Portal interventions in liver transplant recipients

Contrast-enhanced abdominal CT compared with splenoportography in postliver transplant with giant varix and thrombus in portal vein: Case report

Imaging remains an essential aspect in evaluating patients receiving liver transplants, especially in cases of complications such as portal vein thrombosis. Several imaging modalities are available to approach portal vein thrombosis, with portography as the gold standard. However, the development of noninvasive methods such as contrast-enhanced computed tomography (CECT) is preferred nowadays due to the fewer complications in nature. This case report presented a case of a giant varix of the portal vein with thrombus in a 20-year-old male receiving living-donor liver transplant, reliably visualized in both CECT and direct splenoportography. Detailed parameters and sequences required for accurate imaging in CECT are discussed in this study.

Endovascular resolution of post-surgical complications in the portal vein: Report of two cases

Stenosis of the portal vein is one of the main complications after hepatobiliar and pancreatic surgery, with a reported incidence of 19.6% after pancreaticoduodenectomy and 3% after liver transplant. It is associated with the intraoperative resection of the portal vein, local recurrence of the primary tumor and radiotherapy. The portal lesion secondary to bile drainage catheter insertion is extremely rare or unusual, with few cases described in the literature. This article describes 2 cases: the first of a male patients 49 years old post-operative to liver transplant with partial portal thrombosis and stenosis of the mesoportal joint, and the second a female patient 50 years old with history of cholecystectomy, exploration of the bile duct and placement of Kehr "T" tube with secondary portal lesion. The 2 cases were successfully treated through minimally invasive procedures by an interventionist radiologist.

Endovascular Stenting for Idiopathic Stenosis of the Superior Mesenteric Vein: A Case Report

Idiopathic superior mesenteric vein (SMV) stenosis, where no clear causative factor is identifiable, remains a clinical rarity. We present a detailed case report of a patient with idiopathic stenosis of the SMV who underwent successful endovascular stenting. This report outlines the patient's clinical presentation, diagnostic imaging findings, procedural approach by the interventional radiology team, and subsequent management. Endovascular stenting is a viable therapeutic option for patients with idiopathic SMV stenosis. This case demonstrates that with appropriate interventional and post-procedural management, long-term stent patency and thrombosis prevention can be achieved. The success of this case encourages further investigation into endovascular treatments for venous stenoses.

Algorithmic Approach to Deranged Liver Functions After Transplantation

Liver transplant (LT) recipients require close follow-up with regular monitoring of the liver function tests (LFTs). Evaluation of deranged LFT should be individualized depending upon the time since LT, peri-operative events, clinical course, and any complications. These derangements can range from mild and asymptomatic to severe and symptomatic elevations requiring expedited personalized assessment and management. Pattern of LFT derangement (hepatocellular, cholestatic, or mixed), donor-recipient risk factors, timing after LT (post-operative, 1-12 months, and >12 months since LT) along with clinical context and symptomatology are important considerations before proceeding with the initial evaluation. Compliance to immunosuppression and drug interactions should be ascertained along with local epidemiology of infections. Essential initial evaluation must include an ultrasound abdomen with Doppler to rule out any structural causes such as biliary or vascular complications apart from focussed laboratory evaluation. Early allograft dysfunction, ischemia reperfusion injury, small-for-size syndrome, biliary leaks, hepatic artery, and portal vein thrombosis are usual culprits in the early post-operative period whereas viral hepatitis (acute or reactivation), opportunistic infections, and recurrence of the primary disease are more frequent in the later period. Graft rejection, biliary strictures, sepsis, and drug induced liver injury remain possible etiologies at all times points after LT. Initial evaluation algorithm must be customized based on history, clinical examination, risk factors, and pattern and severity of deranged LFT. Allograft rejection is a diagnosis of exclusion and requires liver biopsy to confirm and assess severity. Empirical treatment of rejection sans liver biopsy is discouraged.

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.

