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Majlesara A, Golriz M, Ramouz A, Khajeh E, Sabetkish N, Wielpütz MO, Rio Tinto H, Abbasi Dezfouli S, Loos M, Mehrabi A, Chang DH. Postoperative Management of Portal Vein Arterialization: An Interdisciplinary Institutional Approach. Cancers (Basel) 2024; 16:2459. [PMID: 39001521 PMCID: PMC11240632 DOI: 10.3390/cancers16132459] [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] [Received: 05/31/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024] Open
Abstract
Portal vein arterialization (PVA) is a surgical procedure that plays a crucial role in hepatic vascular salvage when hepatic artery flow restoration remains elusive. Dedicated diagnostic vascular imaging and the timely management of PVA shunts are paramount to preventing complications, such as portal hypertension and thrombosis. Regrettably, a lack of standardized postoperative management protocols for PVA has increased morbidity and mortality rates post-procedure. In response to this challenge, we developed a PVA standard operating procedure (SOP) tailored to the needs of interventional radiologists. This SOP is designed to harmonize postoperative care, fostering scientific comparability across cases. This concise brief report aims to offer radiologists valuable insights into the PVA technique and considerations for post-PVA care and foster effective interdisciplinary collaboration.
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Affiliation(s)
- Ali Majlesara
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
| | - Nastaran Sabetkish
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
| | - Mark O. Wielpütz
- Department of Interventional Radiology, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Hugo Rio Tinto
- Radiology Department, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - Sepehr Abbasi Dezfouli
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - De-Hua Chang
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Radiology, Lucerne Kantonsspital, Spitalstrasse, CH-6000 Lucerne, Switzerland
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Cortes-Mejia NA, Bejarano-Ramirez DF, Guerra-Londono JJ, Trivino-Alvarez DR, Tabares-Mesa R, Vera-Torres A. Portal vein arterialization in 25 liver transplant recipients: A Latin American single-center experience. World J Transplant 2024; 14:92528. [PMID: 38947972 PMCID: PMC11212596 DOI: 10.5500/wjt.v14.i2.92528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/19/2024] [Accepted: 04/28/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Portal vein arterialization (PVA) has been used in liver transplantation (LT) to maximize oxygen delivery when arterial circulation is compromised or has been used as an alternative reperfusion technique for complex portal vein thrombosis (PVT). The effect of PVA on portal perfusion and primary graft dysfunction (PGD) has not been assessed. AIM To examine the outcomes of patients who required PVA in correlation with their LT procedure. METHODS All patients receiving PVA and LT at the Fundacion Santa Fe de Bogota between 2011 and 2022 were analyzed. To account for the time-sensitive effects of graft perfusion, patients were classified into two groups: prereperfusion (pre-PVA), if the arterioportal anastomosis was performed before graft revascularization, and postreperfusion (post-PVA), if PVA was performed afterward. The pre-PVA rationale contemplated poor portal hemodynamics, severe vascular steal, or PVT. Post-PVA was considered if graft hypoperfusion became evident. Conservative interventions were attempted before PVA. RESULTS A total of 25 cases were identified: 15 before and 10 after graft reperfusion. Pre-PVA patients were more affected by diabetes, decompensated cirrhosis, impaired portal vein (PV) hemodynamics, and PVT. PGD was less common after pre-PVA (20.0% vs 60.0%) (P = 0.041). Those who developed PGD had a smaller increase in PV velocity (25.00 cm/s vs 73.42 cm/s) (P = 0.036) and flow (1.31 L/min vs 3.34 L/min) (P = 0.136) after arterialization. Nine patients required PVA closure (median time: 62 d). Pre-PVA and non-PGD cases had better survival rates than their counterparts (56.09 months vs 22.77 months and 54.15 months vs 31.91 months, respectively). CONCLUSION This is the largest report presenting PVA in LT. Results suggest that pre-PVA provides better graft perfusion than post-PVA. Graft hyperperfusion could play a protective role against PGD.
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Affiliation(s)
- Nicolas Andres Cortes-Mejia
- Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
- Transplant and Hepatobiliary Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
| | | | - Juan Jose Guerra-Londono
- Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | | | - Raquel Tabares-Mesa
- General Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
| | - Alonso Vera-Torres
- Transplant and Hepatobiliary Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
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Nejatollahi SMR, Nazari M, Mostafavi K, Ghorbani F. Reoperation etiologies in the initial hospital stay after liver transplantation: a single-center study from Iran. KOREAN JOURNAL OF TRANSPLANTATION 2023; 37:103-108. [PMID: 37435148 PMCID: PMC10332282 DOI: 10.4285/kjt.23.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023] Open
Abstract
Background Liver transplantation (LT) is widely recognized as a life-saving therapy for patients with end-stage liver disease. However, due to certain posttransplant complications, reoperations or endovascular interventions may be necessary to improve patient outcomes. This study was conducted to examine reasons for reoperation during the initial hospital stay following LT and to identify its predictive factors. Methods We evaluated the incidence and etiology of reoperation in 133 patients who underwent LT from brain-dead donors over a 9-year period based on our experiences. Results A total of 52 reoperations were performed for 29 patients, with 17 patients requiring one reoperation, seven requiring two, three requiring three, one requiring four, and one requiring eight. Four patients underwent liver retransplantation. The most common cause of reoperation was intra-abdominal bleeding. Hypofibrinogenemia was identified as the sole predisposing factor for bleeding. Frequencies of comorbidities such as diabetes mellitus and hypertension did not differ significantly between groups. Among patients who underwent reoperation due to bleeding, the mean plasma fibrinogen level was 180.33±68.21 mg/dL, while among reoperated patients without bleeding, it was 240.62±105.14 mg/dL (P=0.045; standard mean difference, 0.61; 95% confidence interval, 0.19-1.03). The initial hospital stay was significantly longer for the reoperated group (47.5±15.5 days) than for the non-reoperated group (22.5±5.5 days). Conclusions Meticulous pretransplant assessment and postoperative care are essential for the early identification of predisposing factors and posttransplant complications. In order to enhance graft and patient outcomes, any complications should be addressed without hesitation, and appropriate intervention or surgery should not be delayed.
