BACKGROUND

IPVS is considered a last resort or a salvage procedure in the event of recurrent PV thrombosis despite multiple attempts at redo PV anastomosis. We employed the opened umbilical vein approach to place the stent in the PV and deliver anticoagulation through a catheter.

MATERIALS AND METHODS

From Jan 2017 to Feb 2022, 150 patients underwent pediatric transplantation at department of liver transplant and hepatobiliary surgery unit, Indraprastha Apollo hospitals, New Delhi. Age, weight, PELD Score, diagnosis, portal vein diameter on preoperative CT, Portal flow after stenting, decrease in spleen size after stenting in follow-up CT were collected from a prospectively maintained data base and reviewed.

RESULTS

Eight patients underwent IPVS following LDLT (mean age-10.6 ± 2.2 months, mean weight 8.1 ± 1.6, mean PELD score 32.7 ± 7.3). The mean PV diameter on preoperative CT scan was 3.6 mm (range 2.7-5.6 mm). The mean portal flow following stenting was 718.75 cc/min. Percentage reduction in size of the spleen was 26.35% beyond 2nd post-operative week. No patient had recurrent PV thrombosis following IPVS and all maintained an adequate portal flow throughout the immediate postoperative period. Two patients had in-hospital mortality secondary to septic complications.

CONCLUSION

Umbilical vein approach is technically feasible, easy to manipulate the stent and catheter placement after stenting helps to deliver anticoagulants locally.

The Role of Imaging in Portal Vein Thrombosis: From the Diagnosis to the Interventional Radiological Management

PURPOSE

To illustrate diagnostic and interventional imaging for the characterization and treatment of portal vein thrombosis (PVT).

INTRODUCTION

The broad spectrum of congenital and acquired PVT manifestations is illustrated, with a focus on the pediatric population; diagnostic and interventional imaging techniques are described.

DESCRIPTION

PVT frequently presents as an incidental finding at imaging in the screening for liver diseases or for other unrelated reasons. PVT can be classified based on: extension (intrahepatic, extrahepatic, involving the spleno-mesenteric tract, etc.); degree (partial or complete); onset (acute or chronic); and with or without cavernomatous transformation. This comprehensive review relies on the experience gained from a large series of congenital and acquired PVT in a referral center for pediatric and adult liver transplantation. Diagnostic and interventional imaging techniques are described, including: color-Doppler and contrast-enhanced Ultrasound; CT and MR angiography; retrograde portography; percutaneous transhepatic, transplenic, and transmesenteric portography; transjugular intrahepatic portosystemic shunt creation. Pre- and post-operative imaging assessment of the surgical meso-rex bypass is discussed. The description is enriched with an original series of pictorial imaging findings.

CONCLUSION

PVT is a clinical condition associated with significant morbidity and mortality. Diagnostic and interventional imaging plays a crucial role in both conservative and operative management.

Usability of intraoperative cine-portogram during liver transplantation in young pediatric patients with biliary atresia

BACKGROUND

Pediatric patients with biliary atresia (BA) often present liver cirrhosis-associated portal hypertension and portal vein (PV) hypoplasia. For successful liver transplantation (LT), it is essential to maintain sufficient PV inflow through stenosis-free PV reconstruction with effective ligation of collateral veins. The aim of this study was to assess the clinical usability of intraoperative cine-portogram (IOCP) in young pediatric patients who underwent LT for BA.

METHODS

Medical records of pediatric patients younger than 10 years who underwent primary LT for BA from 2018 to 2020 were reviewed.

RESULTS

A total of 31 patients had undergone Kasai portoenterostomy soon after birth. Their median ages at Kasai portoenterostomy and LT were 1 and 11 months, respectively. Types of LT were living-donor LT in 13, deceased-donor split LT in 15, and deceased-donor whole LT in three patients. PV interposition using an iliac vein homograft was performed in 28 patients receiving partial liver grafts. Side-to-side PV unification venoplasty was performed in three patients undergoing whole LT. All patients underwent ligation of collateral veins. IOCP was performed in 6 (19.4%) patients. Four showed no or faint residual venous collaterals. Collateral vein embolization and endovascular stenting were performed in one patient each. PV insufficiency-free survival rate was 100% at 1 year and 93.8% at 3 years. All patients are currently alive with a median follow-up period of 23 months.

