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Hunt C, Patel M, Bayona Molano MDP, Patel MS, VanWagner LB. Radiological and Surgical Treatments of Portal Hypertension. Clin Liver Dis 2024; 28:437-453. [PMID: 38945636 DOI: 10.1016/j.cld.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.
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Affiliation(s)
- Charlotte Hunt
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Mausam Patel
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Maria Del Pilar Bayona Molano
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Health Sciences Campus, Los Angeles, CA 90033, USA
| | - Madhukar S Patel
- Division of Organ Transplantation, Department of Surgery, UT Southwestern Medical Center, 5939 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Boulevard, Suite HP4.420M, Dallas, TX 75390-8887, USA.
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2
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Desai SV, Natarajan B, Khanna V, Brady P. Hepatic artery stenosis following adult liver transplantation: evaluation of different endovascular treatment approaches. CVIR Endovasc 2024; 7:39. [PMID: 38642226 PMCID: PMC11032299 DOI: 10.1186/s42155-024-00439-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/19/2024] [Indexed: 04/22/2024] Open
Abstract
PURPOSE To evaluate the efficacy and safety of hepatic artery interventions (HAI) versus extra-hepatic arterial interventions (EHAI) when managing clinically significant hepatic artery stenosis (HAS) after adult orthotopic liver transplantation. MATERIALS AND METHODS A single-center retrospective cohort analysis was conducted on liver transplant patients who underwent intervention for clinically significant HAS from September 2012 to September 2021. The HAI treatment arm included hepatic artery angioplasty and/or stent placement while the EHAI treatment arm comprised of non-hepatic visceral artery embolization. Primary outcomes included peri-procedural complications and 1-year liver-related deaths. Secondary outcomes included biliary ischemic events, longitudinal trends in liver enzymes and ultrasound parameters pre-and post-intervention. RESULTS The HAI arm included 21 procedures in 18 patients and the EHAI arm included 27 procedures in 22 patients. There were increased 1-year liver-related deaths (10% [2/21] vs 0% [0/27], p = 0.10) and complications (29% [6/21] vs 4% [1/27], p = 0.015) in the HAI group compared to the EHAI group. Both HAI and EHAI groups exhibited similar improvements in transaminitis including changes of ALT (-72 U/L vs -112.5 U/L, p = 0.60) and AST (-58 U/L vs -48 U/L, p = 0.56) at 1-month post-procedure. Both treatment arms demonstrated increases in post-procedural peak systolic velocity of the hepatic artery distal to the stenosis, while the HAI group also showed significant improvement in resistive indices following the intervention. CONCLUSION Direct hepatic artery interventions remain the definitive treatment for clinically significant hepatic artery stenosis; however, non-hepatic visceral artery embolization can be considered a safe alternative intervention in cases of unfavorable hepatic anatomy.
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Affiliation(s)
- Sagar V Desai
- Department of Interventional Radiology, Jefferson Einstein Hospital, Philadelphia, PA, USA.
| | | | - Vinit Khanna
- Department of Interventional Radiology, Jefferson Einstein Hospital, Philadelphia, PA, USA
| | - Paul Brady
- Department of Interventional Radiology, Jefferson Einstein Hospital, Philadelphia, PA, USA
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3
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Kirchner VA, Shankar S, Victor DW, Tanaka T, Goldaracena N, Troisi RI, Olthoff KM, Kim JM, Pomfret EA, Heaton N, Polak WG, Shukla A, Mohanka R, Balci D, Ghobrial M, Gupta S, Maluf D, Fung JJ, Eguchi S, Roberts J, Eghtesad B, Selzner M, Prasad R, Kasahara M, Egawa H, Lerut J, Broering D, Berenguer M, Cattral MS, Clavien PA, Chen CL, Shah SR, Zhu ZJ, Ascher N, Ikegami T, Bhangui P, Rammohan A, Emond JC, Rela M. Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2238-2246. [PMID: 37749813 DOI: 10.1097/tp.0000000000004771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.
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Affiliation(s)
- Varvara A Kirchner
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Sadhana Shankar
- The Liver Unit, King's College Hospital, London, United Kingdom
| | - David W Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Nicolas Goldaracena
- Abdominal Organ Transplant and Hepatobiliary Surgery, University of Virginia Health System, Charlottesville, VA
| | - Roberto I Troisi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Public Health, Federico II University Hospital, Naples, Italy
| | - Kim M Olthoff
- Department of Surgery, Division of Transplant Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Elizabeth A Pomfret
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nigel Heaton
- The Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Wojtek G Polak
- The Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Ravi Mohanka
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospital, Mumbai, Maharashtra, India
| | - Deniz Balci
- Department of General Surgery and Organ Transplantation Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Subash Gupta
- Max Centre for Liver and Biliary Sciences, Max Saket Hospital, New Delhi, India
| | - Daniel Maluf
- Program in Transplantation, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD
| | - John J Fung
- Department of Surgery, University of Chicago Medicine Transplant Institute, Chicago, IL
| | - Susumu Eguchi
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - John Roberts
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Bijan Eghtesad
- Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Markus Selzner
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Raj Prasad
- Division of Transplantation, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mureo Kasahara
- National Center for Child Health and Development, Tokyo, Japan
| | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Institute for Experimental and Clinical Research-Université catholique de Louvain, Brussels, Belgium
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Unit, CIBERehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe-Universidad de Valencia, Valencia, Spain
| | - Mark S Cattral
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Chao-Long Chen
- Liver Transplant Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Samir R Shah
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University; and Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Toru Ikegami
- Divsion of Hepatobiliary Surgery and Pancreas Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Jean C Emond
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
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Mendoza Quevedo MD, Vaca-Espinosa MC, Marín Zuluaga JI, Amell Baron BC, Sierra Vargas AK. Refractory Ascites After Liver Transplantation Treated With Splenic Artery Embolization: A Case Report and Literature Review. Cureus 2023; 15:e43910. [PMID: 37746399 PMCID: PMC10512432 DOI: 10.7759/cureus.43910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
After orthotopic liver transplantation, several complications can arise, such as arterial or venous thrombosis, stenosis, biliary leakage, ischemia, or ascites. Although refractory ascites are not a common complication, they can have a significant impact on patients' prognosis and quality of life. This condition can be caused by multiple mechanisms, both intrahepatic and extrahepatic, and one of them is the splenic artery steal syndrome. In this article, we present the case of a patient with advanced cirrhosis who developed refractory ascites following liver transplantation. Despite management with diuretics and paracentesis, the ascites did not respond to conventional treatment. The diagnosis of splenic artery steal syndrome was confirmed through angiography, and subsequent embolization of the splenic artery resulted in symptom resolution.