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Affiliation(s)
- Seyed Mohammad Reza Nejatollahi
- Hepato-Pancreato-Biliary and Transplant Surgery, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Nazari
- Hepato-Pancreato-Biliary and Transplant Surgery, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Keihan Mostafavi
- Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Ghorbani
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ramalingam V, Yang LM, McCarthy CJ, Ahmed M. Interventional Approach to Portal Vein Thrombosis and Liver Transplantation: State of the Art. Life (Basel) 2023; 13:1262. [PMID: 37374045 DOI: 10.3390/life13061262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023] Open
Abstract
Porto-mesenteric vein thrombosis (PVT) is a well-recognized but uncommon disease entity in patients with and without cirrhosis. Given the complexity of these patients, there are many differing treatment algorithms depending on the individual circumstances of a given patient. The focus of this review is primarily patients with cirrhosis, with an emphasis on liver transplantation considerations. The presence of cirrhosis substantially affects work-up, prognosis, and management of these patients and will substantially affect the patient treatment and have additional implications for prognosis and long-term outcomes. Here, we review the incidence of portal vein thrombosis in known cirrhotic patients, medical and interventional treatment options that are currently used, and, in particular, how to approach cirrhotic patients with PVT who are awaiting liver transplantation.
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Affiliation(s)
- Vijay Ramalingam
- Division of Vascular and Interventional Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Lauren M Yang
- Division of Hepatology and Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Colin J McCarthy
- Division of Vascular and Interventional Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Muneeb Ahmed
- Division of Vascular and Interventional Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Swersky A, Borja-Cacho D, Deitch Z, Thornburg B, Salem R. Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt (PVR-TIPS) Facilitates Liver Transplantation in Cirrhotic Patients with Occlusive Portal Vein Thrombosis. Semin Intervent Radiol 2023; 40:38-43. [PMID: 37152801 PMCID: PMC10159708 DOI: 10.1055/s-0043-1764409] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Portal vein thrombosis (PVT) is a heterogeneous condition with multiple possible etiologies and to varying degrees has historically limited candidacy for liver transplant (LT) in the cirrhotic patient population due to resultant difficulties in constructing a robust portal vein anastomosis. While intraoperative approaches to managing PVT are well-described, methods which approximate normal portal physiology are not always feasible depending on the extent of PVT, and other nonphysiologic techniques are linked with substantial morbidity and poor long-term outcomes. Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) creation is an efficacious method of restoring physiologic portal flow in cirrhotic patients prior to LT allowing for end-to-end PV anastomosis, and is the product of decades-long institutional expertise in TIPS/LT and the support of a multidisciplinary liver tumor board. To follow is a review of the pertinent pathophysiology of PVT in cirrhosis, the rationale leading to the development and subsequent evolution of the PVR-TIPS procedure, technical lessons learned, and a summary of outcomes to date.
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Affiliation(s)
- Adam Swersky
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
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Noji T, Hirano S, Tanaka K, Matsui A, Nakanishi Y, Asano T, Nakamura T, Tsuchikawa T. Concomitant Hepatic Artery Resection for Advanced Perihilar Cholangiocarcinoma: A Narrative Review. Cancers (Basel) 2022; 14:cancers14112672. [PMID: 35681652 PMCID: PMC9179358 DOI: 10.3390/cancers14112672] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary In the eighth edition of their cancer classification system, the Union for International Cancer Control (UICC) defines contralateral hepatic artery invasion as T4, which is considered unresectable as it is a “locally advanced” tumour. However, in the last decade, several reports on hepatic artery resection (HAR) for perihilar cholangiocarcinoma (PHCC) have been published. The reported five-year survival rate after HAR is 16–38.5%. Alternative procedures for the treatment of HAR have also been reported. In this paper, we review HAR for PHCC, focusing on its history, diagnosis, procedures, and alternative procedures. Abstract Perihilar cholangiocarcinoma (PHCC) is one of the most intractable gastrointestinal malignancies. These tumours lie in the core section of the biliary tract. Patients who undergo curative surgery have a 40–50-month median survival time, and a five-year overall survival rate of 35–45%. Therefore, curative intent surgery can lead to long-term survival. PHCC sometimes invades the surrounding tissues, such as the portal vein, hepatic artery, perineural tissues around the hepatic artery, and hepatic parenchyma. Contralateral hepatic artery invasion is classed as T4, which is considered unresectable due to its “locally advanced” nature. Recently, several reports have been published on concomitant hepatic artery resection (HAR) for PHCC. The morbidity and mortality rates in these reports were similar to those non-HAR cases. The five-year survival rate after HAR was 16–38.5%. Alternative procedures for arterial portal shunting and non-vascular reconstruction (HAR) have also been reported. In this paper, we review HAR for PHCC, focusing on its history, diagnosis, procedures, and alternatives. HAR, undertaken by established biliary surgeons in selected patients with PHCC, can be feasible.
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Basso CD, Meniconi RL, Usai S, Guglielmo N, Colasanti M, Ferretti S, Sandri GBL, Ettorre GM. Portal vein arterialization following a radical left extended hepatectomy for Klatskin tumor: A case report. Ann Hepatobiliary Pancreat Surg 2021; 25:426-430. [PMID: 34402447 PMCID: PMC8382860 DOI: 10.14701/ahbps.2021.25.3.426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 12/01/2022] Open
Abstract
Portal vein arterialization (PVA) has been attracting attention for its role as a salvage inflow technique in various clinical applications. Initially performed in shunt surgery for portal hypertension, with the aim of preventing a decreased hepatic inflow, it is largely used in case of hepatic artery thrombosis in the transplantation domain or in the enlarged radical operations in case of hilar cancer invading the hepatic artery. A 62-year-old man underwent a left extended hepatectomy with hepatic bile duct resection and right Roux-en-Y hepaticojejunostomy for hilar cholangiocarcinoma. Computed tomography scan on postoperative day (POD) 5 revealed right hepatic artery pseudo-aneurysm, which was confirmed by an angiography. Stent placement was infeasible. Coiling of the pseudoaneurysm was associated with a risk of complete occlusion inducing critical liver failure. Since his general conditions were deteriorated, the patient underwent an emergency laparotomy. Hepatic artery reconstruction was impossible. Thus, a PVA was performed by anastomosing the ileocecal artery and vein. The intraoperative ultrasound showed satisfactory patency of the PVA with good portal flow in the absence of arterial flow. Doppler ultrasound on POD 15 showed that the cross-sectional area and blood flow of the portal vein were increased. The patient was discharged on POD 54 in good general condition. Hepatic artery disruption represents potentially lethal complications of hepatic, biliary, and pancreatic surgery. PVA may be a feasible therapeutic strategy to guarantee arterial inflow to the remnant liver. Although PVA is a salvage surgical procedure, increased portal flow should be controlled to avoid portal hypertension and liver fibrosis.
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Affiliation(s)
- Celeste Del Basso
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Roberto Luca Meniconi
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Sofia Usai
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Stefano Ferretti
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
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Teng F, Sun KY, Fu ZR. Tailored classification of portal vein thrombosis for liver transplantation: Focus on strategies for portal vein inflow reconstruction. World J Gastroenterol 2020; 26:2691-2701. [PMID: 32550747 PMCID: PMC7284174 DOI: 10.3748/wjg.v26.i21.2691] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed via low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.
