Diagnosis and treatment of late-onset portal vein stenosis after pediatric living-donor liver transplantation

Interventional Management of Portal Vein Stenosis after Liver Transplant: Single Center Experience

OBJECTIVES

Portal vein stenosis is a relatively rare complication after liver transplant but has severe consequences. We evaluated the efficacy and longterm results of the endovascular treatment methods for portal vein stenosis.

MATERIALS AND METHODS

From October 2011 to October 2022, we treated 22 patients (5 female, 17 male) with portal vein stenosis using endovascular methods. Doppler ultrasonography was used for initial diagnosis, with consideration of flow rate increase over stenosis, absence of flow, or reduced anastomotic segment size (>50%). Angiography served as the gold standard, with a pressure gradient above 5 mm Hg indicating the need for treatment. Technical success criteria were defined as <50% stenosis remaining and/or a pressure gradient <5mm Hg. The transhepatic approach was used for all patients. Balloon angioplasty was initially performed, and stents were reserved for patients in the early postoperative period or those unresponsive to balloon angioplasty.

RESULTS

The technical success rate was 100%. Mean age was 27.1 years (SD 22.4; range, 4 months to 63 years). Mean time from transplant to intervention was 317 days (range, 0-3135 days). Angioplasty was successful for 7 patients (13.8%). Of 15 patients who underwent stent placement, 9 (40.9%) were in the early postoperative period; in the other 6 patients (27%), results of angioplasty were not satisfactory, and stents were placed. Within 3 months of transplant, 3 patients died because of other complications. Among patients with stents, 2 required reintervention, resulting in reestablishment of good portal venous flow. During the mean follow-up of 24 months (range, 15 days to 9 years), 19 patients (86%) had portal flows within reference limits.

CONCLUSIONS

The endovascular approach is a safe and effective treatment option for management of portal vein stenosis in both adult and pediatric liver transplant recipients in the early or late period.

Portal vein complications and outcomes following pediatric liver transplantation: Data from the Society of Pediatric Liver Transplantation

Children who undergo liver transplantation are at risk for portal vein complications (PVCs) including thrombosis (PVT) and stenosis (PVS). Using multicenter data from the Society of Pediatric Liver Transplantation, we analyzed the prevalence, timing, and risk factors for PVC following a first liver transplantation, and assessed the potential impact of PVC on patient outcomes. Our cohort included 4278 patients, of whom 327 (7.6%) developed PVC. Multivariate analysis discovered several factors independently associated with PVC: younger recipient age, lower weight at time of transplantation, diagnosis of biliary atresia (BA), receiving a technical variant graft (TVG), warm ischemia time over 3 h, PVT in the recipient's pretransplantation native liver, and concurrent hepatic artery thrombosis (all p < 0.05). Subgroup analysis of those with BA found higher prevalence in patients transplanted at less than 2 years of age and those with TVGs. There was no difference in PVC prevalence among patients with BA with vs. without prior Kasai portoenterostomy. Most PVT (77.7%) presented within 90 days after transplantation. Patients with PVC had a higher risk of graft failure (23.9% vs. 8.3%; adjusted hazard ratio [HR], 3.08; p < 0.001) and a higher risk of death (16.4% vs. 8.9%; adjusted HR, 1.96; p = 0.01). Recurrence after retransplantation was similar to the overall prevalence in the cohort (8.2%). Our results recognize the common occurrence of PVC following pediatric liver transplantation, describe independently associated risk factors, and determine that patients with PVC have worse outcomes. Further studies are needed to improve PVC prevention, detection, and management strategies.

Percutaneous transhepatic interventional therapy of portal vein stenosis in paediatric liver transplantation: A systematic review of efficacy and safety

PURPOSE OF THE SYSTEMATIC REVIEW

To determine the efficacy and safety of percutaneous trans-hepatic balloon and/or stent angioplasty (PTA) in the management of portal vein (PV) stenosis following paediatric liver transplantation.

METHODS

Articles were included from a systematic search of Medline, Embase, Cochrane CENTRAL, ClinicalTrials.gov and International Clinical Trials Registry from inception to the 29th of August 2020.