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D'Amico G, Partovi S, Del Prete L, Matsushima H, Diago-Uso T, Hashimoto K, Eghtesad B, Fujiki M, Aucejo F, Kwon CHD, Miller C, Gadani S, Quintini C. Proximal Splenic Artery Embolization for Refractory Ascites and Hydrothorax Post-Liver Transplant. Cardiovasc Intervent Radiol 2023; 46:470-479. [PMID: 36797427 DOI: 10.1007/s00270-023-03376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/27/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Proximal splenic artery embolization (pSAE) has been advocated as a valuable tool to ameliorate portal hyper-perfusion (PHP). The purpose of this study was to determine the safety and efficacy of pSAE to treat refractory ascites (RA) and/or refractory hydrothorax (RH) in the setting of PHP post-liver transplant. MATERIAL AND METHODS A total of 30 patients who underwent pSAE for RA and/or RH after liver transplantation (LT) between January 2007 and December 2017 were analyzed retrospectively. The patients were divided into groups according to the time frame from pSAE to clinical resolution in order to identify predictors of RA/RH response to the procedure. RESULTS Twenty-four (80%) patients responded to pSAE within three months, whereas 6 (20%) still required additional treatments for RA/RH at three months post-pSAE. In all cases clinical symptoms resolved within six months. Complications after pSAE were as follows: 2 cases of splenic infarction (6.6%), one case of post-splenic embolization syndrome (3.3%), one case of hepatic artery thrombosis (3.3%) and one case of portal vein (PV) thrombosis (3.3%). Increased intraoperative PV flow volume and increased pre-pSAE PV velocity, as well as higher estimated glomerular filtration rate were associated with early RA/RH resolution. CONCLUSION pSAE is safe and effective in treating RA and RH due to PHP after LT. This study suggests that clinical parameters indicating more severe PHP and better kidney function are possible predictors for early response to pSAE.
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Affiliation(s)
- Giuseppe D'Amico
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sasan Partovi
- Department of Interventional Radiology, Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Luca Del Prete
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Health Sciences, PhD School in Translational Medicine, University of Milan, 20142, Milan, Italy
| | - Hajime Matsushima
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Teresa Diago-Uso
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Federico Aucejo
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Choon Hyuck David Kwon
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Miller
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sameer Gadani
- Department of Interventional Radiology, Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Cristiano Quintini
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Fujiki M, Hashimoto K, Quintini C, Aucejo F, Kwon CHD, Matsushima H, Sasaki K, Campos L, Eghtesad B, Diago T, Iuppa G, D'amico G, Kumar S, Liu P, Miller C, Pinna A. Living Donor Liver Transplantation With Augmented Venous Outflow and Splenectomy: A Promised Land for Small Left Lobe Grafts. Ann Surg 2022; 276:838-845. [PMID: 35894443 DOI: 10.1097/sla.0000000000005630] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Living donor liver transplantation (LDLT) using small grafts, especially left lobe grafts (H1234-MHV) (LLG), continues to be a challenge due to small-for-size syndrome (SFSS). We herein demonstrate that with surgical modifications, outcomes with small grafts can be improved. METHODS Between 2012 and 2020, we performed 130 adult LDLT using 61 (47%) LLG (H1234-MHV) in a single Enterprise. The median graft-to-recipient weight ratio was 0.84%, with graft-to-recipient weight ratio <0.7% accounting for 22%. Splenectomy was performed in 72 (56%) patients for inflow modulation before (n=50) or after (n=22) graft reperfusion. In LLG-LDLT, venous outflow was achieved using all three recipient hepatic veins. In right lobe graft (H5678) (RLG)-LDLT, the augmented graft right hepatic vein was anastomosed to the recipient's cava with a large cavotomy. Outcome measures include SFSS, early allograft dysfunction (EAD), and survival. RESULTS Graft survival rates at 1, 3, and 5 years were 94%, 90%, and 83%, respectively, with no differences between LLG (H1234-MHV) and RLG (H5678). Splenectomy significantly reduced portal flow without increasing the complication rate. Despite the aggressive use of small grafts, SFSS and EAD developed in only 1 (0.8%) and 18 (13.8%) patients, respectively. Multivariable logistic regression revealed model for end-stage liver disease score and LLG (H1234-MHV) as independent risk factors for EAD and splenectomy as a protective factor (odds ratio: 0.09; P =0.03). For LLG (H1234-MHV)-LDLT, patients who underwent prereperfusion splenectomy tended to have better 1-year graft survival than those receiving postreperfusion splenectomy. CONCLUSIONS LLG (H1234-MHV) are feasible in adult LDLT with excellent outcomes comparable to RLG (H5678). Venous outflow augmentation and splenectomy help lower the threshold of using small-for-size grafts without compromising graft survival.