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Affiliation(s)
- Fei Teng
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Ke-Yan Sun
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Zhi-Ren Fu
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
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Kuriyama N, Kazuaki G, Hayasaki A, Fujii T, Iizawa Y, Kato H, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Isaji S, Mizuno S. Surgical Procedures of Portal Vein Reconstruction for Recipients With Portal Vein Thrombosis in Adult-to-Adult Living Donor Liver Transplantation. Transplant Proc 2020; 52:1802-1806. [PMID: 32448668 DOI: 10.1016/j.transproceed.2020.01.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/22/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Portal vein (PV) reconstruction is an important surgical skill for living donor liver transplantation (LDLT), especially for patients with portal vein thrombosis (PVT). However, this technique remains a critical problem in LDLT because of technical demands and requirements for appropriate venous graft harvesting. This study aimed to evaluate the surgical procedure used for PV reconstruction and outcomes in LDLT recipients with PVT. METHODS Between March 2002 and December 2018, 128 adult LDLTs were performed. Fourteen recipients (10.8%) had PVT at the time of LDLT, classified as grade I in 2, grade II in 5, grade III in 6, and grade IV in 1, according to the Yerdel classification. We retrospectively analyzed the surgical procedure and postoperative complications associated with PV reconstruction of recipients with PVT. RESULTS Surgical treatments for 14 recipients with PVT were as follows: thrombectomies in 2 recipients, replacement of interpositional venous grafts using the internal jugular vein (IJV) in 3 recipients and the external iliac vein (EIV) in 6 recipients, mesoportal jump grafts using the IJV in 1 recipient and the IJV + EIV in 1 recipient, and renoportal anastomosis using the EIV in 1 recipient. Among interpositional venous grafts, 5 venous grafts (IJV: 2, EIV: 3) passed the dorsal side of the pancreas without using the jump graft. Postoperative complications associated with PV anastomosis occurred in 1 of 14 (7.1%) recipients, who developed anastomosis bleeding caused by coagulation disorders at 27 days after LDLT, without any strictures of PV anastomoses. The overall survival rate at 5 years posttransplant was not statistically different between recipients with and without PVT (50.0% vs 65.0%, P = .163). CONCLUSION Our techniques of PV reconstruction, using the appropriate venous grafts and route, are feasible, resulting in a prognosis comparable to that of recipients without PVT.
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Affiliation(s)
- Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan.
| | - Gyoten Kazuaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
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Partial portal vein arterialization during living-donor liver transplantation: a case report. Surg Case Rep 2020; 6:7. [PMID: 31916066 PMCID: PMC6949348 DOI: 10.1186/s40792-020-0781-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/02/2020] [Indexed: 11/18/2022] Open
Abstract
Background Hepatic artery thrombosis can lead to graft loss associated with severe hepatic infarction or bile duct ischemia. When anatomical hepatic artery reconstruction is impossible in liver transplantation or hepato-pancreatic biliary surgery, portal vein arterialization (PVA) is proposed as a salvage technique. Herein, we report our experience with a case that showed favorable clinical outcomes after partial PVA during living-donor liver transplantation (LDLT) because of difficulties in arterial reconstruction. Case presentation A 62-year-old woman with non-B, non-C liver cirrhosis complicated with hepatocellular carcinoma was being prepared for LDLT using an extended left lobe graft. The graft presented with two arteries (left hepatic artery, 2 mm; middle hepatic artery, 2 mm). The first anastomosis was performed using the recipient hepatic artery stumps, but no flow was detected on Doppler control because of thrombus formation. The next attempt was executed using the middle colic artery with a radial artery jump graft and the right gastroepiploic artery, but it led to the same result. Thus, the graft oxygen support by the standard arterial procurement was abandoned, and a shunt was created between the ileocecal artery and the vein to obtain PVA. Arteriography of the superior mesenteric artery showed that the shunt was relatively patent, and the portal vein was apparent. No biliary complication or liver abscess occurred postoperatively, and the patient presented with good liver function and no complications related to portal vein hypertension, nor liver fibrosis 18 months after the LDLT. Conclusion Partial PVA with a shunt created between the ileocecal artery and the vein is useful when arterial reconstruction is difficult during LDLT for preventing graft loss caused by severe hepatic infarction or bile duct ischemia.
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Sasaki K, McVey JC, Firl DJ, Andreatos N, Moro A, Coromina Hernandez L, Matsushima H, Teresa DU, Fujiki M, Aucejo FN, Quintini C, Kwon CD, Eghtesad B, Miller CM, Hashimoto K. Sufficient hepatic artery flow compensates for poor portal vein flow after liver transplantation in patients with portal vein thrombosis. Clin Transplant 2019; 33:e13723. [DOI: 10.1111/ctr.13723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/28/2019] [Accepted: 09/14/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Kazunari Sasaki
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - John C. McVey
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Daniel J. Firl
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | | | - Amika Moro
- Japanese National Physician Graduate Medical Education Program United States Naval Hospital Okinawa Okinawa Japan
| | - Laia Coromina Hernandez
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Hajime Matsushima
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Diago Uso Teresa
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Masato Fujiki
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Federico N. Aucejo
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Choon‐Hyuck D. Kwon
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Bijan Eghtesad
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Charles M. Miller
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Koji Hashimoto
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
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12
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Partial portal vein arterialization using right gastroepiploic artery: A novel solution for portal hypoperfusion. Hepatobiliary Pancreat Dis Int 2018; 17:367-370. [PMID: 30029952 DOI: 10.1016/j.hbpd.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/12/2018] [Indexed: 02/05/2023]
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13
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Lapisatepun W, Chotirosniramit A, Sandhu T, Udomsin K, Ko-Iam W, Chanthima P, Lapisatepun W, Boonsri S, Lorsomradee S, Kaewpoowat Q, Junrungsee S. Price to pay; Portal vein arterialization for hepatic artery thrombosis after living donor liver transplantation; A case report. Int J Surg Case Rep 2018; 47:71-74. [PMID: 29751198 PMCID: PMC5994732 DOI: 10.1016/j.ijscr.2018.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/29/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Hepatic artery thrombosis (HAT) is one of the most serious complications of liver transplantation that can potentially lead to loss of the allograft. Retransplantation is the only option when revascularization can't be performed but the donor may be not available in the short period of time. We report the technique of using portal vein arterialization (PVA) for bridging before retransplantation. There are few reports in living donor setting. CASE DESCRIPTION The recipient of the liver was a 59 year old male who received an extended right lobe graft from his son. Post operative day 41, HAT was diagnosed from angiogram and liver function got rapidly worse. We decided to re-anastomose the hepatic artery but this was not possible due to a thrombosis in the distal right hepatic artery. So PVA by anastomosis of the common hepatic artery to splenic vein was performed. During the early postoperative period liver function gradually improved. Unfortunately, he died from massive GI hemorrhage one month later. DISCUSSION PVA has previously been reported as being useful when revascularization was not successful. The surgical technique is not complicated and can be performed in sick patient. Liver graft may be salvaged with oxygenated portal flow and recover afterwards. However, portal hypertension after PVA seem to be an inevitable complication. CONCLUSIONS PVA may be a bridging treatment for retransplantation in patients whom hepatic artery reconstruction is impossible after HAT. Regards to the high morbidity after procedure, retransplantation should be performed as definite treatment as soon as possible.
