Liver Transplantation in Patients With Complete Portal Vein Thrombosis: Renoportal or Varicoportal Anastomosis Using Cryopreserved Vein Grafts

A novel approach for portal system reconstruction in liver transplant patients with grade IV portal vein thrombosis: Case study and literature review

Background

Portal vein thrombosis is a common problem of end-stage liver disease in patients with portal hypertension and Yerdel grade IV thrombosis may be a contraindication for liver transplantation. Advances in surgical technique have indicated the feasibility of liver transplantation with PVT such as Reno-portal anastomosis, cavo-portal hemitransposition, but low graft portal blood perfusion and regional portal hypertension were the limitations.

Methods

We introduce a new approach for portal system reconstruction in a patient underwent liver transplantation: A 28-year-old male was diagnosed with Budd-Chari syndrome and portal hypertension with grade IV portal vein thrombosis.

Results

The "Pull-out" technique was applicated for thrombectomy, which can aid in exposing the superior mesenteric vein and portal vein branches and reducing technical difficulties associated with the identification and dissociation of surrounding anatomical structures. To collect sufficient portal vein blood perfusion and avoid regional portal hypertension, the portal vein system was reconstructed through double-approach procedure: reno-portal anastomosis combined with portal-portal anastomosis.

Conclusion

Based on a precision preoperative evaluation, application of the Pull-out technique and double-approach procedure may be an effective method of thrombectomy especially in cases of grade IV portal vein thrombosis.

Multivisceral transplant as an option to transplant cirrhotic patients with severe portal vein thrombosis

Non-tumoral portal vein thrombosis (PVT) is a critical complication in the patient with advanced cirrhosis awaiting liver transplantation (LT). With the evolution of liver transplant (LT) technique, PVT has morphed from an absolute contraindication to a relative contraindication, depending on the grade of the thrombus. The Yerdel classification is one system of grading PVT severity. Patients with Yerdel class 1-3 PVT can undergo LT at centers with experience in complex portal vein (PV) dissection, thrombectomy, and reconstruction. Class 4 PVT, however, is even more complex and may require heroic techniques such as cavoportal hemitransposition, PV arterialization or multivisceral transplant (MVT). Some centers use a MVT back-up approach for patients with Yerdel class 4 PVT. In these patients, all organs with PV outflow are procured simultaneously as a cluster graft from a deceased donor (liver, pancreas, intestine±stomach). If physiologic PV inflow is established intraoperatively, the recipient undergoes LT. Otherwise the MVT graft is transplanted. MVT establishes physiologic PV flow, but transplantation of the intestine confers significant lifelong risks including rejection, graft-versus host disease and post-transplant lymphoma. Yerdel class 1-4 PVT patients undergoing successful LT have 5-year survival similar to non-PVT patients, while patients requiring full MVT experience somewhat higher mortality because of the complexity of the surgery and medical management.

Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation

Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.

Liver Transplant in Patients With Portal Vein Thrombosis: The Experience of 55 Patients

OBJECTIVES

Portal vein thrombosis is no longer a contraindication for liver transplantation. However, varied outcomes are still reported with regard to patients with complete portal vein thrombosis.

MATERIALS AND METHODS

We analyzed data of 505 patients who underwent liver transplant between January 2014 and June 2017. Of 505 patients, 55 (10.9%) had portal vein thrombosis, which included 37 patients (67%) who had living-donor and 18 patients (33%) who had deceased-donor liver transplant. According to Yerdel classification, 5 (9%), 28 (51%), 12 (22%), and 10 patients (18%) had grade I, II, III, and IV portal vein thrombosis, respectively.

RESULTS

Thrombectomy was successful in 46 patients (84%). Forty-three patients had patent portal inflow (93.5%), but 3 patients (6.5%) required a second thrombectomy on day 1 posttransplant. Of 10 patients with grade IV portal vein thrombosis, 9 (16%) underwent extra-anatomic portal vein anastomosis. Of these 9 patients, 7 (77.7%) showed patent portal inflow during the early postoperative period. Median follow-up time was 15.5 ± 13.1 months. During this time, portal vein stenosis was detected in 5 patients. Risk of repeat thrombosis was not significantly different between patients with deceased-donor and patients with living-donor liver transplant. Overall patient survival rates for patients with and without portal vein thrombosis were 73% (40/55) and 84% (376/450), respectively, which showed significant difference (P = .05).

CONCLUSIONS

In contrast to early-grade portal vein thrombosis, complete portal vein thrombosis still provides a treatment challenge with high risk of morbidity and poor early outcomes in liver transplant recipients.

Congenital Thrombophilia in Patients With Superior Mesenteric Venous Thrombosis or Portal Vein Thrombosis

We explored the relationship between abdominal vein thromboses, including portal vein thrombosis (PVT) and superior mesenteric vein thrombosis (SMVT), and thrombophilia. The frequency of thrombophilia, such as antithrombin (AT), protein C (PC), or protein S (PS) gene mutations, was examined in 21 patients with PVT, 6 patients with SMVT, and 6 patients with both PVT and SMVT. Low levels of AT, PC, or PS were frequently detected in patients with PVT or mesenteric vein thrombosis, and 4 mutations in the PS gene, 3 mutations in the PC gene, and 2 mutations in AT the gene were detected. Protein S Tokushima was detected in 3 of 4 patients with a PS gene mutation and was associated with 2 other PS gene mutations. The onset of PVT or SMVT was almost idiopathic in patients with congenital thrombophilia. Both PVT and SMVT were frequently caused by an AT, a PC, or a PS mutation, and the onset of these thromboses due to thrombophilia was frequently idiopathic.