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Affiliation(s)
| | | | | | | | | | | | | | - Luis Campos
- Transplant Center, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - Teresa Diago
- Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Giuseppe Iuppa
- Transplant Center, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - Shiva Kumar
- Transplant Center, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Peter Liu
- Department of Radiology, Cleveland Clinic, Cleveland, OH
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Ebada HE, Montasser MF, Abdelghaffar MF, Bahaa MM, Elbaset HSA, Sakr MA, Dabbous HM, Montasser IF, Hassan MS, Aboelmaaty ME, Elmeteini MS. Ascites post-living donor liver transplantation: Risk factors and outcome. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100112] [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: 02/07/2023] Open
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8
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Ostojic A, Petrovic I, Silovski H, Kosuta I, Sremac M, Mrzljak A. Approach to persistent ascites after liver transplantation. World J Hepatol 2022; 14:1739-1746. [PMID: 36185723 PMCID: PMC9521448 DOI: 10.4254/wjh.v14.i9.1739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 02/06/2023] Open
Abstract
Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.
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Affiliation(s)
- Ana Ostojic
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Igor Petrovic
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Hrvoje Silovski
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Maja Sremac
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
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9
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Boike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, VanWagner LB. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol 2022; 20:1636-1662.e36. [PMID: 34274511 PMCID: PMC8760361 DOI: 10.1016/j.cgh.2021.07.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/01/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.
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Affiliation(s)
- Justin R. Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bartley G. Thornburg
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Michael B. Fallon
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Manhal J. Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth C. Verna
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| | - Andrew S. Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmohan S. Bajaj
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Scott W. Biggins
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Washington Medical Center, Seattle, WA, USA
| | - Michael D. Darcy
- Department of Radiology, Division of Interventional Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maryjane A. Farr
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Guadalupe Garcia-Tsao
- Department of Digestive Diseases, Yale University, Yale University School of Medicine, and VA-CT Healthcare System, CT, USA
| | - Shelley A. Hall
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Caroline C. Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Michael J. Krowka
- Department of Pulmonary and Critical Care Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeanne Laberge
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Edward W. Lee
- Department of Radiology, Division of Interventional Radiology, University of California-Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David C. Mulligan
- Department of Surgery, Division of Transplantation, Yale University School of Medicine, New Haven, CT, USA
| | - Mitra K. Nadim
- Department of Medicine, Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California, USA
| | - Patrick G. Northup
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Riad Salem
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Cathryn J. Shaw
- Department of Radiology, Division of Interventional Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Douglas A. Simonetto
- Department of Physiology, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Susman
- Department of Radiology, Division of Interventional Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - K. Pallav Kolli
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Address for correspondence: Lisa B. VanWagner MD MSc FAST FAHA, Assistant Professor of Medicine and Preventive Medicine, Divisions of Gastroenterology & Hepatology and Epidemiology, Northwestern University Feinberg School of Medicine, 676 N. St Clair St - Suite 1400, Chicago, Illinois 60611 USA, Phone: 312 695 1632, Fax: 312 695 0036,
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10
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Usefulness of partial splenic embolization for left-sided portal hypertension in a patient with a pancreatic neuroendocrine neoplasm: a case report and review of the literature. Clin J Gastroenterol 2022; 15:796-802. [PMID: 35430638 PMCID: PMC9334412 DOI: 10.1007/s12328-022-01631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/30/2022] [Indexed: 11/01/2022]
Abstract
AbstractLeft-side portal hypertension (LSPH) is caused by isolated obstruction of the splenic vein and is associated with esophagogastric varices that extend from the lower esophagus to the greater curvature of the gastric body. Here, we report on a 74-year-old man with a pancreatic neuroendocrine neoplasm (NEN) in the pancreatic tail with multiple liver metastases. We decided that partial splenic embolization (PSE) was the best course of treatment to prevent rupture of the gastric varices, which were classified as markedly enlarged, nodular, or tumor-shaped and showed erosion of the mucosa. After PSE, the patient had no major complications and was discharged. At 3 and 6 months after the procedure, esophagogastroduodenoscopy and enhanced computerized tomography showed that the gastric varices had improved. This case demonstrates the usefulness of PSE for LSPH in patients with unresected pancreatic NEN.