CONCLUSIONS

Intraoperative cine-portogram can be a useful method for identification and embolization of residual portosystemic collateral veins in young pediatric patients who undergo LT for biliary atresia.

The Application of Interventional Radiology in Living-Donor Liver Transplantation

Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.

Direct transmesenteric venous interventions in the acute post liver transplant setting

INTRODUCTION

Portal venous thrombosis and stenosis are uncommon but serious causes of liver transplant graft failure. While surgical thrombectomy can be utilized for the treatment of portal steno-occlusive disease, venous interventions with IR have been performed with encouraging results.

CASE DESCRIPTION

69-year-old female with non-alcoholic steatohepatitis cirrhosis who received a liver transplant complicated by portal vein thrombus. Efforts between transplant surgery and IR allowed for successful thrombus removal via direct SMV access.

RESULTS

The advantages of direct SMV access with the surgery team include direct approach to accessing thrombus, sparing of liver parenchyma, and significant hemostatic control.

Right trisectionectomy with en bloc portal vein resection for cholangiocarcinoma after preoperative stenting for main portal vein occlusion

Deprivation of portal blood flow decreases the hepatic function, thus hepatobiliary cancer patients with total occlusion of the main portal vein (PV) are usually not indicated for major hepatectomy. We herein present a 37-year-old male patient with advanced intrahepatic cholangiocarcinoma, in whom right trisectionectomy was indicated. However, the main PV was nearly completely occluded by tumor invasion, thus resolution of jaundice was markedly slow. To restore the liver function through PV recanalization, a wall stent was inserted percutaneously. Jaundice resolved progressively after PV stenting. Right trisectionectomy, caudate lobectomy, bile duct resection, and en bloc PV segmental resection with iliac vein homograft interposition were performed. However, PV thrombosis developed at the site of PV stent removal, thus a new wall stent was inserted during the operation. The pathology report presented that the tumor was a 5.2 cm-sized well-differentiated adenocarcinoma of periductal infiltrating type with lymph node metastasis. During the follow-up, the interposed PV segment with a wall stent was gradually occluded with development of portal collaterals. At 5 years after surgery, the PV stent was completely occluded and collaterals developed. The patient experienced repetition of febrile episodes of unknown causes. He is currently alive for 8 years with no evidence of tumor recurrence. The detailed surgical procedures were presented with a supplementary video clip of 5 minutes.

Successful Living-Donor Liver Transplantation With Intraoperative Endovascular Recanalization via Transsplenic Access in a Recipient With Grade III Portal Vein Thrombosis: A Case Report

Extensive portosplenomesenteric thrombosis is regarded as a relative contraindication to liver transplantation because of the complexity of the surgical procedure. This report describes a case of living-donor liver transplantation (LDLT) for a patient with extensive portosplenomesenteric thrombosis, in whom portal flow was successfully restored by intraoperative transplenic portal vein and superior mesenteric vein stenting after surgical thrombectomy. The patient's liver function remained normal with a patent portal vein stent 6 months after LDLT, and Doppler ultrasonography demonstrated a normal wave form for portal flow. To the best of our knowledge, this is the world's first case of endovascular management of the portal vein via percutaneous transsplenic access during LDLT, demonstrating that transsplenic access can be an alternative approach without liver graft injury when the superior mesenteric vein branch and inferior mesenteric vein cannot be used as access routes.

P4 Stump Approach for Intraoperative Portal Vein Stenting in Pediatric Living Donor Liver Transplantation: An Innovative Technique for a Challenging Problem

OBJECTIVE

The aim of this study was to evaluate the utility of the P4 stump stenting approach for treating portal vein (PV) complications in pediatric living donor liver transplantation (LDLT).