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Affiliation(s)
- Worakitti Lapisatepun
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Anon Chotirosniramit
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Trichak Sandhu
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Kanya Udomsin
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Wasana Ko-Iam
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Phuriphong Chanthima
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Thailand
| | | | - Settapong Boonsri
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Thailand
| | | | - Quanhathai Kaewpoowat
- Division of Infectious and Tropical Medicine, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand
| | - Sunhawit Junrungsee
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand.
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14
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Thornburg B, Desai K, Hickey R, Hohlastos E, Kulik L, Ganger D, Baker T, Abecassis M, Caicedo JC, Ladner D, Fryer J, Riaz A, Lewandowski RJ, Salem R. Pretransplantation Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt Creation for Chronic Portal Vein Thrombosis: Final Analysis of a 61-Patient Cohort. J Vasc Interv Radiol 2017; 28:1714-1721.e2. [PMID: 29050854 DOI: 10.1016/j.jvir.2017.08.005] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/27/2017] [Accepted: 08/08/2017] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To report the final analysis of the safety and efficacy of portal vein (PV) recanalization (PVR) and transjugular intrahepatic portosystemic shunt (TIPS) creation (PVR-TIPS) in patients with PV thrombosis (PVT) in need of liver transplantation. MATERIALS AND METHODS Sixty-one patients with cirrhosis and PVT underwent PVR-TIPS to improve transplantation candidacy. Median patient age was 58 years (range, 22-75 y), and median pre-TIPS Model for End-Stage Liver Disease score was 14 (range, 7-42). The most common etiologies of cirrhosis were nonalcoholic fatty liver disease in 18 patients (30%) and hepatitis C in 13 patients (21%). Twenty-seven patients (44%) had partial PVT, and 34 patients (56%) had complete thrombosis. Forty-nine patients (80%) had Yerdel grade 2 PVT, and 12 (20%) had Yerdel grade 3 PVT. Twenty-nine patients (48%) had cavernous transformation of the PV. RESULTS PVR-TIPS was technically successful in 60 of 61 patients (98%). PV/TIPS patency was maintained in 55 patients (92%) at a median follow-up of 19.2 months (range, 0-105.9 mo). Recurrent PV/TIPS thrombosis occurred in 5 patients (8%), all of whom initially presented with complete PVT. The most common adverse events were TIPS stenosis in 13 patients (22%) and transient encephalopathy in 11 patients (18%). Twenty-four patients (39%) underwent transplantation, 23 of whom (96%) received an end-to-end anastomosis. There were no cases of recurrent PVT following transplantation, with a median imaging follow-up of 32.5 months (range, 0.4-75.4 mo). Five-year overall survival rate was 82%. CONCLUSIONS PVR-TIPS is a safe, effective, and durable treatment option for patients with chronic PVT who need liver transplantation.
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Affiliation(s)
- Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Elias Hohlastos
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Laura Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Juan C Caicedo
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Daniela Ladner
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Jonathan Fryer
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois; Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611.
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15
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Thornburg B, Katariya N, Riaz A, Desai K, Hickey R, Lewandowski R, Salem R. Interventional radiology in the management of the liver transplant patient. Liver Transpl 2017; 23:1328-1341. [PMID: 28741309 DOI: 10.1002/lt.24828] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) is commonly used to treat patients with end-stage liver disease. The evolution of surgical techniques, endovascular methods, and medical care has led to a progressive decrease in posttransplant morbidity and mortality. Despite these improvements, a multidisciplinary approach to each patient remains essential as the early diagnosis and treatment of the complications of transplantation influence graft and patient survival. The critical role of interventional radiology in the collaborative approach to the care of the LT patient will be reviewed. Liver Transplantation 23 1328-1341 2017 AASLD.
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Affiliation(s)
- Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Nitin Katariya
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Robert Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL.,Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
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16
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Ozdemir F, Kutluturk K, Barut B, Abbasov P, Kutlu R, Kayaalp C, Yılmaz S. Renoportal anastomosis in living donor liver transplantation with prior proximal splenorenal shunt. World J Transplant 2017; 7:94-97. [PMID: 28280701 PMCID: PMC5324034 DOI: 10.5500/wjt.v7.i1.94] [Citation(s) in RCA: 4] [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: 10/01/2016] [Revised: 11/24/2016] [Accepted: 01/18/2017] [Indexed: 02/05/2023] Open
Abstract
For transplant surgeons, end-stage liver disease with portal venous thrombosis and a previous splenorenal shunt (SRS) is a significant challenge during liver transplantation. Thrombosis of the portal vein can be corrected by surgical interventions, such as portal venous thrombectomy or surgical removal of the thrombosed portal vein. Even also placement of a graft between the mesenteric vein and the graft portal vein can be performed. If these maneuvers fail, a renoportal anastomosis (RPA) can be performed to achieve adequate graft inflow. A 51-year-old male patient who had a history of proximal SRS and splenectomy underwent living donor liver transplantation (LDLT) due to cryptogenic cirrhosis. LDLT was performed with RPA using a cadaveric iliac vein graft. The early postoperative course of the patient was completely uneventful and he was discharged 20 d after transplantation. To the best of our knowledge, this was the first patient to receive LDLT with RPA after surgical proximal SRS and splenectomy.
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17
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Su ZJ, Li WG, Huang JL, Xiao LF, Chen FZ, Wang BL. Pancreaticoduodenectomy assisted by 3-D visualization reconstruction and portal vein arterialization: A case report (a CARE-compliant article). Medicine (Baltimore) 2016; 95:e4697. [PMID: 27603365 PMCID: PMC5023887 DOI: 10.1097/md.0000000000004697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Three-dimensional visualization reconstruction, the 3-D visualization model reconstructed by software using 2-D CT images, has been widely applied in medicine; but it has rarely been applied in pancreaticoduodenectomy. Although the hepatic artery is very important for the liver, it has to be removed when tumor invades it. Therefore, portal vein arterialization has been used in clinic as a remedial measure, but there still is professional debate on portal vein arterialization. METHODS Here, we report 1 case that was diagnosed with poorly differentiated adenocarcinoma of the duodenum. The tumor had large size and invaded surrounding organs and vessels. RESULTS Preliminary diagnoses were poorly differentiated adenocarcinoma of the duodenum and viral hepatitis B. Pancreaticoduodenectomy assisted by 3-D visualization reconstruction and portal vein arterialization were performed in this case. The tumor was removed. Liver function returned to normal limits 1 week after operation. Digital subtraction arteriography showed compensatory artery branches within the liver 1 month after operation. CONCLUSION 3-D visualization reconstruction can provide a reliable assistance for the accurate assessment and surgical design before pancreatoduodenectomy, and it is certainly worth adopting portal vein arterialization when retention of hepatic artery is impossible or conventional arterial anastomosis is required during pancreatoduodenectomy.