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González DV, López KPP, Nungaray SAV, Madrigal LGM. Tratamiento de ascitis refractaria: estrategias actuales y nuevo panorama de los beta bloqueadores no selectivos. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:715-723. [DOI: 10.1016/j.gastrohep.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 02/07/2023]
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Moon HH. Refractory Ascites with Intrahepatic Portal Thrombosis after Living Donor Liver Transplantation Successfully Treated by Splenic Artery Embolization and Apixaban (Case Report). KOSIN MEDICAL JOURNAL 2021. [DOI: 10.7180/kmj.2021.36.2.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Refractory ascites is a rare complication after liver transplantation, and its incidence ranges from 5% to 7%. A 56-yearold man diagnosed with HBV-LC with massive ascites underwent living donor liver transplantation. After transplantation, more than 1000 ml/day of ascites was steadily drained until two weeks after LT. CT showed intrahepatic Rt. portal vein thrombosis and many remnant collaterals with splenomegaly. We decided to embolize the proximal splenic artery and use apixaban to reduce portal flow and resolve the intrahepatic portal thrombosis. One day after splenic artery embolization, the patient's ascites dramatically decreased. Three days later, he was discharged from the hospital. Three months later, a follow-up liver CT showed resolution of thrombosis and no ascites. Splenic artery embolization was an effective and safe procedure for portal flow modulation in portal hyertension. Apixaban was effective for partial portal vein thrombosis in a liver transplant recipient.
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Caporali C, Turco L, Prampolini F, Quaretti P, Bianchini M, Saltini D, Miceli F, Casari F, Felaco D, Garcia‐Pagan JC, Trebicka J, Senzolo M, Guerrini GP, Di Benedetto F, Torricelli P, Villa E, Schepis F. Proximal Splenic Artery Embolization to Treat Refractory Ascites in a Patient With Cirrhosis. Hepatology 2021; 74:3534-3538. [PMID: 34218452 PMCID: PMC9292732 DOI: 10.1002/hep.32037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 12/21/2022]
Affiliation(s)
- Cristian Caporali
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Laura Turco
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Francesco Prampolini
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Pietro Quaretti
- Unit of Interventional Radiology ‐ Radiology DepartmentIRCCS Policlinico San Matteo FoundationPaviaItaly
| | - Marcello Bianchini
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Dario Saltini
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Francesca Miceli
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Federico Casari
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Davide Felaco
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Juan Carlos Garcia‐Pagan
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehdHealth Care Provider of the European Reference Network on Rare Liver Disorders (ERN‐Liver)BarcelonaSpain
| | - Jonel Trebicka
- Department of Internal Medicine IUniversity of FrankfurtFrankfurtGermany
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and GastroenterologyPadova University HospitalPadovaItaly
| | - Gian Piero Guerrini
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio EmiliaModenaItaly
| | - Fabrizio Di Benedetto
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio EmiliaModenaItaly
| | - Pietro Torricelli
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Erica Villa
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Filippo Schepis
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
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D'Amico G, Matsushima H, Del Prete L, Diago Uso T, Armanyous SR, Hashimoto K, Eghtesad B, Fujiki M, Aucejo F, Sasaki K, Kwon CHD, Simioni A, Miller C, Quintini C. Long term outcomes and complications of reno-portal anastomosis in liver transplantation: results from a propensity score-based outcome analysis. Transpl Int 2021; 34:1938-1947. [PMID: 34008257 DOI: 10.1111/tri.13920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/29/2021] [Accepted: 05/11/2021] [Indexed: 12/23/2022]
Abstract
Diffuse splanchnic vein thrombosis (DSVT) remains a serious challenge in liver transplantation (LT). Reno-portal anastomosis (RPA) has previously been reported as a valid option for management of patients with DSVT during LT. The aim of this study was to evaluate post-transplant renal function and surgical outcomes of patients with DSVT who underwent RPA during LT. Between January 2005 and December 2017, 1270 patients underwent LT at our institution, including 16 with DSVT managed with RPA (RPA group). We compared renal function and surgical outcomes in these patients to outcomes in 48 propensity score (PS)-matched patients without thrombosis (control group), using a 1:3 matching model. The two groups had similar rates of postoperative portal vein thrombosis (PVT), renal dysfunction as measured by estimated glomerular filtration rate (eGFR), and overall postoperative complications (Clavien grade III), although the RPA group had a higher incidence of postoperative upper gastrointestinal (GI) bleeding (31.3% vs 4.2%; P = 0.009) that had no clinical consequence. There were no significant differences in five-year graft and patient survival rates between the groups (P = 0.133 and P = 0.166, respectively). RPA is an established technique in the management of patients with DSVT during LT, with comparable outcomes to patients without thrombosis. Our report is the first to demonstrate similar surgical outcomes, including long-term renal function, in LT recipients with or without RPA.
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Affiliation(s)
| | | | - Luca Del Prete
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Federico Aucejo
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Kazunari Sasaki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Andrea Simioni
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
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15
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Jenkins M, Satoskar R. Ascites After Liver Transplantation. Clin Liver Dis (Hoboken) 2021; 17:317-319. [PMID: 33968396 PMCID: PMC8087930 DOI: 10.1002/cld.1050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michelle Jenkins
- Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
| | - Rohit Satoskar
- Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
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Matsushima H, Fujiki M, Sasaki K, Cywinski JB, D’Amico G, Uso TD, Aucejo F, David Kwon CH, Eghtesad B, Miller C, Quintini C, Hashimoto K. Can pretransplant TIPS be harmful in liver transplantation? A propensity score matching analysis. Surgery 2020; 168:33-39. [DOI: 10.1016/j.surg.2020.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/10/2020] [Accepted: 02/18/2020] [Indexed: 12/31/2022]
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17
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Kim CY, Pinchot JW, Ahmed O, Braun AR, Cash BD, Feig BW, Kalva SP, Knavel Koepsel EM, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Hohenwalter EJ. ACR Appropriateness Criteria® Radiologic Management of Gastric Varices. J Am Coll Radiol 2020; 17:S239-S254. [PMID: 32370968 DOI: 10.1016/j.jacr.2020.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/13/2022]
Abstract
Hemorrhage, resulting from gastric varies, can be challenging to treat, given the various precipitating etiologies. A wide variety of treatment options exist for managing the diverse range of the underlying disease processes. While cirrhosis is the most common cause for gastric variceal bleeding, occlusion of the portal or splenic vein in noncirrhotic states results in a markedly different treatment paradigm. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Charles Y Kim
- Duke University Medical Center, Durham, North Carolina.