RESULTS

There were 213 paediatric liver recipients who underwent PTA for PV stenosis in 19 included studies published between 1991 and 2019. Balloon angioplasty was the initial treatment in the majority (n = 153). Primary stent placement (n = 34) was performed for elastic recoil, intimal tears and PV kinks and rescue stent placement (n = 14) for recurrent PV stenosis following primary balloon angioplasty. The technical success was 97.6%-100% overall, 97.6%-100% for balloon-angioplasty-only and 100% for primary stenting. The clinical success was 50%-100% overall, 50%-100% for balloon-angioplasty-only and 100% for primary stenting. Long-term PV patency was 50%-100% overall, 37.5%-100% for balloon-angioplasty-only and 100% for primary stenting. Primary balloon angioplasty was successful in 78% of the cases. Of the recurrent PV stenoses, 9% resolved with stent placement and one required a meso-Rex shunt. There was one re-transplantation without stenting. The complication rate was 2.6% for balloon-angioplasty-only (bleeding, liver abscess, 2 PV thromboses) and 5.9% for primary stenting (bleeding, stent-fracture). There was no procedure-related mortality.

CONCLUSION

Percutaneous transhepatic balloon angioplasty may be the initial management of portal vein stenosis in paediatric liver recipients. Stent placement may be a primary option in selected cases and a reliable rescue option for recurrent portal vein stenosis following balloon-angioplasty-only.

Portal vein obstruction after pediatric liver transplantation: A systematic review of current treatment strategies

INTRODUCTION

Portal vein obstruction (PVO) is a significant vascular complication after liver transplantation (LT) in pediatric patients. Current treatment strategies include percutaneous transluminal angioplasty (PTA), with or without stent placement, mesorex bypass (MRB), splenorenal shunt, mesocaval shunt, endovascular recanalization (EVR), splenic artery embolization and splenectomy. However, specific characteristics of patients undergoing intervention and selection of individual treatment and its efficacy have remained unclear. This review systematically analyzed biochemical and clinical characteristics, selection of treatment, efficacy, and post-procedural complications.

METHODS

We systematically searched PubMed and Embase between January 1995 and March 2021 for studies on the management of PVO after LT. We analyzed the reports for biochemical and clinical characteristics at the timing of the intervention in different patients, selection of treatment, and reported efficacies.

RESULTS

We found 22 cohort studies with 362 patients who had the following characteristics: biliary atresia (83%), living-donor LT (85%), thrombocytopenia (73%), splenomegaly (40%), ascites (16%), or gastrointestinal bleeding (26%). The 3-year primary patency of PTA without stent placement was similar to that with stent placement (70%-80% and 43%-94%, respectively). MRB was used as an initial treatment with a 3-year patency of 75% to 100%. One study showed that 5-year primary patency of EVR was 80%. Secondary patency was 90% to 100% after 3 years in all studies with PTA alone, PTA/stent placement, and stent placement alone.

CONCLUSION

This is the first review of all treatment protocols in PVO after pediatric LT. We showed that an important group of patients has severe symptoms of portal hypertension. Efficacy of all treatment modalities was high in the included studies which make them important modalities for these patients.

The Application of Interventional Radiology in Living-Donor Liver Transplantation

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

Risk factors for portal vein stenosis in pediatric liver transplantation

OBJECTIVE

To analyze the incidence and risk factors of portal vein stenosis (PVS) in pediatric liver transplantation (LT).

METHODS

This retrospective analysis of 396 cases of pediatric LT (patients aged ≤ 14 years old) was conducted at the Liver Transplantation Center of Beijing Friendship Hospital (China) from June 2013 to December 2017. We collected relevant data and calculated the incidence. We analyzed a total of 23 risk factors for PVS children during the perioperative period.

RESULTS

The incidence of PVS in pediatric LT was 6.6%. The following were identified as risk factors for PVS in pediatric LT: Preoperative portal hypertension was complicated, weight (≤7 kg), recipients of portal vein diameter ≤4 mm, GRWR (≥3.5%), the use of cold preservation vein grafts, anastomosis in the region of superior mesenteric vein and splenic vein and reverse blood flow in the portal vein shown in preoperative ultrasound examination. Recipients of portal vein diameter ≤4 mm and the use cold preservation grafts were independent risks factors for PVS in pediatric LT.

CONCLUSION

For recipients with the risk factors identified in this study, we strongly recommend a strict follow-up and the provision of suitable interventions when indicated.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study)

OBJECTIVES

Hepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.

METHODS

We retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.

RESULTS

The overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.

CONCLUSION

HA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study)

Objectives

Hepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.

Methods

We retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.

Results

The overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.

Conclusion

HA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

•

Preoperative PVT was significant predictor of HA and/or PV complications.