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Affiliation(s)
- Zhao-jie Su
- Department of Hepatobiliary Surgery, Chenggong Hospital Affiliated to Xiamen University
| | - Wen-gang Li
- Department of Hepatobiliary Surgery, Chenggong Hospital Affiliated to Xiamen University
- Correspondence: Wen-gang Li, Department of Hepatobiliary Surgery, Chenggong Hospital Affiliated to Xiamen University, No. 96, Wenyuan Road, Xiamen 361000, China (e-mail: )
| | - Jun-li Huang
- Department of Hepatobiliary Surgery, Chenggong Hospital Affiliated to Xiamen University
| | - Lin-feng Xiao
- Department of Hepatobiliary Surgery, Chenggong Hospital Affiliated to Xiamen University
| | - Fu-zhen Chen
- Department of Hepatobiliary Surgery, Chenggong Hospital Affiliated to Xiamen University
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18
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Thornburg B, Desai K, Hickey R, Kulik L, Ganger D, Baker T, Abecassis M, Lewandowski RJ, Salem R. Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt Creation for Chronic Portal Vein Thrombosis: Technical Considerations. Tech Vasc Interv Radiol 2016; 19:52-60. [PMID: 26997089 DOI: 10.1053/j.tvir.2016.01.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Portal vein thrombosis (PVT) is common in cirrhotic patients and presents a challenge at the time of transplant. Owing to the increased posttransplant morbidity and mortality associated with complete PVT, the presence of PVT is a relative contraindication to liver transplantation at many centers. Our group began performing portal vein (PV) recanalization and transjugular intrahepatic portostystemic shunt placement (PVR-TIPS) several years ago to optimize the transplant candidacy of patients with PVT. The procedure has evolved to include transsplenic access to assist with recanalization, which is now our preferred method due to its technical success without significant added morbidity. Here, we describe in detail our approach to PVR-TIPS with a focus on the transsplenic method. The procedure was attempted in 61 patients and was technically successful in 60 patients (98%). After transitioning to transsplenic access to assist with recanalization, the technical success rate has improved to 100%. The recanalized portal vein and TIPS have maintained patency during follow-up, or to the time of transplant, in 55 patients (92%) with a mean follow-up of 16.7 months. In total, 23 patients (38%) have undergone transplant, all of whom received a physiologic anastomosis (end-to-end anastomosis in 22 of 23 patients, 96%). PVR-TIPS placement should be considered as an option for patients with chronic PVT in need of transplantation. Transsplenic access makes the procedure technically straightforward and should be considered as the primary method for recanalization.
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Affiliation(s)
- Bartley Thornburg
- Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, IL
| | - Kush Desai
- Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, IL
| | - Ryan Hickey
- Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, IL
| | - Laura Kulik
- Department of Medicine, Northwestern University, Chicago, IL
| | - Daniel Ganger
- Department of Medicine, Northwestern University, Chicago, IL
| | - Talia Baker
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Michael Abecassis
- Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Robert J Lewandowski
- Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, IL
| | - Riad Salem
- Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, IL; Department of Surgery, Comprehensive Transplant Center, Northwestern University, Chicago, IL; Department of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL.
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19
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Piardi T, Lhuaire M, Bruno O, Memeo R, Pessaux P, Kianmanesh R, Sommacale D. Vascular complications following liver transplantation: A literature review of advances in 2015. World J Hepatol 2016; 8:36-57. [PMID: 26783420 PMCID: PMC4705452 DOI: 10.4254/wjh.v8.i1.36] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 12/02/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Tullio Piardi
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Martin Lhuaire
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Onorina Bruno
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Riccardo Memeo
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Patrick Pessaux
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Reza Kianmanesh
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Daniele Sommacale
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
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20
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Systemic Venous Inflow to the Liver Allograft to Overcome Diffuse Splanchnic Venous Thrombosis. Gastroenterol Res Pract 2015; 2015:810851. [PMID: 26539214 PMCID: PMC4619939 DOI: 10.1155/2015/810851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 03/17/2015] [Indexed: 12/11/2022] Open
Abstract
Diffuse splanchnic venous thrombosis (DSVT), formerly defined as contraindication for liver transplantation (LT), is a serious challenge to the liver transplant surgeon. Portal vein arterialisation, cavoportal hemitransposition and renoportal anastomosis, and finally combined liver and small bowel transplantation are all possible alternatives to deal with this condition. Five patients with preoperatively confirmed extensive splanchnic venous thrombosis were transplanted using cavoportal hemitransposition (4x) and renoportal anastomosis (1x). Median follow-up was 58 months (range: 0,5 to 130 months). Two patients with previous radiation-induced peritoneal injury died, respectively, 18 days and 2 months after transplantation. The three other patients had excellent long-term survival, despite the fact that two of them needed a surgical reintervention for severe gastrointestinal bleeding. Extensive splanchnic venous thrombosis is no longer an absolute contraindication to liver transplantation. Although cavoportal hemitransposition and renoportal anastomosis undoubtedly are life-saving procedures allowing for ensuring adequate allograft portal flow, careful follow-up of these patients remains necessary as both methods are unable to completely eliminate the complications of (segmental) portal hypertension.
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21
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Mori A, Iida T, Iwasaki J, Ogawa K, Fujimoto Y, Uemura T, Hatano E, Okajima H, Kaido T, Uemoto S. Portal vein reconstruction in adult living donor liver transplantation for patients with portal vein thrombosis in single center experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:467-74. [PMID: 25755116 DOI: 10.1002/jhbp.235] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 02/03/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplantation (LT) used to be contraindicated in patients with portal vein thrombosis (PVT). In comparison to deceased donor LT, living donor LT (LDLT) still presents additional difficulties in determining appropriate vein grafts and overcoming small-for-size syndrome. Here, we introduce our LDLT strategies and assess their outcomes in adult patients with pre-existing PVT. METHODS We performed 282 consecutive adult LDLTs between April 2006 and December 2011. Forty-eight patients (17%) had pre-existing PVT (grade I; 15, II; 20, III; 12, IV; 1). RESULTS Our preferred treatments for PVT were thrombectomies/thromboendovenectomies in 30 patients, replaced grafts in seven, jump grafts in seven, renoportal anastomosis in one and no surgical intervention owing to minimal thrombosis in three. Post-transplant portal vein complications occurred in eight of 48 (17%) cases, which were treated by surgery, anticoagulation therapy, and/or interventional radiology. Post-transplant survival rates of patients with preexisting PVT at 1 year and 5 years were comparable to a PVT-free cohort (1 year; 81% vs. 77%, 5 years; 81% vs. 73%). CONCLUSIONS The excellent survival rates in patients with PVT who underwent LDLT could be attributed to our strategies, which included surgical techniques and timely treatment of postoperative complications.