| | | | | | - Aaron R Braun
- St Elizabeth Regional Medical Center, Lincoln, Nebraska
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | | | | | - Kristofer Schramm
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | | | | | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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Too Much, Too Little, or Just Right? The Importance of Allograft Portal Flow in Deceased Donor Liver Transplantation. Transplantation 2020; 104:770-778. [DOI: 10.1097/tp.0000000000002968] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Bezjak M, Kocman B, Jadrijević S, Gašparović H, Mrzljak A, Kanižaj TF, Vujanić D, Bubalo T, Mikulić D. Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case report. World J Clin Cases 2019; 7:3266-3270. [PMID: 31667177 PMCID: PMC6819289 DOI: 10.12998/wjcc.v7.i20.3266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/23/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Refractory ascites is a rare complication following orthotopic liver transplantation (OLT). The broad spectrum of differential diagnosis often leads to delay in diagnosis. Therapy depends on recognition and treatment of the underlying cause. Constrictive pericarditis is a condition characterized by clinical signs of right-sided heart failure. In the advanced stages of the disease, hepatic congestion leads to formation of ascites. In patients after OLT, cardiac etiology of ascites is easily overlooked and it requires a high degree of clinical suspicion.
CASE SUMMARY We report a case of a 55-year-old man who presented with a refractory ascites three months after liver transplantation for alcoholic cirrhosis. Prior to transplantation the patient had a minimal amount of ascites. The transplant procedure and the early postoperative course were uneventful. Standard post-transplant work up failed to reveal any typical cause of refractory post-transplant ascites. The function of the graft was good. Apart from atrial fibrillation, cardiac status was normal. Eighteen months post transplantation the patient developed dyspnea and severe fatigue with peripheral edema. Ascites was still prominent. The presenting signs of right-sided heart failure were highly suggestive of cardiac etiology. Diagnostic paracentesis was suggestive of cardiac ascites, and further cardiac evaluation showed typical signs of constrictive pericarditis. Pericardiectomy was performed followed by complete resolution of ascites. On the follow-up the patient remained symptom-free with no signs of recurrent ascites and with normal function of the liver graft.
CONCLUSION Refractory ascites following liver transplantation is a rare complication with many possible causes. Broad differential diagnosis needs to be considered.
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Affiliation(s)
- Miran Bezjak
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Branislav Kocman
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Stipislav Jadrijević
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Hrvoje Gašparović
- Division of Cardiology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
| | - Tajana Filipec Kanižaj
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
| | - Darko Vujanić
- Division of Cardiology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
| | - Tomislav Bubalo
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Danko Mikulić
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
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Bezjak M, Kocman B, Jadrijević S, Gašparović H, Mrzljak A, Kanižaj TF, Vujanić D, Bubalo T, Mikulić D. Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case report. World J Clin Cases 2019. [DOI: 10.12998/wjcc.v7.i20.3267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Nutu OA, Justo Alonso I, Marcacuzco Quinto AA, Calvo Pulido J, Jiménez Romero LC. Complete splenic embolization for the treatment of refractory ascites after liver transplantation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:257-259. [PMID: 29411988 DOI: 10.17235/reed.2018.5338/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Refractory ascites is an uncommon complication that may develop postoperatively after liver transplantation. The diagnosis and treatment of this condition is a real challenge. We report two cases of patients who underwent a transplant due to cryptogenic cirrhosis and developed refractory ascites during the immediate postoperative period. This is a serious complication associated with decreased survival by up to one year and a reduced quality of life. After ruling out the main causes of ascites, a portal hyperflow was a potential etiology. This condition perpetuates itself with splenic circulation and brings about a reduction in the hepatic arterial flow. Therefore, if arterial blood flow to the spleen is diminished, venous return and portal circulation will be reduced and arterial blood flow will improve. Splenic artery embolization is a procedure introduced many years ago for the management of splenic artery steal syndrome and small-for-size living donor liver transplantation. This procedure is performed in order to reduce portal hyperflow and consequently, ascites. In conclusion, splenic artery embolization is a therapeutic option for the treatment of refractory ascites after liver transplantation.
