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Gundlach JP, Günther R, Both M, Trentmann J, Schäfer JP, Cremer JT, Röcken C, Becker T, Braun F, Bernsmeier A. Inferior Vena Cava Constriction After Liver Transplantation Is a Severe Complication Requiring Individually Adapted Treatment: Report of a Single-Center Experience. Ann Transplant 2020; 25:e925194. [PMID: 32747619 PMCID: PMC7427346 DOI: 10.12659/aot.925194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Reports on vena cava occlusion after liver transplantation (LT) are rare, but this finding represents a severe complication in the early postoperative period. In the context of the complex presentation of a patient after LT, symptoms are often misinterpreted and can be subtle. Material/Methods In our cohort of 138 LTs performed between 2014 and 2017 at our University’s Transplantation Department, 117 transplantations were valid for further analysis after exclusion of pediatric transplantations and transplants with primary non-function grafts. In 101 cases (73%), patients received a deceased-donor full-size organ. Living-donor LT was performed in 8 patients (6.4%) and 8 patients (6.4%) received a split graft. We report on 6 patients who had inferior vena cava (IVC) occlusion and summarize the treatment choices. Results In our series, patients with positive findings (age 38–70 years) received an orthotopic full-size deceased-donor graft with end-to-end IVC anastomosis. In the subsequent period, imaging revealing IVC occlusion was done on a follow-up basis (n=2), due to dyspnea (n=1), and for progressive ascites (n=2). In 3 cases, a thrombus was found. We give detailed information on our treatment options from interventional treatment to transcardial thrombus removal and anastomosis augmentation. Conclusions IVC constriction and subsequent thrombosis are severe complications after LT that require individually adapted treatment in specialized centers. Since patients often present with subclinical symptoms, vascular diagnosis should be performed early to detect caval anastomosis pathologies. Despite regular ultrasonography, we favor CT and cavography for subsequent quantification. We also review the literature on IVC occlusion after LT.
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Affiliation(s)
- Jan-Paul Gundlach
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Rainer Günther
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Marcus Both
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jens Trentmann
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jost Philipp Schäfer
- Institute of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Jochen T Cremer
- Department of Cardiovascular Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Christoph Röcken
- Department of Pathology, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Thomas Becker
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Alexander Bernsmeier
- Department of General, Visceral, Thoracic, Transplantation, and Pediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
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Latchana N, Dowell JD, Al Taani J, Michaels A, Elkhammas E, Black SM. Ultrasound-accelerated, catheter-directed thrombolysis for inferior vena cava thrombosis after an orthotopic liver transplant. EXP CLIN TRANSPLANT 2014; 13:96-9. [PMID: 24918871 DOI: 10.6002/ect.2013.0195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Inferior vena cava thrombosis is a rare occurrence after an orthotopic liver transplant that is associated with a high rate of retransplant and mortality. There is no consensus regarding the optimal therapeutic strategy. Surgical management, including thrombectomy with revision of the cavocaval anastomosis, has been described. With the use of endovascular therapies, several minimally invasive approaches are available that are effective and avoid the high morbidity associated with reoperative surgery. We describe our successful experience using an approach after a liver transplant in which the inferior vena cava thrombosis in a patient presenting with acute renal failure, anorexia, weight loss, and fatigue using an ultrasound-accelerated, catheter-directed thrombolysis platform in conjunction with systemic anticoagulation.
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Affiliation(s)
- Nicholas Latchana
- From the Department of Surgery, Division of Transplantation, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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McAree BJ, O'Donnell ME, Fitzmaurice GJ, Reid JA, Spence RAJ, Lee B. Inferior vena cava thrombosis: a review of current practice. Vasc Med 2013; 18:32-43. [PMID: 23439778 DOI: 10.1177/1358863x12471967] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Inferior vena cava (IVC) thrombosis remains under-recognised as it is often not pursued as a primary diagnosis. The aetiology of IVC thrombosis can be divided into congenital versus acquired, with all aetiological factors found among Virchow's triad of stasis, injury and hypercoagulability. Signs and symptoms are related to aetiology and range from no symptoms to cardiovascular collapse. Painful lower limb swelling combined with lower back pain, pyrexia, dilatation of cutaneous abdominal wall veins and a concurrent rise in inflammatory markers are suggestive of IVC thrombosis. Following initial lower limb venous duplex, magnetic resonance imaging (MRI) is the optimal non-invasive imaging tool. Aetiology directs treatment, which ranges from anticoagulation and lower limb compression to open surgery, with endovascular therapies increasingly favoured. The objective of this review is to assess current literature on the aetiology, presentation, investigation, treatment, prognosis and other factors pertaining to IVC thrombosis.
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Affiliation(s)
- B J McAree
- Department of Vascular and Endovascular Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
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Gunasekaran G, Bencsath K, Hupertz V, Fung JJ, Pettersson G, Miller C. Deep hypothermia with circulatory arrest to aid in the management of suprahepatic vena cava stenosis after liver transplantation. Liver Transpl 2010; 16:1434-6. [PMID: 21117254 DOI: 10.1002/lt.22183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Liver transplantation is the treatment of choice for many liver diseases in the pediatric population. Complications involving late suprahepatic vena cava obstructions after liver transplantation are not common, but they tend to be more frequently seen in pediatric recipients. When such complications have occurred, approaches involving direct abdominal surgery or interventional radiology guidance have been used with satisfactory results. We present a case report of an alternative approach to a suprahepatic vena cava complication. An 18-year-old man who underwent pediatric liver transplantation for biliary atresia presented with a symptomatic total occlusion of the suprahepatic caval anastomosis that could not be crossed with a wire. We used a right atrial approach and hypothermic circulatory (cardiac) arrest. The anastomotic stricture was easily identified and excised. The postoperative course was uneventful with a rapid resolution of the symptoms. Because the occlusion was not amenable to angioplasty or stenting, a direct surgical approach was necessary. The right atrial approach with hypothermic cardiac arrest gave us direct access to the obliterated cavoatrial anastomosis through a virgin area and allowed us to avoid the difficulties and dangers of the large collaterals in the abdomen.
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Affiliation(s)
- Ganesh Gunasekaran
- Hepato-Pancreato-Biliary and Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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