Percutaneous transluminal venoplasty after venous pressure measurement in patients with hepatic venous outflow obstruction after living donor liver transplantation

4D Flow MRI in the portal venous system: imaging and analysis methods, and clinical applications

Thus far, ultrasound, CT, and 2D cine phase-contrast MRI has been adopted to evaluate blood flow and vascular morphology in the portal venous system; however, all these techniques have some shortcomings, such as limited field of view and difficulty in accurately evaluating blood flow. A new imaging technique, namely 3D cine phase-contrast (4D Flow) MRI, can acquire blood flow data of the entire abdomen at once and in a time-resolved manner, allowing visual, quantitative, and comprehensive assessment of blood flow in the portal venous system. In addition, a retrospective blood flow analysis, i.e., "retrospective flowmetry," is possible. Although the development of 4D Flow MRI for the portal system has been delayed compared to that for the arterial system owing to the lower flow velocity of the portal venous system and the presence of respiratory artifacts, several useful reports have recently been published as the technology has advanced. In the first part of this narrative review article, technical considerations of image acquisition and analysis methods of 4D Flow MRI for the portal venous system and the validations of their results are described. In the second part, the current clinical application of 4D Flow MRI for the portal venous system is reviewed.

Surgical Outcomes of Domino Liver Transplantation Using Grafts From Living Donors With Familial Amyloid Polyneuropathy

Domino liver transplantation (DLT) using grafts from donors with familial amyloid polyneuropathy is an acceptable procedure for expanding the donor pool. The vascular and biliary reconstructions in living donor DLT (LDDLT) are technically demanding, and data on the short-term and long-term surgical outcomes of domino donors and recipients in LDDLT are limited. In this study, we identified 25 domino recipients from our liver transplantation program (1999-2018), analyzed the vascular and biliary reconstructions performed, and evaluated the surgical outcomes, including graft survival. Piggyback technique was adopted in all 25 domino donors. The only surgical complication in domino donors was hepatic vein (HV) stenosis with an incidence rate of 4%. In 22 domino recipients, right HV and middle/left HV were reconstructed separately. A total of 10 recipients had 2 arteries anastomosed, and 18 underwent duct-to-duct biliary anastomosis. HV stenosis and biliary stricture had incidence rates of 8% and 24%, respectively, in the recipients, but none of them developed hepatic artery thrombosis. The 1-year and 5-year graft survival rates were 100% each in the domino donors, and 84.0% and 67.3% in the domino recipients, respectively. In conclusion, LDDLT has acceptable outcomes without increasing the operative risk in donors despite the demanding surgical technique involved.

Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplant: Single Center Experience

OBJECTIVES

In this study, we share our approach for care of patients with hepatic venous outlet obstruction after living-donor liver transplant.

MATERIALS AND METHODS

We retrospectively examined the demographic, clinical, and radiologic data of 35 patients who developed hepatic venous outlet obstruction after living-donor liver transplant. Patients were subgrouped on the basis of onset (8 patients with early onset [< 30 days posttransplant] and 27 patients with late onset [≥ 30 days posttransplant]) and postoperative survival (24 survivors, 11 nonsurvivors).

RESULTS

Patients ranged in age from 1 to 61 years (24 adults and 11 children). All adult patients had undergone right lobe living-donor liver transplant. In the pediatric group, 8 had undergone left lateral segment and 3 had undergone left lobe living-donor liver transplant. Nineteen adult patients and all 11 pediatric patients underwent hepatic venous reconstruction, with all procedures based on common large-opening drainage models using various vascular graft materials. Development of hepatic venous outlet obstruction occurred at mean posttransplant day 233 ± 298.5 in the adult patients and mean posttransplant day 139 ± 97.8 in the pediatric patients. After development of obstruction, the patients underwent 1-6 sessions (1.5 ± 1.1 sessions) of balloon angioplasty. After the first balloon angioplasty procedure, 25% of the adults and 36.3% of the pediatric patients developed recurrence. The early-onset and late-onset subgroups showed statistically significant differences in serum albumin (P = .01), underlying causes (P < .001), time from transplant to obstruction (P = .02), and time from transplant to last visit (P = .02). The survivor and nonsurvivor subgroups showed statistically significant differences in total bilirubin (P = .03) and time from transplant to last visit (P = .03).