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Affiliation(s)
- Oana Anisa Nutu
- Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario 12 de Octubre, ESPAÑA
| | - Iago Justo Alonso
- Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario 12 de Octubre, ESPAÑA
| | | | - Jorge Calvo Pulido
- Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario 12 de Octubre, ESPAÑA
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Host Immunological Effects of Partial Splenic Embolization in Patients with Liver Cirrhosis. J Immunol Res 2018; 2018:1746391. [PMID: 30116748 PMCID: PMC6079527 DOI: 10.1155/2018/1746391] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 04/24/2018] [Accepted: 05/09/2018] [Indexed: 01/20/2023] Open
Abstract
Purpose Restoration of the balance between T lymphocyte subsets and between Th1/Th2 cytokines together with improvement of antitumor immunity has been reported after hepatosplenectomy in patients with liver cirrhosis (LC) and hepatocellular carcinoma (HCC). However, the detailed effects of partial splenic embolization (PSE) on host immunity are unknown. Accordingly, this study evaluated host immunity in patients with cirrhosis receiving PSE for thrombocytopenia. Methods Twenty-three adult Japanese patients with cirrhosis and thrombocytopenia underwent PSE using straight coils at our hospital between 2010 and 2015. Blood samples were collected before PSE and 4 weeks after PSE. Results The platelet counts were significantly higher 4 weeks after PSE compared with before PSE. The white blood cell count (neutrophils, lymphocytes, and monocytes) also increased significantly after PSE. Furthermore, Th1 cells and Th2 cells showed a significant increase at 4 weeks after PSE compared with before PSE, although there was no significant change of Treg cells. Moreover, serum levels of TNF-alpha, soluble TNF receptor I, and soluble Fas were significantly increased after PSE. There was no significant change of the Child-Pugh score. Conclusions In patients with cirrhosis and thrombocytopenia, PSE not only promoted the recovery of leukopenia and thrombocytopenia but also induced activation of host immunity.
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23
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Probability, management, and long-term outcomes of biliary complications after hepatic artery thrombosis in liver transplant recipients. Surgery 2017; 162:1101-1111. [DOI: 10.1016/j.surg.2017.07.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 06/22/2017] [Accepted: 07/05/2017] [Indexed: 12/13/2022]
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Baba Y, Hayashi S, Nagasato K, Higashi M, Yoshiura T. Preliminary experimental study on splenic hemodynamics of radiofrequency ablation for the spleen. MINIM INVASIV THER 2017; 26:193-199. [PMID: 28145148 DOI: 10.1080/13645706.2017.1281315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To test the splenic blood flow change after radiofrequency ablation (RFA) of the spleen in a porcine experimental model. MATERIAL AND METHODS Six pigs underwent RFA of the spleen via laparotomy. During the procedure of RFA, clamping of splenic artery (one) and both splenic artery/vein (one) was also performed. Measurement of blood flow of both splenic artery (SA) and splenic vein (SV) with flow-wire at pre- and post-RFA of the spleen was also performed. RESULTS Ablated splenic lesions were created as estimating ∼50% area of the spleen in all pigs. Resected specimens reveal not only the coagulated necrosis but also the congestion of the spleen. On the SA hemodynamics, maximum peak velocity (MPV) changed from 37 ± 7 to 24 ± 8 cm/s (normal), 11 to 10 cm/s (clamp of the SA), and 12 to 7.5 cm/s (clamp of both SA/SV), respectively. On the SV hemodynamic, MPV changed from 15 ± 5 to 13 ± 4 cm/s (normal), 17 to 15 cm/s (clamp of the SA), and 17 to 26 cm/s (clamp of both SA/SV), respectively. CONCLUSIONS RFA of the spleen could induce coagulation necrosis and reduce the splenic arterial blood flow.
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Affiliation(s)
- Yasutaka Baba
- a Department of Radiology , Kagoshima University , Kagoshima , Japan.,c Department of Diagnostic Radiology , Hiroshima University , Hiroshima , Japan
| | - Sadao Hayashi
- a Department of Radiology , Kagoshima University , Kagoshima , Japan
| | - Kohei Nagasato
- a Department of Radiology , Kagoshima University , Kagoshima , Japan
| | - Michiyo Higashi
- b Department of Human Pathology , Kagoshima University , Kagoshima , Japan
| | - Takashi Yoshiura
- a Department of Radiology , Kagoshima University , Kagoshima , Japan
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Evidence-based clinical practice guidelines for liver cirrhosis 2015. J Gastroenterol 2016; 51:629-50. [PMID: 27246107 DOI: 10.1007/s00535-016-1216-y] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 04/12/2016] [Indexed: 02/04/2023]
Abstract
The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.
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Pravisani R, Baccarani U, Adani G, Lorenzin D, Vit A, Cherchi V, Calandra S, Rispoli I, Toniutto P, Sponza M, Risaliti A. Splenic Artery Syndrome as a Possible Cause of Late Onset Refractory Ascites After Liver Transplantation: Management With Proximal Splenic Artery Embolization. Transplant Proc 2016; 48:377-9. [PMID: 27109959 DOI: 10.1016/j.transproceed.2016.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/03/2016] [Accepted: 01/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal hyperperfusion (PHP) is a hemodynamic condition which may develop after liver transplantation and cause refractory ascites (RA). The diagnosis is established by exclusion of other causes of increased sinusoidal pressure/resistance such as cellular rejection or toxicity and outflow obstruction. PHP as part of the pathogenesis of the splenic artery syndrome (SAS) can be treated with splenic artery embolization (SAE). METHODS This is a retrospective study on a cohort of first-time whole-size liver transplant recipients diagnosed with RA due to PHP and treated by proximal SAE (pSAE) at the Liver Transplant Unit of the University Hospital of Udine between 2004 and 2014. RESULTS For this study, 23 patients were identified (prevalence 8%) and treated. Preliminary clinical workup to diagnose SAS was based on exclusion of other possible causes of RA with graft biopsy, cavogram with hepatic venous pressure measurement, computed tomography scan, and angiography. The pSAE was performed 110 ± 61 days after transplantation, and no procedure-related complications occurred. pSAE resulted in a significant decrease of portal vein velocity (P = .01) and wedge hepatic venous pressure (P = .03). The diameter of the spleen showed a slightly significant reduction (P = .047); no modification of hepatic artery resistive index were encountered (P = .34). Moreover, pSAE determined the resolution of RA in all cases. CONCLUSIONS pSAE is a safe and effective procedure to modulate the hepatic inflow and thus to treat RA secondary to SAS, with a low incidence of complications and a high rate of clinical response.