BACKGROUND

PV complications cause significant morbidity and mortality in pediatric LDLT. Biliary atresia in the backdrop of pathological PV hypoplasia and sclerosis heightens the complexity of PV reconstruction. The authors developed a novel approach for intraoperative PV stenting via the graft segment 4 PV stump (P4 stump) to address this challenge.

METHODS

From April 2009 to December 2016, 15 pediatric LDLT recipients (mean age 10.3 ± 5.0 months, mean graft-recipient weight ratio 3.70%) underwent intraoperative stenting for suboptimal PV flow (<10 cm/s) or PV occlusion after collateral ligation and graft repositioning. Under portography, metallic stents were deployed via the reopened P4 stump of the left lateral segment grafts.

RESULTS

PV diameter and peak flow increased significantly after stent placement (2.93 ± 1.74 to 7.01 ± 0.91 mm and 2.0 ± 9.2 to 17.3 ± 3.5 cm/s, respectively, P = 0.001 for both), and there were no technical failures. Stents in all surviving patients remained patent up to 8 years (mean 27.7 months), with no vascular or biliary complications. After implementation of the P4 approach, the incidence of variceal bleeding as a late complication decreased from 7% to zero.

CONCLUSION

The P4 stump stenting approach affords procedural convenience, ease of manipulation, and consistent results with the potential for excellent long-term patency in children despite continued growth. This technique obviates the need for more demanding post-transplant stenting, and may become a substitute for complicated revision surgery, portosystemic shunting, or retransplantation.

Long-term outcomes of transmesenteric portal vein recanalization for the treatment of chronic portal vein thrombosis after pediatric liver transplantation

Portal vein thrombosis (PVT) may occur at any time following liver transplantation. We describe our experience with portal vein recanalization in cases of thrombosis after liver transplantation. Twenty-eight children (5%) out of 566 liver transplant recipients underwent portal vein recanalization using a transmesenteric approach. All children received left hepatic segments, developed PVT, and had symptoms or signs of portal hypertension. Portal vein recanalization was performed via the transmesenteric route in all cases. Twenty-two (78.6%) patients underwent successful recanalization and stent placement. They received oral anticoagulants after the procedure, and clinical symptoms subsided. Symptoms recurred due to portal vein restenosis/thrombosis in seven patients. On an intention-to-treat basis, the success rate of the proposed treatment was 60.7%. Only 17 out of 28 children with posttransplant chronic PVT retained stent patency (primary + assisted) at the end of the study period. In cases of portal vein obstruction, the transmesenteric approach via minilaparotomy is technically feasible with good clinical and hemodynamic results. It is an alternative procedure to reestablish the portal flow to the liver graft that can be performed in selected cases and a therapeutic addition to other treatment strategies currently used to treat chronic PVT.

Living Donor Liver Transplantation: Technical Innovations

Living donor liver transplantation (LDLT) has found a place to serve the end-stage liver disease community as the donor safety and recipient suitability has been elucidated. Donor safety is of paramount importance and transplant programs must continue endeavors to maintain the highest possible standards. At the same time, adequacy of grafts based on recipient clinical status via their model for end-stage liver disease (MELD) score and volumetric studies to achieve a GRBWR >0.8, along with special attention to anatomic tailoring and portal venous flow optimization are necessary for successful transplantation. Technical innovations have improved sequentially the utility and availability of LDLT.

Portal vein stenting as a significant risk factor for biliary stricture in adult living donor liver transplantation

BACKGROUND

Although perioperative portal vein (PV) stent implantation is an effective treatment for steno-occlusive disease in adult living donor liver transplantation (LDLT) recipients, we experienced high incidence of biliary anastomotic strictures (BAS) after PV stenting. In this study, we sought to clarify the relation between BAS and PV stenting and to suggest the possible mechanism of BAS and measures to reduce its incidence.