Pediatric Transplant Interventions

The field of pediatric organ transplantation has grown significantly in recent decades, with interventional radiology (IR) playing an essential role in managing pre and post-transplant complications. Pediatric transplant patients face unique challenges compared to adults, including donor-recipient size mismatch, and complications of a growing child with changing physiology. Interventional radiologists play a major role in pediatric renal and liver transplant. IR interventions begin early in the child's pretransplant journey, with diagnostic procedures such as biopsies, angiograms, and cholangiograms. These procedures are essential for understanding the etiology of organ failure and identifying potential transplant candidates. Minimally invasive therapeutic procedures may serve as bridges to transplant and may include vascular access optimization for hemodialysis, transjugular intrahepatic portosystemic shunts (TIPS) creation, and tumor embolization or ablation. After transplant, image-guided biopsies for the surveillance of graft rejection and treatment of vascular or luminal stenoses, pseudoaneurysms, and anastomotic leaks can maintain the function and longevity of the transplant organ. Careful consideration must be given to patient size and evolving anatomy, radiation exposure, and the need for deeper sedation for pediatric patients. Despite these challenges, the integration of IR in pediatric transplant care has proven beneficial, offering minimally invasive alternatives to surgery, faster recovery times, and improved outcomes.

Endovascular Treatment of Venous Outflow and Portal Venous Complications After Liver Transplantation

Liver transplantation continues to rapidly evolve, and in 2020, 8906 orthotopic liver transplants were performed in the United States. As a technically complex surgery with multiple vascular anastomoses, stenosis and thrombosis of the venous anastomoses are among the recognized vascular complications. While rare, venous complications may be challenging to manage and can threaten the graft and the patient. In the last 20 years, endovascular approaches have been increasingly utilized to treat post-transplant venous complications. Herein, the evaluation and interventional treatment of post-transplant venous outflow complications, portal vein stenosis, portal vein thrombosis, and recurrent portal hypertension with transjugular intrahepatic portosystemic shunt (TIPS) are reviewed.

Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.

Vascular complications after liver transplantation: contemporary approaches to detection and treatment. A literature review

Vascular complications (VCs) after liver transplantation (LT) are rare but are one of the most dreaded conditions that can potentially lead to graft loss and recipient death. This paper has analyzed the international experience in the early diagnosis of various VCs that can develop following LT, as well as the optimal timing and methods of treatment of these complications.

Imaging and Intervention in the Management of Vascular Complications Following Liver Transplantation

Liver transplantation is the treatment of choice in majority of the patients with end stage liver disease. Vascular complication following liver transplantation is seen in around 7-13% of the patients and is associated with graft dysfunction and high morbidity and mortality. Early diagnosis and prompt treatment are crucial in management of these patients. Advances in interventional radiology have significantly improved the management of vascular complications using minimally invasive percutaneous approach. Endovascular management is preferred in patients with late hepatic artery thrombosis, or stenosis, whereas retransplantation, surgical revision, or endovascular management can be considered in patients with early hepatic artery thrombosis or stenosis. Hepatic artery pseudoaneurysm, arterioportal fistula, and splenic artery steal syndrome are often treated by endovascular means. Endovascular management is also preferred in patients with symptomatic portal vein stenosis, early portal vein thrombosis, and symptomatic late portal vein thrombosis, whereas surgical revision or retransplantation is preferred in patients with perioperative portal vein thrombosis occurring within 3 days of transplantation. Venoplasty with or without stent placement can be considered in patients with hepatic venous outflow tract or inferior vena cava obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) may be required in transplant recipients who develop cirrhosis, often, secondary to disease recurrence, or chronic rejection. Indications for TIPS remain same in the transplant patients; however, major difference is altered vascular anatomy, for which adjunct techniques may be required to create TIPS.

The Role of Imaging in Portal Vein Thrombosis: From the Diagnosis to the Interventional Radiological Management

PURPOSE

To illustrate diagnostic and interventional imaging for the characterization and treatment of portal vein thrombosis (PVT).

INTRODUCTION

The broad spectrum of congenital and acquired PVT manifestations is illustrated, with a focus on the pediatric population; diagnostic and interventional imaging techniques are described.