CONCLUSIONS

Common large-opening reconstruction minimizes hepatic venous outlet obstruction development after living-donor liver transplant. Balloon angioplasty and/or stenting is almost always the first option in the care of this complication.

Efficacy of repeated balloon venoplasty for treatment of hepatic venous outflow obstruction after pediatric living-donor liver transplantation: A single-institution experience

HVOO is a rare complication after LT and an important cause of graft failure. Balloon venoplasty is the first-line treatment for HVOO, but the effect of repeated balloon venoplasty and stent placement for HVOO recurrence after pediatric LDLT remains unclear. Between 1998 and 2016, 147 pediatric patients underwent LDLT in our institution. Among them, the incidence of HVOO and the therapeutic strategy were retrospectively reviewed. Ten patients were diagnosed with HVOO. All the patients underwent LLS grafts. Median age at the initial endovascular intervention was 2.7 years (range, 5 months-8 years). The median interval between the LDLT and the initial interventional radiology was 2.7 months (range, 29 days-35.7 months). Four patients experienced no recurrence after a single balloon venoplasty; 6 underwent balloon venoplasty more than 3 times because of HVOO recurrence; and 2 underwent stent placement due to the failure of repeated balloon venoplasty. All patients are alive with no symptoms of HVOO. The HVOO recurrence-free period after the last intervention ranged from 20 days to 15.5 years (median, 8.9 years). Repeated balloon venoplasty may prevent unnecessary stent placement to treat recurrent HVOO after pediatric LDLT.

Novel use of percutaneous thrombosuction to rescue the early thrombosis of the conduit vein graft after living donor liver transplantation

A 54-year-old woman with liver cirrhosis and hepatocellular carcinoma received a living donor liver transplant. Thrombosis of the segmental hepatic vein occurred on postoperative day 7. We undertook percutaneous catheter thrombosuction under local anesthesia to extract the thrombus successfully without re-exploration. Thrombosuction has been used for thrombosis of the cardiovascular system, limbs, and brain. We first used it in hepatic venous thrombus after liver transplantation. This procedure is simple, less invasive, feasible, safe, repeatable, and effective.

Left lobe graft poses a potential risk of hepatic venous outflow obstruction in adult living donor liver transplantation

Hepatic venous outflow obstruction (HVOO) is a critical complication after living donor liver transplantation (LDLT). This study aimed to evaluate the incidence of HVOO and the risk factors for HVOO in adults. From 2005 to 2015, 430 adult LDLT patients (right lobe [RL] graft, 270 patients; left lobe [LL] graft, 160 patients) were enrolled and divided into no HVOO (n = 413) and HVOO (n = 17) groups. Patient demographics and surgical data were compared, and risk factors for HVOO were analyzed. Furthermore, the longterm outcomes of percutaneous interventions as treatment for HVOO were assessed. HVOO occurred in 17 (4.0%) patients. The incidence of HVOO in patients receiving a LL graft was significantly higher than in those receiving a RL graft (8.1% versus 1.5%; P = 0.001). The body weight and caliber of hepatic vein anastomosis in the HVOO group were significantly lower compared with the no HVOO group (P = 0.02 and P = 0.008, respectively). Multivariate analysis revealed that only LL graft was an independent risk factor for HVOO (OR, 4.782; 95% CI, 1.387-16.488; P = 0.01). Among 17 patients with HVOO, 7 patients were treated with single balloon angioplasty, and 9 patients who developed recurrence were treated with repeated interventions. Overall, 6 patients underwent stent placement: 1 at the initial procedure, 3 at the second procedure for early recurrence, and 2 following repeated balloon angioplasty (≥3 interventions). These 6 patients experienced no recurrence. Overall graft survival was not significantly different between the HVOO and no HVOO groups (P = 0.99). In conclusion, the use of a LL graft was associated with HVOO, and percutaneous interventions were effective for treating adult HVOO after LDLT. Liver Transplantation 22 785-795 2016 AASLD.