METHODS

We retrospectively analyzed 44 LDLT recipients who underwent PV stent implantation across the line of PV anastomosis regardless of the location of steno-occlusion (stent group) and their matched controls (non-stented LDLT recipients, n=131).

RESULTS

The incidence of BAS was higher in patients in the stent group than that in the control group (43.2% vs 17.6%, P=0.001). Cumulative 6-month and 1-, 2- and 5-year BAS rates were 31.8%, 34.1%, 41.4% and 43.2%, respectively, in the stent group and 13.0%, 13.8%, 16.1% and 17.8%, respectively, in the control group (P=0.001). Multivariate analysis revealed that PV stenting was an independent risk factor for BAS.

CONCLUSIONS

Although PV stent implantation is a reliable treatment modality for steno-occlusive PV in adult LDLT recipients, innovative methods to prevent the PV stent from crossing the line of PV anastomosis may be necessary to reduce the incidence of postoperative BAS.

A review of current status of living donor liver transplantation

Living donor liver transplantation (LDLT) has become an inevitable procedure in Asia due to its shortage of deceased donor under the influence of the religion and native cultures. Through a broad variety of experience, LDLT has been evolved and extended its indication. Although there have been many surgical and ethical efforts to prevent donor risk, concerns of donor's safety still are remaining questions due to its strict selection criteria. Therefore, dual grafts LDLT or ABO incompatible (ABO-I) LDLT may be effective means in its application and safety aspect. Many Asian LDLT centers have pointed out the useful extended criteria of LDLT for hepatocellular carcinoma (HCC), but the applicability of extended criteria should be validated and standardized by worldwide prospective studies based on the Milan criteria. Recent struggling efforts have been reported to surmount extensive portal vein thrombosis and Budd-Chiari syndrome which were previously contraindicated to LDLT. There is no doubt that LDLT is a surely complicated therapy to be performed successfully and requires devoted efforts by surgeons and co-workers. Nonetheless, comprehensive increasing understandings of partial graft LT and improvements of surgical techniques with challenges to obstacles in LDLT will make its prosperity with satisfactory outcomes.

A complete treatment of adult living donor liver transplantation: a review of surgical technique and current challenges to expand indication of patients

The growing disparity between the number of liver transplant candidates and the supply of deceased donor organs has motivated the development of living donor liver transplantation (LDLT). Over the last two decades, the operation has been markedly improved by innovations rendering modern results comparable with those of deceased donor liver transplantation (DDLT). However, there remains room for further innovation, particularly in adult living donor liver transplantation (ALDLT). Unlike whole-size DDLT and pediatric LDLT, size-mismatching between ALDLT graft and recipient body weight and changing dynamics of posttransplant allograft regeneration have remained major challenges. A better understanding of the complex surgical anatomy and physiologic differences of ALDLT helps avoid small-for-size graft syndrome, graft congestion from outflow obstruction and graft hypoperfusion from portal flow steal. ALDLT for high-urgency patients (Model for End-Stage Liver Disease score >30) can achieve results comparable to DDLT in high volume centers. Size limitations of partial grafts and donor safety issues can be overcome with dual grafts and modified right-lobe grafts that preserve the donor's middle hepatic vein trunk. Extended application of LDLT for unresectable hepatocellular carcinoma above Milan criteria is an optional strategy at the cost of slightly compromised survival. ABO-blood group incompatibility obstacles have been broken down by introducing a paired donor exchange program and refined peri-operative management of ABO-incompatible ALDLT. This review focuses on recent innovations of surgical techniques, safe donor selection, current strategies to expand ALDLT with broadened patient selection criteria and important aspects of teamwork required for success.

Living donor liver transplantation

PURPOSE OF REVIEW

Living donor liver transplantation (LDLT) continues to evolve, generating interesting issues on the applicability and safety of new techniques.