DESCRIPTION

PVT frequently presents as an incidental finding at imaging in the screening for liver diseases or for other unrelated reasons. PVT can be classified based on: extension (intrahepatic, extrahepatic, involving the spleno-mesenteric tract, etc.); degree (partial or complete); onset (acute or chronic); and with or without cavernomatous transformation. This comprehensive review relies on the experience gained from a large series of congenital and acquired PVT in a referral center for pediatric and adult liver transplantation. Diagnostic and interventional imaging techniques are described, including: color-Doppler and contrast-enhanced Ultrasound; CT and MR angiography; retrograde portography; percutaneous transhepatic, transplenic, and transmesenteric portography; transjugular intrahepatic portosystemic shunt creation. Pre- and post-operative imaging assessment of the surgical meso-rex bypass is discussed. The description is enriched with an original series of pictorial imaging findings.

CONCLUSION

PVT is a clinical condition associated with significant morbidity and mortality. Diagnostic and interventional imaging plays a crucial role in both conservative and operative management.

Direct portal vein recanalization with stenting associated with embolization of esophagogastric varices in a patient with portal vein thrombosis

Introduction

Chronic extrahepatic non-tumoral thrombotic portal vein occlusion in non-cirrhotic patients is a rare condition, affecting 5–10% of patients with portal hypertension.

Presentation of case

The present study reports the case of a young patient without previous comorbidities who presented with portal hypertension secondary to chronic extrahepatic non-tumoral thrombotic occlusion of the portal vein. He underwent portal recanalization with a 12 × 80 mm nitinol self-expandable stent and embolization of esophagogastric varices with fibrous springs and cyanoacrylate via transparieto-hepatic access. Immediate resolution of the trans-lesion pressure gradient was obtained transoperatively, while complete remission of esophagogastric varices was verified by endoscopic control during outpatient follow-up.

Discussion

Chronic portal vein occlusion is associated or not with liver cirrhosis. The chronic phase is characterized by cavernomatous transformation of the portal vein, which consists of the formation of multiple collaterals that bypass the lesion. This phase usually courses with portal hypertension and consequent variceal gastrointestinal bleeding. Decompression of the portal system through direct recanalization (angioplasty with stenting) is one therapeutic options.

Conclusion

We conclude that, in the present case, resolving portal hypertension by direct portal recanalization was a good therapeutic option, as it decompressed the portal system while maintaining the hepatopetal flow.

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Chronic extrahepatic non-tumoral thrombotic portal occlusion is a rare condition.

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Portal recanalization with stent for resolution of portal hypertension.

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Transparieto-hepatic access is the approach of choice among non-cirrhotics.

Transsplenic Portal System Catheterization: Review of Current Indications and Techniques

Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of portal vein access, transsplenic access (TSA) has gained recognition as an effective and safe technique to access the portal system in patients with contraindications to traditional approaches. Recently, the utility of percutaneous TSA has grown, with described treatments including recanalization of chronic portal vein occlusion, placement of stents for portal vein stenosis, portal vein embolization of the liver, embolization of gastric varices, placement of complicated transjugular intrahepatic portosystemic shunts, and interventions after liver transplant. The authors provide a review of percutaneous TSA, including indications, a summary of related portal vein diseases, and the different techniques used for access and closure. In addition, an imaging-based review of technical considerations of TSA interventions is presented, with a review of potential procedural complications. With technical success rates that mirror or rival the standard methods and reported low rates of major complications, TSA can be a safe and effective option in clinical scenarios where traditional approaches are not feasible. ^©RSNA, 2022.

Safety and Efficacy of Endovascular Treatment of Portal Vein Stenosis in Liver Transplant Recipients: A Systematic Review

PURPOSE

To evaluate the efficacy of Angioplasty and Stent Placement for the treatment of Portal Vein Stenosis in Liver Transplant Recipients by performing a systematic review.

MATERIALS AND METHODS

The PubMed Database was extensively searched for articles describing Portal Vein Stenosis (PVS) as a complication in Liver Transplant (LT) patients. The initial database search yielded 488 unique records published in the PubMed Database, 19 of which were deemed to meet the inclusion criteria. Outcomes were separated into 2 groups (Group A included patients with primary angioplasty, Group B included patients with primary stent placement), and further subdivided into Adult and Pediatric populations.