Vascular complications following liver transplantation: A literature review of advances in 2015

Although vascular complications (VCs) following orthotopic liver transplantation (OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the blood flow of the transplant (either inflow or outflow). Diagnosis and therapeutic management of VCs constitute a major challenge in terms of increasing the success rate of liver transplantation. While surgical treatment used to be considered the first choice for management, advances in endovascular intervention have increased to make this a viable therapeutic option. Considering VC as a rare but a major and dreadful issue in OLT history, and in view of the continuing and rapid progress in recent years, an update on these uncommon conditions seemed necessary. In this sense, this review comprehensively discusses the important features (epidemiological, clinical, paraclinical, prognostic and therapeutic) of VCs following OLT.

Utility of liver biopsy in predicting clinical outcomes after percutaneous angioplasty for hepatic venous obstruction in liver transplant patients

AIM: To determine utility of transplant liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty (PTA) for hepatic venous obstruction (HVOO).

METHODS: Adult liver transplant patients treated with PTA for HVOO (2003-2013) at a single institution were reviewed for pre/post-PTA imaging findings, manometry (gradient with right atrium), presence of HVOO on pre-PTA and post-PTA early and late biopsy (EB and LB, < or > 60 d after PTA), and clinical outcome, defined as good (no clinical issues, non-HVOO-related death) or poor (surgical correction, recurrent HVOO, or HVOO-related death).

RESULTS: Fifteen patients meeting inclusion criteria underwent 21 PTA, 658 ± 1293 d after transplant. In procedures with pre-PTA biopsy (n = 19), no difference was seen between pre-PTA gradient in 13/19 procedures with HVOO on biopsy and 6/19 procedures without HVOO (8 ± 2.4 mmHg vs 6.8 ± 4.3 mmHg; P = 0.35). Post-PTA, 10/21 livers had EB (29 ± 21 d) and 9/21 livers had LB (153 ± 81 d). On clinical follow-up (392 ± 773 d), HVOO on LB resulted in poor outcomes and absence of HVOO on LB resulted good outcomes. Patients with HVOO on EB (3/7 good, 4/7 poor) and no HVOO on EB (2/3 good, 1/3 poor) had mixed outcomes.

CONCLUSION: Negative liver biopsy greater than 60 d after PTA accurately identifies patients with good clinical outcomes.

Prospective Randomized Trial Comparing Hepatic Venous Outflow and Renal Function after Conventional versus Piggyback Liver Transplantation

Background

This randomized prospective clinical trial compared the hepatic venous outflow drainage and renal function after conventional with venovenous bypass (n = 15) or piggyback (n = 17) liver transplantation.

Methods

Free hepatic vein pressure (FHVP) and central venous pressure (CVP) measurements were performed after graft reperfusion. Postoperative serum creatinine (Cr) was measured daily on the first week and on the 14^th, 21^st and 28^th postoperative days (PO). The prevalence of acute renal failure (ARF) up to the 28th PO was analyzed by RIFLE-AKIN criteria. A Generalized Estimating Equation (GEE) approach was used for comparison of longitudinal measurements of renal function.

Results

FHVP-CVP gradient > 3 mm Hg was observed in 26.7% (4/15) of the patients in the conventional group and in 17.6% (3/17) in the piggyback group (p = 0.68). Median FHVP-CVP gradient was 2 mm Hg (0–8 mmHg) vs. 3 mm Hg (0–7 mm Hg) in conventional and piggyback groups, respectively (p = 0.73). There is no statistically significant difference between the conventional (1/15) and the piggyback (2/17) groups regarding massive ascites development (p = 1.00). GEE estimated marginal mean for Cr was significantly higher in conventional than in piggyback group (2.14 ± 0.26 vs. 1.47 ± 0.15 mg/dL; p = 0.02). The conventional method presented a higher prevalence of severe ARF during the first 28 PO days (OR = 3.207; 95% CI, 1.010 to 10.179; p = 0.048).

Conclusion

Patients submitted to liver transplantation using conventional or piggyback methods present similar results regarding venous outflow drainage of the graft. Conventional with venovenous bypass technique significantly increases the harm of postoperative renal dysfunction.