RECENT FINDINGS

Specific selection criteria and standardized surgical techniques with high ethical and medical standards are needed to minimize donor risk. In this aspect, minimally invasive donor hepatectomy has caused controversies. The reproducibility and safety of pure laparoscopic major hepatectomy in LDLT remains uncertain. Therefore, a stepwise approach is needed to avoid unnecessary donor risk. To expand the living donor pool, dual graft and ABO-incompatible LDLT have emerged as well tolerated and effective methods. The extended selection criteria for hepatocellular carcinoma in LDLT appear acceptable to balance donor risk and recipient outcome. However, these criteria should be validated based on the risk-benefit ratio. Despite technical advances, technical challenges persist such as Budd-Chiari syndrome and portal vein thrombosis. To address these issues, several innovative surgical techniques have been proposed and have shown promising results.

SUMMARY

LDLT is associated with donor safety concerns, technical complexity, and small-for-size issues. Nonetheless, accumulated experience and technical know-how from large-volume Asian LDLT centers have led to progress in LDLT. Further technical refinement and investigation to overcome the disadvantages of partial grafts will broaden the applicability of LDLT.

Management of late-onset portal vein complications in pediatric living-donor liver transplantation

The purpose of this study was to evaluate retrospectively the results of PTA for late-onset PV complications after pediatric LDLT and to assess whether a meso-Rex shunt is a viable option for treating restenosis of the PV after PTA in selected cases. Seventy-five children who underwent adult-to-child LDLT were included in this study, and there were six late-onset PV complications (8.0%). The initial therapeutic approach was PTA, with or without stent: PTA with balloon dilation for three children, PTA with stent placement for one child, and failure to cannulate the occluded PV for two children. A meso-Rex shunt was performed in the two children after failed PTA: One suffered complete obstruction of the main PV, and the other, restenosis with total thrombosis after PTA with stent. The PTA was a technical and clinical success in four with PV stenosis of the six patients (66.7%), and successful application of a meso-Rex shunt in the other two children resulted in restoration of PV flow. In conclusion, PTA is a safe and effective procedure for treating late-onset PV stenosis after pediatric LDLT. However, in growing pediatric recipients with restenosis of the PV after PTA or chronic PV thrombosis, a meso-Rex shunt may be a better choice for late-onset PV complications.

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.

Cavo-caval intervention stent insertion after deceased-donor liver transplantation using side-to-side piggyback technique: report of a case

Liver transplantation with preservation of the recipient vena cava (piggyback technique) has been performed as an alternative to the conventional method. Outflow disturbance or obstruction of the vena cava in the early period after liver transplantation is associated with high morbidity and mortality. We used side-to-side cavo-caval anastomosis (modified piggyback technique) in a deceased-donor liver transplantation (DDLT) for venous outflow reconstruction. On postoperative day 9, the patient developed abdominal discomfort, and abnormal liver function showing serum total bilirubin of 6.2 mg/dl and serum AST/ALT of 297/597 IU/L. Doppler ultrasound showed mono-phasic wave forms of the hepatic vein. Computed tomography showed focal narrowing of 9.5 mm×12 mm in diameter at the cavo-caval anastomosis site. Liver biopsy was showed that there was no evidence of acute allograft rejection. Direct venogram showed stenosis of the cavo-caval anastomosis with a pressure gradient of 12 mmHg. An interventional stent was inserted in the stenotic site of the inferior vena cava, and the pressure gradient decreased to 2 mmHg. He was discharged from hospital on postoperative day 23 without any other complications. Herein we report a case of deceased-donor liver transplantation using the modified piggyback technique, who received an inferior vena cava stent due to stricture of the reconstructed orifice of the vena cava.