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Affiliation(s)
- Akira Mori
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Taku Iida
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Junji Iwasaki
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yasuhiro Fujimoto
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tadahiro Uemura
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Etsuro Hatano
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideaki Okajima
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshimi Kaido
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinji Uemoto
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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22
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Portal vein recanalization-transjugularintrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis. J Vasc Interv Radiol 2015; 26:499-506. [PMID: 25666626 DOI: 10.1016/j.jvir.2014.12.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To present the transsplenic route as an alternative approach for portal vein recanalization-transjugular portosystemic shunt (PVR-TIPS) for chronic main portal vein thrombosis (PVT) in potential transplant candidates. MATERIALS AND METHODS In 2013-2014, 11 consecutive patients with cirrhosis-induced chronic main PVT underwent transsplenic PVR-TIPS. All patients had been denied listing for transplant because of the presence of main PVT, a relative contraindication in this center. The patients were followed for adverse events. Portal vein patency was assessed at 1 month by splenoportography and every 3 months subsequently by ultrasound or magnetic resonance imaging. After PVR-TIPS, patients were reviewed (and subsequently listed for transplant) at a weekly multidisciplinary conference. RESULTS PVR-TIPS using the transsplenic approach was successful in all 11 patients with no major complications. Median age was 61 years (range, 33-67 y) and 9 of 11 patients (82%) were men. Nonalcoholic steatohepatitis was the leading cause of liver disease in 4 of 11 patients (36%), and hepatitis C was present in 4 of 11 patients (36%). Complete main PVT was found in 8 of 11 patients (73%). Of 11 patients, 4 (36%) had a Model for End-Stage Liver Disease score > 18, and 8 (73%) had a baseline Child-Pugh score of 7-10. Minor adverse events occurred in 2 of 11 patients (fever, encephalopathy). At the end of the procedure, 5 of 11 patients (45%) exhibited some minor remaining thrombus in the portal vein; 3 of the 5 patients (60%) had complete thrombus resolution at 1 month, with the remaining 2 patients having resolution at 3 months (no anticoagulation was needed). Three patients underwent successful liver transplant with end-to-end anastomoses. CONCLUSIONS Transsplenic PVR-TIPS is a potentially safe and effective method to treat PVT and improve transplant candidacy.
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Li J, Cai C, Guo H, Guan X, Yang L, Li Y, Zhu Y, Li P, Liu X, Zhang B. Portal vein arterialization promotes liver regeneration after extended partial hepatectomy in a rat model. J Biomed Res 2014; 29:69-75. [PMID: 25745478 PMCID: PMC4342438 DOI: 10.7555/jbr.29.20140054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/05/2014] [Accepted: 09/12/2014] [Indexed: 11/14/2022] Open
Abstract
In the current study, we sought to establish a novel rat model of portal vein arterialization (PVA) and evaluate its impact on liver regeneration after extended partial hepatectomy (PH). A total of 105 Sprague-Dawley rats were randomly assigned to three groups: 68% hepatectomy (the PH group), portal arterialization after 68% hepatectomy (the PVA group), and right nephrectomy only (the control group). Liver regeneration rate (LRR), 5-bromo-2-deoxyuridine (BrdU) labeling index, and liver functions were assessed on postoperative day 2, 7, 14 and 28. The 28-day survival rates were compared among the three groups. The 28-day survival rates were similar in all groups (P = 0.331), and the anastomotic patency was 100%. The LRR in the PVA group was significantly higher than that of the PH group within postoperative 14 days (P < 0.05). The PVA and PH group had increased serum alanine aminotransferase levels (232 ± 61 U/L and 212 ± 53 U/L, respectively) compared with the control group (101 ± 13 U/L) on postoperative day 2, whereas from postoperative day 7 to day 28 there were no differences among the three groups. Serum albumin values were higher after the PVA procedure within postoperative day 14, which gradually became comparable on postoperative day 28 among the three groups. The peaks of BrdU labeling index appeared on postoperative day 2 in all rats, and the PVA procedure was associated with increased BrdU labeling index from postoperative day 7 to 28. The 28-day survival of the PVA rats was comparable. Our findings demonstrate that the PVA procedure utilizing portal vein trunk-renal artery microvascular reconstruction promotes remnant liver regeneration and confers beneficial effects on maintaining and even optimizing liver function after extended partial hepatectomy in rats.
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Affiliation(s)
- Jian Li
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Chaonong Cai
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Hui Guo
- Departments of Radiology, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Xiaodong Guan
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Lukun Yang
- Anesthesiology, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Yuechan Li
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Yanhua Zhu
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Peiping Li
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Xialei Liu
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Baimeng Zhang
- Departments of General Surgery, the 5th Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China
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Bhangui P, Salloum C, Lim C, Andreani P, Ariche A, Adam R, Castaing D, Kerba T, Azoulay D. Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience. HPB (Oxford) 2014; 16:723-38. [PMID: 24329988 PMCID: PMC4113254 DOI: 10.1111/hpb.12200] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 10/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Portal vein arterialization (PVA) has been used as a salvage inflow technique when hepatic artery (HA) reconstruction is deemed impossible in liver transplantation (LT) or hepatopancreatobiliary (HPB) surgery. Outcomes and the management of possible complications have not been well described. METHODS The present study analysed outcomes in 16 patients who underwent PVA during the period from February 2005 to January 2011 for HA thrombosis post-LT (n = 7) or after liver resection (n = 1), during curative resection for locally advanced HPB cancers (requiring HA interruption) (n = 7) and for HA resection without reconstruction (n = 1). In addition, a literature review was conducted. RESULTS Nine patients were women. The median age of the patients was 58 years (range: 30-72 years). Recovery of intrahepatic arterial signals and PVA shunt patency were documented using Doppler ultrasound until the last follow-up (or until shunt thrombosis in some cases). Of five postoperative deaths, two occurred as a result of haemorrhagic shock, one as a result of liver ischaemia and one as a result of sepsis. The fifth patient died at home of unknown cause. Three patients (19%) had major bleeding related to portal hypertension (PHT). Of these, two underwent re-exploration and one underwent successful shunt embolization to control the bleeding. Four patients (25%) had early shunt thrombosis, two of whom underwent a second PVA. After a median follow-up of 13 months (range: 1-60 months), 10 patients (63%) remained alive with normal liver function and one submitted to retransplantation. CONCLUSIONS Portal vein arterialization results in acceptable rates of survival in relation to spontaneous outcomes in patients with completely de-arterialized livers. The management of complications (especially PHT) after the procedure is challenging. Portal vein arterialization may represent a salvage option or a bridge to liver retransplantation and thus may make curative resection in locally advanced HPB cancers with vascular involvement feasible.