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Affiliation(s)
- R Pravisani
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - U Baccarani
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
| | - G Adani
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - D Lorenzin
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - A Vit
- Division of Interventional Radiology, University Hospital of Udine, Udine, Italy
| | - V Cherchi
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - S Calandra
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - I Rispoli
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - P Toniutto
- Department of Medicine and Pathology Clinical and Experimental, Medical Liver Transplantation Unit, Internal Medicine, University of Udine, Udine, Italy
| | - M Sponza
- Division of Interventional Radiology, University Hospital of Udine, Udine, Italy
| | - A Risaliti
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
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27
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Splenic Artery Embolization for Treatment of Refractory Ascites After Liver Transplantation. ACG Case Rep J 2016; 3:136-8. [PMID: 26958571 PMCID: PMC4748207 DOI: 10.14309/crj.2016.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 11/03/2015] [Indexed: 12/11/2022] Open
Abstract
Post-transplantation refractory ascites is uncommon; however, it can be a serious problem, increasing both morbidity and mortality in patients. Despite scant literature available, splenic artery embolization (SAE) has been shown to be an effective treatment for refractory ascites after cadaveric orthotopic liver transplantation (OLT). We report a successful use of therapeutic SAE for refractory ascites post-OLT.
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28
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Endovascular Management of Refractory Hepatic Encephalopathy Complication of Transjugular Intrahepatic Portosystemic Shunt (TIPS): Comprehensive Review and Clinical Practice Algorithm. Cardiovasc Intervent Radiol 2015; 39:170-82. [PMID: 26285910 DOI: 10.1007/s00270-015-1197-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/23/2015] [Indexed: 12/17/2022]
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29
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Novelli PM, Shields J, Krishnamurthy V, Cho K. Two Unusual but Treatable Causes of Refractory Ascites After Liver Transplantation. Cardiovasc Intervent Radiol 2015; 38:1663-9. [PMID: 26017456 DOI: 10.1007/s00270-015-1120-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
Refractory ascites (RA) is thought to complicate the postoperative course of 5-7% (Nishida et al. in Am J Transplant. 6: 140-149, 2006; Gotthardt et al. in Ann Transplant. 18: 378-383, 2013) of liver transplant recipients. RA after liver transplantation is often a frustrating diagnostic dilemma with few good management options unless an obvious mechanical factor is identified. Supportive therapies often fail until a treatable precipitating cause is identified and removed. We describe two patients who developed RA following liver transplantation for primary sclerosing cholangitis, and hepatitis C and alcoholic liver disease, respectively. The cause for RA was hyperkinetic portal hypertension secondary to splenomegaly in the first case and a pancreatic AVM in the 2nd case. After failure of other interventions, surgical splenectomy resulted in immediate and durable resolution of the previously intractable ascites.
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Affiliation(s)
- P M Novelli
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - J Shields
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - V Krishnamurthy
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - K Cho
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
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30
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Chen B, Wang W, Tam MD, Quintini C, Fung JJ, Li X. Transjugular intrahepatic portosystemic shunt in liver transplant recipients: indications, feasibility, and outcomes. Hepatol Int 2015; 9:391-8. [DOI: 10.1007/s12072-015-9632-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/06/2015] [Indexed: 12/11/2022]
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31
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Roll GR, Muiesan P. The safety and efficacy of proximal splenic artery embolization after liver transplantation are still not clearly defined. Liver Transpl 2015; 21:417-8. [PMID: 25690513 DOI: 10.1002/lt.24093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/24/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Garrett R Roll
- Liver Unit, Liver Transplantation and Hepato-Pancreato-Biliary Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
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32
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Presser N, Quintini C, Tom C, Wang W, Liu Q, Diago-Uso T, Fujiki M, Winans C, Kelly D, Aucejo F, Hashimoto K, Eghtesad B, Miller C. Safety and efficacy of splenic artery embolization for portal hyperperfusion in liver transplant recipients: a 5-year experience. Liver Transpl 2015; 21:435-41. [PMID: 25604488 DOI: 10.1002/lt.24081] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 10/26/2014] [Accepted: 12/04/2014] [Indexed: 02/07/2023]
Abstract
Severe portal hyperperfusion (PHP) after liver transplantation has been shown to cause intrahepatic arterial vasoconstriction secondary to increased adenosine washout (hepatic artery buffer response). Clinically, posttransplant PHP can cause severe cases of refractory ascites and hydrothorax. In the past, we reported our preliminary experience with the use of splenic artery embolization (SAE) as a way to reduce PHP. Here we present our 5-year experience with SAE in orthotopic liver transplantation (OLT). Between January 2007 and December 2011, 681 patients underwent OLT at our institution, and 54 of these patients underwent SAE for increased hepatic arterial resistance and PHP (n=42) or refractory ascites/hepatic hydrothorax (n=12). Patients undergoing SAE were compared to a control group matched by year of embolization, calculated Model for End-Stage Liver Disease score, and liver weight. SAE resulted in improvements in hepatic artery resistive indices (0.92±0.14 and 0.76±0.10 before and after SAE, respectively; P<0.001) and improved hepatic arterial blood flow (HAF; 15.6±9.69 and 28.7±14.83, respectively; P<0.001). Calculated splenic volumes and spleen/liver volume ratios were correlated with patients requiring SAE versus matched controls (P=0.002 and P=0.001, respectively). Among the 54 patients undergoing SAE, there was 1 case of postsplenectomy syndrome. No abscesses, significant infections, or bleeding was noted. We thus conclude that SAE is a safe and effective technique able to improve HAF parameters in patients with elevated portal venous flow and its sequelae.