Long-term results of the percutaneous transhepatic venoplasty of portal vein stenoses after pediatric liver transplantation

  This paper has the objective to evaluate retrospectively the long-term results of transhepatic treatment of PV stenoses after pediatric LT. During an eight-yr period, 15 children with PV stenoses underwent PTA with balloon dilation or stent placement in case of PTA failure after LT. Patients' body weights ranged from 9.3 to 46kg (mean, 15.5kg). PV patency was evaluated in the balloon dilation and in the stent placement groups. Technical and clinical successes were achieved in all cases with no complication. Eleven patients (11/15; 73.3%) were successfully treated by single balloon dilation. Four patients (4/15; 26.7%) needed stent placement. One patient was submitted to stent placement during the same procedure because of PTA failure. The other three developed clinical signs of portal hypertension because of PV restenoses two, eight, and twenty-eight months after the first PTA. They had to be submitted to a new procedure with stent placement. The follow-up time ranged from 3 to 8.1 yr (mean, 6.3 yr). In conclusion, transhepatic treatment of PV stenoses after pediatric LT with balloon dilation or stent placement demonstrated to be a safe and effective treatment that results in long-term patency.

No-touch hepatic hilum technique to treat early portal vein thrombosis after pediatric liver transplantation

A 'no-touch' hilum technique used to treat early portal vein complications post-liver transplantation in five children with body weight <10 kg is described. Four patients developed thrombosis and one portal flow absence secondary to collateral steal flow. A vascular sheath was placed through the previous laparotomy in the ileocolic vein (n = 2), inferior mesenteric vein (n = 1) or graft umbilical vein (n = 1). Portal clots were mechanically fragmented with balloon angioplasty. In addition, coil embolization of competitive collaterals (n = 3) and stent placement (n = 1) were performed. The catheter was left in place and exteriorized through the wound (n = 2) or a different transabdominal wall puncture (n = 3). A continuous transcatheter perfusion of heparin was subsequently administered. One patient developed recurrent thrombosis 24 h later which was resolved with the same technique. Catheters were removed surgically after a mean of 10.6 days. All patients presented portal vein patency at the end of follow-up. Three patients are alive after 5 months, 1.5 and 3.5 years, respectively; one patient required retransplantation 18 days postprocedure and the remaining patient died of adenovirus infection 2 months postprocedure. In conclusion, treatment of early portal vein complications following pediatric liver transplantation with this novel technique is feasible and effective.

Vascular stents in the management of portal venous complications in living donor liver transplantation

To evaluate the efficacy of stent placement in the treatment of portal vein (PV) stenosis or occlusion in living donor liver transplant (LDLT) recipients, 468 LDLT records were reviewed. Sixteen (10 PV occlusions and 6 stenoses) recipients (age range, 8 months-59 years) were referred for possible interventional angioplasty (dilatation and/or stent) procedures. Stent placement was attempted in all. The approaches used were percutaneous transhepatic (n = 10), percutaneous transsplenic (n = 4), and intraoperative (n = 2). Technical success was achieved in 11 of 16 patients (68.8%). The sizes of the stents used varied from 7 mm to 10 mm in diameter. In the five unsuccessful patients, long-term complete occlusion of the PV with cavernous transformation precluded catherterization. The mean follow-up was 12 months (range, 3-24). The PV stent patency rate was 90.9% (10/11). Rethrombosis and occlusion of the stent and PV occurred in a single recipient who had a cryoperserved vascular graft to reconstruct the PV during the LDLT operation. PV occlusion of >1 year with cavernous transformation seemed to be a factor causing technical failure. In conclusion, early treatment of PV stenosis and occlusion by stenting is an effective treatment in LDLT. Percutaneous transhepatic and transsplenic, and intraoperative techniques are effective approaches depending on the situation.

Transvenous variceal embolization during or after living-donor liver transplantation to improve portal venous flow

PURPOSE

Diversion of portal vein (PV) flow from the partial liver graft in living-donor liver transplantation (LDLT) can be life-threatening and warrant interruption of large collateral vessels. The purpose of this study is to evaluate the clinical efficacy of percutaneous or intraoperative transvenous embolization of portosystemic collateral vessels to improve PV inflow during or after LDLT.