Trial Registration

ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT01707810

Successful percutaneous transluminal balloon dilatation for hepatic venous outflow obstruction after pediatric liver transplantation: A series of cases

AIM

Whether percutaneous transluminal balloon dilatation (PTBD) or stent placement should be used in children with hepatic venous outflow obstruction (HVOO) is still controversial. The aim of the present study was to retrospectively describe experience in diagnosis and treatment of HVOO and to evaluate the outcome of PTBD in HVOO patients after pediatric liver transplantation (P-LT).

METHODS

From January 2001 to January 2011, 54 children received P-LT at our center. The clinical features of children with HVOO analyzed included demography, type of donor and liver transplant, the new-onset symptoms, liver function test, interventional examination, and treatment and outcome.

RESULTS

Three children were treated successfully with PTBD without stenting. All patients received percutaneous interventional management successfully. In the total of eight episodes of PTBD across the stenosis, the mean pressure gradient ± standard deviation was 16.6 ± 7.90 mmHg before PTBD and 6.8 ± 2.27 mmHg after PTBD. The difference was significant (P < 0.05). All of the three HVOO patients were still surviving with primary graft functioning normally until the last follow up.

CONCLUSION

HVOO after P-LT should be taken seriously. PTBD is an effective and safe treatment for HVOO in younger patients subjected to P-LT and re-venoplasty is recommended even in patients with recurrent HVOO.

Long-term outcome of percutaneous interventions for hepatic venous outflow obstruction after pediatric living donor liver transplantation: experience from a single institute

PURPOSE

To evaluate retrospectively the long-term outcome of percutaneous interventions for hepatic venous outflow obstruction (HVOO) occurring after pediatric living donor liver transplantation (LDLT).

MATERIALS AND METHODS

Between October 1997 and December 2012, 48 patients (24 boys, 24 girls; median age, 6 y) who had undergone LDLT were confirmed to have HVOO using percutaneous hepatic venography and manometry. All patients underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, patency rates, stent placement, and major complications were evaluated.

RESULTS

Technical success was achieved in 92 of 93 sessions (99.0%) and in 47 of 48 patients (97.9%), and clinical success was achieved in 41 of 48 patients (85.4%). During the follow-up period (range, 1-182 mo; median, 51.5 mo), 28 patients were treated with a single session of balloon angioplasty, and 20 patients who developed recurrent stenosis were treated with repeated percutaneous interventions. The rates of primary and primary-assisted patency at 1, 3, 5, and 10 years after balloon angioplasty were 64%, 57%, 57%, and 52% (primary patency) and 98%, 95%, 95%, and 95% (primary-assisted patency). Of six patients with stent placement, four had no recurrent HVOO after the stent placement, but two developed recurrent stenosis. The stent migrated to the right atrium in one patient.

CONCLUSIONS

Percutaneous interventions were effective treatments for HVOO after LDLT.

Standard hepatic vein reconstruction with patch plasty using the native portal vein in adult living donor liver transplantation

An outflow obstruction of the hepatic vein is a critical complication after living donor liver transplantation (LDLT) and occasionally leads to hepatic failure. Here we introduce a simple method for preventing outflow obstructions by patch plasty in adult LDLT. Between September 2001 and May 2010, 468 adult LDLT procedures were performed at Kyoto University Hospital. We harvested each recipient's portal vein (PV) from the extirpated liver for a patch. We intended to re-form several orifices of the hepatic veins into a single, large orifice. The patch was attached to the anterior wall of the re-formed orifice on the bench. After we put in the liver graft, the procedure for the hepatic vein anastomosis to the inferior vena cava was simple enough that the warm ischemia time was reduced. Three of the 468 cases were diagnosed with an outflow obstruction. All 3 cases underwent hepatic vein reconstruction without patch plasty. In contrast, none of the 159 cases that underwent LDLT with patch plasty suffered from an outflow obstruction, regardless of the liver graft type. The procedure for hepatic vein plasty using a patch from the native PV is simple and elegant and results in excellent outcomes. We propose this as the standard procedure for hepatic vein reconstruction in adult LDLT.