•

HA and/or PV complications especially early ones lead to significant poor outcome.

•

Proper dealing with the risk factors like pre LT PVT improves outcome.

•

The effective management of these complications is mandatory for improving outcome.

Current state of the art in management of vascular complications after pediatric liver transplantation

Vascular complications by compromising the blood flow to the allograft can have significant and sometimes life-threatening consequences after pediatric liver transplantation. High level of suspicion and aggressive utilization of diagnostic modalities can lead to early diagnosis and salvage of the allograft. This review will summarize the current trends in management of vascular complications after pediatric liver transplantation.

Immunosuppressive Medication Adherence, Therapeutic Adherence, School Performance, Symptom Experience, and Depression Levels in Patients Having Undergone a Liver Transplant During Childhood

OBJECTIVES

This study sought to investigate immunosuppressive medication adherence, therapeutic adherence, school performance, symptom experiences, and depression levels of patients having undergone liver transplant during childhood.

MATERIALS AND METHODS

We performed a retrospective, cross-sectional, case-controlled study to compare the depression levels of subjects with those of their healthy peers. Data were collected between June 23, 2014, and July 10, 2014, from 0- to 18-year-old patients having undergone a liver transplant between 1996 and 2014 (n = 27; the participant's mean age, 17.59 y [SD = 4.29, min-max = 8-28 y]). The mean score for the immunosuppressant therapy adherence was 11.18. To collect the data, the Demographic and Clinical Characteristics Form, Immunosuppressant Therapy Adherence Scale, Therapeutic Regimen Adherence Assessment Questionnaire, School Performance Assessment Questionnaire, Modified Transplant Symptom Occurrence and Symptom Distress Scale-58, and Beck Depression Inventory were used. To analyze the data, descriptive statistics (frequencies, mean, and standard deviation), Mann-Whitney U test, and ridit scoring were used.

RESULTS

While the rate of adherence with clinical appointments was 55.5%, it was 33.3% with the diet (prescribed regimen) and 44.4% with exercise. While 33.3% of the participants repeated a grade or were held back, 44.4% of them missed more than 20 school days. Of the symptoms, the recipients mostly experienced anxiety, restlessness, nervousness, fatigue, and difficulty in concentrating. The patients' mean depression score was 7.77 when they were compared to their healthy peers, the difference was not statistically significant (P > .05).

CONCLUSIONS

In our study, the recipients' adherence with immunosuppressive therapy and clinical appointment was high. This study will provide data for the literature about pediatric liver transplant recipients' adherence with diet and exercise, and physiological and psychological symptoms such as fatigue and anxiety.

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

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

Radiologic assessment of hepatobiliary surgical complications

The complexity of hepatobiliary procedures continues to evolve at a rapid rate, with an increasing number of living donor liver transplants and extensive cancer resections being performed. The associated complications are a significant cause of morbidity and mortality, and are often complex injuries, involving both vascular and biliary structures. In this paper we describe the complications associated with laparoscopic cholecystectomy, liver transplant surgery, and hepatic resection. Focus is on the classical imaging appearances, imaging modality options, and varying management strategies for these injuries, to show how the radiologist's role is vital in ensuring the correct diagnosis is made and the appropriate treatment is instigated.

Interventional treatment of lumen-reconstruction-related complications after pediatric living-donor liver transplantation

BACKGROUND

Interventional radiology has recently been reported as an effective means of treating complications after liver transplantation. In children, however, the number of such reports is relatively small. In addition, there is ongoing discussion regarding the best interventional devices and methods for specific complications.

OBJECTIVE

The aim of this study was to determine the value of interventional treatment for vessel and bile duct complications after pediatric living-donor liver transplantation.

MATERIALS AND METHODS

Six cases with lumen-reconstruction-related complications after liver transplantation received intervention. Three cases had hepatic artery thrombosis, one had portal vein stenosis, and two had bilioenteric anastomotic stenosis. Catheter-directed thrombolysis was used to treat cases with hepatic artery thrombosis; balloon dilation and stent placement were used for portal vein stenosis; balloon dilation and drainage were used for bilioenteric anastomotic stenosis.

RESULTS

All interventions were performed successfully, and treatment efficacy was 100 %. Except for one death from multiple organ failure, all other cases survived through follow-up, which lasted up to 18 months. No case had intervention-related complication.

CONCLUSION

Interventional treatment is safe and effective, and can be the first choice for the treatment of complications associated with pediatric living-donor liver transplantation.