MATERIALS AND METHODS

From 2000 to 2007, 105 of 1,435 patients (7%) who had undergone LDLT underwent percutaneous (n = 17) or intraoperative (n = 88) venography to evaluate the status of PV inflow and portosystemic collateral vessels. Among these 105 patients, 19 underwent percutaneous (n = 6) or intraoperative (n = 13) transvenous embolization of portosystemic collateral vessels to improve PV inflow. This included 12 men and seven women with a mean age of 46.5 years.

RESULTS

Successful embolization of the portosystemic collateral vessels with subsequently improved PV inflow was achieved in all 13 patients (100%) treated with the intraoperative approach and in four of six (67%) patients treated with the percutaneous approach. During follow-up (median, 8 months), Doppler ultrasonography showed adequate PV inflow in 17 of 19 patients, and follow-up computed tomography showed that collateral flow to the varices disappeared in 13 patients and decreased in four patients. One patient died of acute reactivated hepatitis 2 months after the procedure. Overall clinical success was achieved in 16 of the 19 study patients (84%).

CONCLUSIONS

Transvenous embolization of varices may be an effective method to improve PV inflow in LDLT recipients.

[Mesenteric venous ischemia secondary to portal stenosis following liver transplantation]

We report a case of portal vein stenosis six months after previous orthotopic liver transplantation. The patient presented with mesenteric venous ischemia. He underwent successful percutaneous transhepatic portal vein angioplasty and stent placement.

Adult to pediatric living donor liver transplantation for portal cavernoma

AIM

Portal cavernoma (PC) is an important cause of non-cirrhotic portal hypertension with severe complications, such as variceal hemorrhage in pediatric patients. With the development of new surgical techniques, living donor liver transplantation (LDLT) has recently been recognized as a viable but challenging treatment option for PC. The purpose of the present study was to summarize the efficacy of LDLT in PC patients and to carry out a follow-up study of pediatric recipients.

METHODS

The primary indication for LDLT in our research was PC with severe variceal bleeding and liver function decompensation. Three patients were diagnosed with PC following evaluation with computed tomography angiography and abdominal color Doppler ultrasonography (CDU).

RESULTS

Various surgical techniques, including jump bypass grafting for portal vein anastomosis, were carried out according to the range and degree of cavernous transformation within the splenic vein and superior mesenteric vein. Postoperative CDU confirmed the early integrity of the portal vein (PV) in each patient. PV rethrombosis occurred in one patient 7 days after LDLT, despite anticoagulation therapy with coumadin. Two of the three patients had no further episodes of variceal hemorrhage during the 2-year follow-up period.

CONCLUSIONS

The present study is the first report of the successful use of LDLT to treat pediatric PC patients. We conclude that LDLT is effective for the majority of pediatric patients with PC.

Technique and outcome of autologous portal Y-graft interposition for anomalous right portal veins in living donor liver transplantation

This study was intended to describe in detail the surgical technique and long-term outcome of autologous portal vein (PV) Y-graft interposition for adult living donor liver transplantation (LDLT). We assessed the outcome of 841 patients who underwent right lobe LDLT from January 2002 to December 2007 with respect to the reconstruction of double-graft PVs. PV anatomy of the donor livers was classified as type I in 796 patients (94.6%), type II in 15 patients (1.8%), and type III in 30 patients (3.6%). Seven type II grafts and all type III PV grafts had double PV orifices. Autologous PV Y-graft interposition was used in 31 patients, and complications occurred in only 1 patient during a median follow-up of 27 months. Overall, the 1- and 3-year graft survival rates were 87.5% and 80.6%, respectively. Use of a Y-graft was not a risk factor for biliary complications, but the liver anatomy of anomalous PV per se seems to be associated with a higher occurrence of biliary complications, especially during the early posttransplant period. The favorable outcome and technical feasibility of autologous portal Y-graft interposition imply that this technique could be the standard procedure for reconstruction of right lobe grafts with double PV orifices.