RESULTS

Group A included a total of 282 LT patients with portal vein stenosis. The population was predominantly pediatric (n = 243). Group B included a total of 111 LT patients with portal vein stenosis. This population was predominantly adult (n = 66). Technical success was significantly higher in both Group B pediatric (100%) and adults (97%) compared to Group A (69.5%) and (66.7%) respectively. Re-stenosis rates were significantly lower in Group B pediatric group compared to Group A (2.3% vs 29.7%, χ² = 13.9; p < 0.001). Overall major (3.1%) and minor complications rates (1.5%) were low.

CONCLUSION

Primary stent placement appears to have higher technical success in both populations and lower re-stenosis rates for treatment of PVS in pediatric populations.

Per-Cutaneous Trans-splenic Vein Thrombolysis of Acute Major Portal Vein Thrombosis in Post-Liver Transplant Recipient: A Unique Experience

Portal venous thrombosis (PVT) is an uncommon complication in post-liver transplant recipients. The reported incidence is 1-4%. It may occur within a month, called early or after one month of transplantation, known as late PVT. Early PVT has a poor prognosis, leading to graft failure in most cases. Treatment of such cases is quite challenging because of difficult alternative portal inflow establishment. We performed successful thrombolysis of acute major PVT with a unique technique using ultrasound-guided percutaneous trans-splenic vein access in a post-liver transplant recipient. The per-cutaneous trans- splenic vein approach-based thrombolysis described here in this report might be very helpful in similar cases. This technique minimizes the potential risk of graft loss, avoids re-exploration, has a low risk of bleeding, and is cost-effective.

Sonography of liver transplantation

Orthotopic liver transplant (OLT) is established as the definitive treatment of choice for end stage liver disease. Over the years, refined surgical techniques as well as advancements in organ preservation and immunosuppressive regimens have improved graft and patient survival rates. Imaging has also contributed to improved graft and patient survival. Ultrasound is the initial investigation of choice for evaluation of post-transplant anatomy and for identifying early complications. A thorough knowledge of surgical techniques and normal post-operative appearance of the OLT is needed to accurately identify and characterize graft complications. The objective of this article is to review the sonographic findings of normal liver transplant as well as post-operative complications. Indications and contraindications for OLT as well as different surgical techniques will also be briefly reviewed.

Living Donor Liver Transplantation for Perihilar Cholangiocarcinoma: Outcomes and Complications

BACKGROUND

Neoadjuvant therapy and liver transplantation is an effective treatment for perihilar cholangiocarcinoma (pCCA). Living donor liver transplantation (LDLT) addresses the problem of organ shortage, but has higher risk of technical complication that can be aggravated by radiotherapy. We investigated the incidence of vascular and biliary complication in pCCA compared with non-pCCA patients and their impact on patient and graft survival.

STUDY DESIGN

All consecutive LDLTs (n = 247) performed between 2000 and 2017 were reviewed, including demographics, donor variables, operative details, and postoperative outcomes. Logistic regression models were used to investigate the relationship between variables and outcomes.

RESULTS

Seventy-four LDLTs (30.0%) were performed for pCCA and 173 for other indications. Forty-nine patients (66.2%) had primary sclerosing cholangitis-associated pCCA; the remainder had de novo pCCA. LDLT for pCCA was associated with nonstandard arterial (p = 0.001) or portal vein reconstruction (p < 0.001) and Roux-en-Y choledochojejunostomy (p < 0.001). The incidence of early hepatic artery thromboses was similar (5.4% vs 7.6%; p = 0.54). Late hepatic artery (18.9% vs 4.1%; p < 0.001) and portal vein (37.8% vs 8.7%; p < 0.001) complication was more common in the pCCA group. Anastomotic biliary complications occurred in 39.2% vs 54.1% (p = 0.032) of patients. Overall survival for pCCA at 1, 5, and 10 years was 84.9%, 66.5%, and 55.6%, respectively. Cancer recurred in 12.3%. Residual tumor on explant prognosticated inferior survival (hazard ratio 5.69; 95% CI, 1.97 to 16.35) and vascular and biliary complications did not.

CONCLUSIONS

Late vascular complication is common after LDLT for pCCA, but do not adversely affect long-term survival. LDLT provides excellent survival, particularly for patients with no residual disease at the time of transplantation.