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Affiliation(s)
- Prashant Bhangui
- Department of Surgery, Medanta Institute of Liver Transplantation and Regenerative MedicineDelhi, India
| | - Chady Salloum
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Chetana Lim
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Paola Andreani
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Arie Ariche
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - René Adam
- Department of Hepato-Biliary Surgery and Liver Transplantation, Paul Brousse Hospital, AP-HPVillejuif, France
| | - Denis Castaing
- Department of Hepato-Biliary Surgery and Liver Transplantation, Paul Brousse Hospital, AP-HPVillejuif, France
| | - Tech Kerba
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Daniel Azoulay
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
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Wang Z, Yang L. Gastric coronary vein to portal vein reconstruction in liver transplant: case report. EXP CLIN TRANSPLANT 2014; 12:562-4. [PMID: 24918690 DOI: 10.6002/ect.2013.0186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Portal vein thrombosis is a common complication in end-stage liver diseases of candidates for liver transplant. Most portal vein thromboses can be removed with thrombectomy. However, if the thrombosis extends to the distal superior mesenteric vein, it is difficult to reconstruct the portal vein. We report herein a case of dilated gastric coronary vein to portal vein reconstruction in liver transplant. CASE REPORT During the operation, the portal vein thrombosis was confirmed; it extended to the distal superior mesenteric vein. It could not be removed, and a jumping graft vein could not be used either. The dilated gastric coronary vein was dissected. After a piggy-back caval anastomosis, the recipient gastric coronary vein was anastomosed to donor portal vein using side-to-end anastomosis. Successive ultrasound studies demonstrated patent portal anastomosis. At postoperative day 30, computed tomography scans confirmed the patency of the portal anastomosis. The patient recovered fully and at the time of this writing, was doing well 1 year after transplant. Neither ascites nor upper gastrointestinal bleeding occurred. CONCLUSIONS If complete portal vein thrombosis extends to the distal superior mesenteric vein, and a jumping graft vein cannot be applied, the recipient gastric coronary vein or other collateral varix anastomosed to the donor portal vein is an alternative.
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Affiliation(s)
- Zifa Wang
- From the Department of Transplant, California Pacific Medical Center, 2340 Clay Street, Suite 118, San Francisco, California 94115, USA and the Department of General Surgery, First Affiliated Hospital, Xinxiang Medical University, 100 Jiankang Road, Weihui, Henan 453003, China
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Paloyo S, Nishida S, Fan J, Tekin A, Selvaggi G, Levi D, Tzakis A. Portal vein arterialization using an accessory right hepatic artery in liver transplantation. Liver Transpl 2013; 19:773-5. [PMID: 23554089 DOI: 10.1002/lt.23653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/26/2013] [Indexed: 01/12/2023]
Abstract
Portal vein thrombosis remains to be a challenging issue during liver transplantation even with the acquisition of innovative surgical techniques and years of experience. Most frequently, an initial eversion thromboendovenectomy is performed and depending on the extent of thrombosis and intraoperative findings, further revascularization options include venous jump grafts, portocaval hemitransposition, renoportal anastomosis or portal vein arterialization. Reports on these surgical approaches are limited although with acceptable outcomes. We present a 64-year-old patient with hepatitis C cirrhosis who underwent orthotopic liver transplantation with portal vein arterialization using an accessory right hepatic artery. Liver graft function has remained stable four years after transplant with notable aneurysmal dilatation of the portal vein.
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Affiliation(s)
- Siegfredo Paloyo
- Division of Transplantation, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.
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Management of nonneoplastic portal vein thrombosis in the setting of liver transplantation: a systematic review. Transplantation 2013; 94:1145-53. [PMID: 23128996 DOI: 10.1097/tp.0b013e31826e8e53] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonneoplastic portal vein thrombosis (PVT) is frequent in patients with cirrhosis who undergo liver transplantation (LT); however, data on its impact on outcome and strategies of management are sparse. METHODS A systematic review of the literature was performed by analyzing studies that report on PVT in LT recipients and were published between January 1986 and January 2012. RESULTS Of 25,753 liver transplants, 2004 were performed in patients with PVT (7.78%), and approximately half presented complete thrombosis. Thrombectomy/thromboendovenectomy was employed in 75% of patients; other techniques included venous graft interposition and portocaval hemitransposition. Overall, the presence of PVT significantly increased 30-day (10.5%) and 1-year (18.8%) post-LT mortality when compared to patients without PVT (7.7% and 15.4%, respectively). However, only complete PVT accounted for this increased mortality. Rethrombosis occurred in up to 13% of patients with complete PVT and in whom no preventative strategies were used, and was associated with increased morbidity and mortality. CONCLUSIONS PVT is common in patients with cirrhosis undergoing LT, and it affects survival when it is complete, at least in the short term after transplant. Therefore, screening for this condition is essential, alongside adequate treatment strategies to attempt repermeation of the PV and prevent thrombosis extension.
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Pécora RAA, Canedo BF, Andraus W, Martino RBD, Santos VR, Arantes RM, Pugliese V, D´Albuquerque LAC. Trombose de veia porta no transplante hepático. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012; 25:273-8. [DOI: 10.1590/s0102-67202012000400012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 06/17/2012] [Indexed: 02/14/2023]
Abstract
INTRODUÇÃO: A trombose de veia porta foi considerada contraindicação ao transplante de fígado no passado em razão da elevada morbi-mortalidade. Diversos avanços permitiram melhora dos resultados. OBJETIVO: Revisão dos avanços e das estratégias cirúrgicas utilizadas para realização do transplante de fígado na vigência de trombose de veia porta. MÉTODO: Revisão da literatura nas bases de dados Medline, Scielo, Lilacs cruzando os descritores: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Foram estudados a epidemiologia, fatores de risco, classificação, diagnóstico, estratégias cirúrgicas e resultados. CONCLUSÃO: A trombose de veia porta deixou de ser contraindicação para o transplante hepático. O cirurgião dispõe atualmente de uma série de estratégias para realização do transplante, variando conforme o grau da trombose. Apesar de implicar em maior morbidade e taxas de re-trombose, os resultados do transplante na presença de trombose portal são semelhantes aos observados nas séries habituais.
