Stenosis of the hepatic vein anastomosis after liver transplantation: treatment with a heparin-coated metal stent

Early posttransplant hepatic venous outflow obstruction: Long-term efficacy of primary stent placement

Although balloon angioplasty has been accepted as the safe and effective initial treatment to manage hepatic venous outflow abnormalities, it may induce rupture of the fresh anastomosis but also may be ineffective to eliminate various etiologies of venous outflow abnormalities in the early post-transplant period. Therefore, we performed primary stent placement in 108 patients to treat early-onset (</=4 weeks) post-transplant hepatic venous outflow abnormality. The following parameters were documented retrospectively: technical success and complications: clinical success; recurrence; and patency of stent-inserted hepatic veins.Technical success was achieved in 166 (97.6%) of 170 anastomoses (107 patients). Major complications occurred in 5 (4.6%) patients: partial stent migration (n = 2) and stent malposition (n = 3). Clinical success was achieved in 83 (82.2%) of 101 patients who had abnormal liver enzymes or clinical symptoms. Seven patients without initial clinical symptoms have remained healthy. Restenosis or occlusion of the stent-inserted hepatic veins was documented in 22 patients at a mean of 9.6 +/- 8.6 months after stent placement. Four of them underwent stent replacement or retransplantation due to liver function deterioration. Overall 1-, 3-, and 5-year primary patency rates were 82.3 +/- 0.3%, 75.0 +/- 0.4%, and 72.4 +/- 0.5%, respectively. Multivariate Cox regression analysis showed that diameter of stents was an independent factor associated with patency of stents (p = 0.001).Primary stent placement seems to be an effective treatment modality with an acceptable long-term patency to treat early post-transplant hepatic venous outflow obstruction.

Endovascular stent placement for interposed middle hepatic vein graft occlusion after living-donor liver transplantation using right-lobe graft

Middle hepatic vein (MHV) reconstruction is performed to drain the right paramedian sector to prevent hepatic venous congestion (HVC). The aim of the present study was to evaluate endovascular stent placement in patients with stenosed and/or occluded interposition vein graft (IVG) to segment V hepatic vein (V5) and segment VIII hepatic vein (V8) after living-donor liver transplantation (LDLT). The procedure was performed in 11 recipients; 7 underwent it within 24 hours of LDLT. The following parameters, including technical success, clinical success, complications, patient survival data, and serial computed tomography (CT) findings during follow-up, were documented retrospectively. Technical success was defined as both successful stent placement and resolution of stenosis or occlusion with copious flow of contrast medium through the stent, while clinical success was defined as both improvement of liver function tests (LFTs) and reduction or disappearance of hepatic low-attenuation areas on follow-up CT scans taken within 1 week of stent placement. Technical success was achieved in 10 of 11 patients (91%), and clinical success was achieved in 9 of 11 patients (82%). Acute thrombotic occlusion of the stent-inserted hepatic vein occurred in 1 patient 1 day following stent placement. During the mean follow-up period of 468 days (range, 13-891 days), 9 patients survived and 2 patients died. No death was directly related to stent placement or its related complications. The low-attenuation area in the involved hepatic segment V (S5) and/or VIII (S8) area prior to stent placement disappeared completely on follow-up CT scans performed at 3-12 days (mean, 5.4 days) after stent placement in all 9 patients with clinical success. No attenuation change occurred even in cases with chronic occlusion of the stent-inserted hepatic veins. In conclusion, though IVG to V5 and V8 remains controversial, the treatment of their stenosis or occlusion is safe and effective, even during their immediate postoperative period.

Thromboembolism in Plastic Surgery

Thromboembolism is a dreaded complication of surgery in multiple disciplines, including plastic surgery, and deep venous thrombosis and pulmonary embolus cause significant morbidity, even death. This article provides methods for understanding and preventing deep venous thrombosis and pulmonary embolus in plastic surgery.

Efficacy of cutting balloon for anastomotic stricture of the hepatic vein

Anastomotic stricture of the hepatic vein is an annoying complication, especially in living donor liver transplantation. Balloon dilation has been utilized but is sometimes associated with recurrences. Recently, a cutting balloon was invented for treatment of arteriosclerosis. Herein we report the results of application of this device for treatment of anastomotic strictures of the hepatic vein in two living donor liver transplant recipients who underwent percutaneous dilation of the hepatic vein with a cutting balloon (8 x 10 mm, Atherotome, Boston Scientific). Case 1, a 26-year-old woman transplanted for subacute fulminant hepatitis, had been treated for an anastomotic stricture by balloon dilation on 15 occasions over a 2- to 3-month interval. Case 2, a 13-year-old boy transplanted for cryptogenic liver cirrhosis, had been treated for an anastomotic stricture by balloon dilation biannually. The cutting balloon was applied safely without severe complications. The first case showed a recurrent anastomotic stricture at 6 months after dilation. Follow-up at 6 months in the second case revealed a mild recurrence of the stricture. Anastomotic stricture of the hepatic vein jeopardizes the graft and the recipient. The reported treatments involve venoplastic surgery and expandable metallic stents. Application of a cutting balloon seemed to be a safe, convenient modality. However, its effect was not indefinite, so a cutting balloon of greater diameter or application of an expandable metallic stent may be considered for patients with multiple recurrences of their anastomotic stricture.

Hepatic vein anastomotic stricture after living donor liver transplantation

This report discusses the pathophysiology of and therapeutic methods to address hepatic vein anastomotic stricture after living donor liver transplantation (LDLT). From 1994 to 2002, our 15 LDLTs using the lateral segments or left lobes included four recipients who experienced 28 occurrences of this complication after the operation. The period between LDLT and the first stricture was 4.0 +/- 1.2 months. The age of the affected recipients (31.0 +/- 8.2 years) was significantly higher than that of the nonaffected patients (7.0 +/- 4.1 years, P < .05). Graft liver/standard liver volume ratio was 39.1% +/- 3.8% in the former and 77.9% +/- 12.7% in the latter cases (P < .05). Initial symptoms of stricture were ascites (42.9%), abdominal distention (42.9%), liver enzyme elevation (10.7%), and gastrointestinal bleeding (3.6%). In addition, 14 of 28 stricture cases (50%) showed increased blood trough levels of tacrolimus. Doppler ultrasonography was used for diagnosis, and balloon dilatations performed in all stricture patients, thereby hepatic significantly reducing venous blood pressure from 33.5 +/- 1.7 to 20.3 +/- 1.5 cmH2O. All patients finally resolved the strictures after several treatments. The stricture after LDLT was associated with small-for-size grafts, suggesting that liver regeneration may lead to anatomical changes and strictures. Since tacrolimus is metabolized by the liver, its blood trough level is one initial symptoms of stricture. Balloon dilatation was useful and safe as the treatment, while problems have been reported after stent insertion in the hepatic vein.