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Affiliation(s)
- Naftali Presser
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH
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33
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Quintini C, Spaggiari M, Hashimoto K, Aucejo F, Diago T, Fujiki M, Winans C, D'Amico G, Trenti L, Kelly D, Eghtesad B, Miller C. Safety and effectiveness of renoportal bypass in patients with complete portal vein thrombosis: an analysis of 10 patients. Liver Transpl 2015; 21:344-52. [PMID: 25420619 DOI: 10.1002/lt.24053] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 11/08/2014] [Indexed: 02/07/2023]
Abstract
The presence of portal vein thrombosis (PVT) is still considered by many transplantation centers to be an absolute contraindication to liver transplantation because of the technical difficulties that it can present and its association with a higher rate of patient morbidity and mortality. Renoportal bypass (RPB) can help to remove these barriers. This study describes our institution's experience with RPB through the description of a new and successful simplified surgical strategy, a patient and graft outcome analysis, intraoperative vascular flow measurements, and the use of splenic artery embolization (SAE) as an effective adjunct for treating sporadic cases of unrelieved portal hypertension. Between January 2004 and January 2013, 10 patients with grade 4 PVT underwent RPB. At the last follow-up (42.2 ± 21.1 months), the patient and graft survival rates were 100%. Five patients (50%) experienced posttransplant ascites, and 2 of those underwent proximal SAE to modulate the liver inflow and overcome the ascites. Three patients (30%) experienced transient kidney injury in the early posttransplant period and were treated efficiently with medical therapy. The renoportal flows were close to the desirable 100 mL/100 g of liver tissue in all cases. The experience and data support RPB as a feasible and easily reproducible technique without the risks and technical challenges associated with the tedious dissection of a cavernous hilum.
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Affiliation(s)
- Cristiano Quintini
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, OH
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34
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Hadduck TA, McWilliams JP. Partial splenic artery embolization in cirrhotic patients. World J Radiol 2014; 6:160-168. [PMID: 24876920 PMCID: PMC4037542 DOI: 10.4329/wjr.v6.i5.160] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/09/2014] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
Splenomegaly is a common sequela of cirrhosis, and is frequently associated with decreased hematologic indices including thrombocytopenia and leukopenia. Partial splenic artery embolization (PSE) has been demonstrated to effectively increase hematologic indices in cirrhotic patients with splenomegaly. This is particularly valuable amongst those cirrhotic patients who are not viable candidates for splenectomy. Although PSE was originally developed decades ago, it has recently received increased attention. Presently, PSE is being utilized to address a number of clinical concerns in the setting of cirrhosis, including: decreased hematologic indices, portal hypertension and its associated sequela, and splenic artery steal syndrome. Following PSE patients demonstrate significant increases in platelets and leukocytes. Though progressive decline of hematologic indices occur following PSE, they remain improved as compared to pre-procedural values over long-term follow-up. PSE, however, is not without risk and complications of the procedure may occur. The most common complication of PSE is post-embolization syndrome, which involves a constellation of symptoms including fever, pain, and nausea/vomiting. The rate of complications has been shown to increase as the percent of total splenic volume embolized increases. The purpose of this review is to explore the current literature in regards to PSE in cirrhotic patients and to highlight their techniques, and statistically summarize their results and associated complications.
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35
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Xiao L, Li F, Wei B, Li B, Tang CW. Small-for-size syndrome after living donor liver transplantation: successful treatment with a transjugular intrahepatic portosystemic shunt. Liver Transpl 2012; 18:1118-20. [PMID: 22511462 DOI: 10.1002/lt.23457] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Small-for-size syndrome (SFSS) is a serious complication after living donor liver transplantation (LDLT) that can disrupt liver regeneration and result in hepatic dysfunction. Until now, the treatment options for SFSS after LDLT have been very limited. Here we describe a patient with SFSS after LDLT who was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 56-year-old man who had undergone adult-to-adult LDLT because of decompensated liver cirrhosis started displaying signs of acute jaundice and ascites within 72 hours of the operation. The patient was diagnosed with SFSS, and because he had already undergone splenectomy before the transplant, partial splenic embolization was not feasible. Consequently, the TIPS procedure was chosen in an attempt to reduce portal hyperperfusion. After the procedure, the patient's symptoms were gradually ameliorated and were eventually resolved. In conclusion, when partial splenic embolization is not feasible, TIPS placement may be a feasible option for the treatment of SFSS after LDLT.
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Affiliation(s)
- Li Xiao
- Department of Gastroenterology, West China Hospital, Chengdu, China
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