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Francoz C, Valla D, Durand F. Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 2012; 57:203-12. [PMID: 22446690 DOI: 10.1016/j.jhep.2011.12.034] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 12/08/2011] [Accepted: 12/22/2011] [Indexed: 12/13/2022]
Abstract
Portal vein thrombosis is not uncommon in candidates for transplantation. Partial thrombosis is more common than complete thrombosis. Despite careful screening at evaluation, a number of patients are still found with previously unrecognized thrombosis per-operatively. The objective is to recanalize the portal vein or, if recanalization is not achievable, to prevent the extension of the thrombus so that a splanchnic vein can be used as the inflow vessel to restore physiological blood flow to the allograft. Anticoagulation during waiting time and transjugular intrahepatic portosystemic shunt (TIPS) are two options to achieve these goals. TIPS may achieve recanalization in patients with complete portal vein thrombosis. However, a marked impairment in liver function, which is a characteristic feature of most candidates for transplantation, may be a contraindication for TIPS. Importantly, the MELD score is artificially increased by the administration of vitamin K antagonists due to prolonged INR. When patency of the portal vein and/or superior mesenteric vein is not achieved, only non-anatomical techniques (renoportal anastomosis or cavoportal hemitransposition) can be performed. These techniques, which do not fully reverse portal hypertension, are associated with higher morbidity and mortality risks. Multivisceral transplantation including the liver and small bowel needs to be evaluated. In the absence of prothrombotic states that may persist after transplantation, there is no evidence that pre-transplant portal vein thrombosis justifies long term anticoagulation post-transplantation, provided portal flow has been restored through conventional end-to-end portal anastomosis.
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Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care, Hopital Beaujon, Clichy, INSERM U773 CRB3, University of Paris VII Denis Diderot, Paris, France
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Abstract
OBJECTIVE To evaluate the clinical outcomes of multivisceral transplantation (MVT) in the setting of diffuse thrombosis of the portomesenteric venous system. BACKGROUND Liver transplantation (LT) in the face of cirrhosis and diffuse portomesenteric thrombosis (PMT) is controversial and contraindicated in many transplant centers. LT using alternative techniques such as portocaval hemitransposition fails to eliminate complications of portal hypertension. MVT replaces the liver and the thrombosed portomesenteric system. METHODS A database of intestinal transplant patients was maintained with prospective analysis of outcomes. The diagnosis of diffuse PMT was established with dual-phase abdominal computed tomography or magnetic resonance imaging with venous reconstruction. RESULTS Twenty-five patients with grade IV PMT received 25 MVT. Eleven patients underwent simultaneous cadaveric kidney transplantation. Biopsy-proven acute cellular rejection was noted in 5 recipients, which was treated successfully. With a median follow-up of 2.8 years, patient and graft survival were 80%, 72%, and 72% at 1, 3, and 5 years, respectively. To date, all survivors have good graft function without any signs of residual/recurrent features of portal hypertension. CONCLUSIONS MVT can be considered as an option for the treatment of patients with diffuse PMT. MVT is the only procedure that completely reverses portal hypertension and addresses the primary disease while achieving superior survival results in comparison to the alternative options.
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Maggi U, Camagni S, Reggiani P, Lauro R, Sposito C, Melada E, Rossi G. Portal vein arterialization for hepatic artery thrombosis in liver transplantation: a case report, Doppler-ultrasound aspects, and review of the literature. Transplant Proc 2010; 42:1369-74. [PMID: 20534305 DOI: 10.1016/j.transproceed.2010.03.087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Portal vein arterialization (PVA) is a salvage procedure for insufficient hepatic arterial or portal vascularization. It plays a role in auxiliary and orthotopic liver transplantation (OLT). In OLT, current indications for PVA include hepatic artery thrombosis (HAT), pre-OLT or post-OLT extended splanchnic vein thrombosis, intraoperative low portal flow, and anatomic variations like the absence of portal and mesenteric veins. Out of the transplantation domain, PVA is used both in extensive surgery for malignancies of the liver, biliary tract, and pancreas and in the treatment of fulminant hepatic failure (FHF) due to intoxications. We describe a case of acute post-OLT HAT successfully treated with PVA as a short bridge to retransplantation. By Doppler ultrasound of clinical PVA we detected an increased intrahepatic portal flow velocity, with disappearance of the arterial spikes, a finding that needs further investigation. PVA represents a rare surgical procedure. In fact, it has been used most of all in urgent conditions or in case of abrupt vascular complications during surgery. According to the literature, PVA emerges as a salvage procedure for poor arterial or portal hepatic flow, both in OLT and in general abdominal surgery. The outcome of this procedure is unpredictable. The aim of the shunt is to gain time, awaiting the onset of collateral arterial vessels or the performance of definitive surgery. Its early thrombosis may be a catastrophic event, due to acute liver ischemia. In contrast, a late occlusion is often well tolerated. Strict surveillance is always useful because sometimes it is mandatory to embolize the arterioportal fistula to treat or to prevent the onset of portal hypertension.
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Affiliation(s)
- U Maggi
- Unitá Operativa Chirurgia Generale e Trapianti di Fegato, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano, Italy.
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Nemes B, Görög D, Fehérvári I, Mándli T, Sárváry E, Kóbori L, Doros A, Fazakas J. Unusual portal reconstructions after liver transplantation — Case report and review of literature. Interv Med Appl Sci 2010. [DOI: 10.1556/imas.2.2010.3.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Portal vein reconstruction might be a challenge in certain cases of liver transplantation. The problem usually arises due to small vessels in pediatric transplantation and/or living related donor and split liver transplantation, or as a result of extensive PVT in adult recipients. Authors report a case of a 60-year-old alcoholic cirrhotic patient with reverse portal flow. The standard end to end portal anastomosis did not work well, so a mesoportal shunt with a donor iliac vein conduit was performed first, followed by a cavoportal hemitransposition. After unsuccessful attempts of providing good portal flow, the donor umbilical vein and the iliac conduit was used for portal flow reconstruction as meso-Rex graft. The patient has been doing fine for eight months after her liver transplantation. Unusual types of portal reconstructions consist of meso-portal, umbilico-portal, renoportal anastomoses that are primarily used as rescue techniques. However, it is rare that one has to use them sequentially in the same patient.
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Affiliation(s)
- Balázs Nemes
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - D. Görög
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - I. Fehérvári
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - T. Mándli
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - E. Sárváry
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - L. Kóbori
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - A. Doros
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - J. Fazakas
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
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