Recanalization of Chronic Portal Vein Occlusion in Pediatric Liver Transplant Patients

PURPOSE

To evaluate technical and clinical success and report long-term outcomes of portal vein (PV) recanalization in pediatric orthotopic liver transplant (OLT) patients with chronic PV occlusion.

MATERIALS AND METHODS

This is a retrospective review of 15 OLT patients (5 males) with chronic PV occlusion who underwent PV recanalization (33 procedures) between October 2011 and February 2018. Median age was 4.5 years (range, 1-16 years); median weight was 16.6 kg (range, 11.5-57.3 kg). Median time interval from OLT to first intervention was 3.25 years (range, 0.6-15.7 years). Clinical presentations included hypersplenism (n = 12), gastrointestinal bleeding (n = 9), and ascites (n = 3). One patient had incidental diagnosis of PV occlusion. Primary, primary-assisted, and secondary patency at 3, 6, 12, and 24 months were evaluated.

RESULTS

Technically successful PV recanalization and reduction of PV pressure gradient to ≤ 5 mm Hg was performed in 13/15 patients (87%). Ten of 15 (67%) patients had successful recanalization with the first attempt. Clinical success, defined as improvement in signs and symptoms of portal hypertension, was achieved in 12/13 (92%) patients. Five of 33 (15%) major complications (Society of Interventional Radiology class C), including perisplenic hematoma (n = 2), hemoperitoneum (n = 2), and hepatic artery pseudo aneurysm (n = 1), were managed with pain medication and blood product replacement. Median follow-up was 22 months (range, 1-77 months). Median primary patency was 5 months. Primary patency at 3, 6, 12, and 24 months was 53.8%, 46.2%, 38.5%, and 30.8%, respectively. Primary-assisted patency was 84.6%, 76.9%, 53.8%, and 46.2%, respectively. Secondary patency was 92.3%, 84.6%, 53.8%, and 46.2%, respectively.

CONCLUSIONS

PV recanalization is a safe and effective minimally invasive option in the management of chronic PV occlusion after pediatric OLT.

Systematic review with meta-analysis: portal vein recanalisation and transjugular intrahepatic portosystemic shunt for portal vein thrombosis

BACKGROUND

Transjugular intrahepatic portosystemic shunt has been increasingly used in patients with portal vein thrombosis to obtain patency, but evidenced-based decisions are challenging.

AIM

To evaluate published data on efficacy and safety of endovascular therapy in portal vein thrombosis.

METHODS

Systematic search of PubMed, ISI, Scopus, and Embase for studies (in English, until October 2017) reporting feasibility, safety, 12-month portal vein recanalisation, transjugular intrahepatic portosystemic shunt patency, and survival in patients with benign portal vein thrombosis undergoing endovascular treatment. An independent extraction of articles using predefined data fields and quality indicators was used; pooled analyses based on random-effects models; heterogeneity assessment by Cochran's Q, I² statistic, subgroup analyses, and meta-regression.

RESULTS

Thirteen studies including 399 patients (92% cirrhosis; portal vein thrombosis: complete 46%, chronic 87%, cavernous transformation 17%, superior mesenteric vein involvement 55%) were included. Transjugular intrahepatic portosystemic shunt was technically feasible in 95% (95% CI: 89%-98%) with heterogeneity (I²  = 57%, P < 0.001) explained by cavernous transformation. Major complications occurred in 10% (95% CI: 6.0%-18.0%; I²  = 52%, P = 0.55). Additional catheter-directed thrombolysis was associated with more complications compared to transjugular intrahepatic portosystemic shunt alone or plus thrombectomy (17.6% vs 3.3%). Twelve-month portal vein recanalisation was 79% (95% CI: 67%-88%; I²  = 78%, P < 0.01). Shunt patency at 12 months was 84% (95% CI: 76%-90%; I²  = 62%, P < 0.01). Overall 12-month survival rate was 89%, with no heterogeneity.

CONCLUSIONS

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis recanalisation was highly feasible, effective, and safe. Cavernous transformation was the main determinant of technical failure. Additional catheter-directed thrombolysis was associated with higher risk of severe complications.

Transjugular Intrahepatic Portosystemic Shunt Insertion for the Management of Portal Hypertension in Children

OBJECTIVES

the aim of the study was to describe our 20-year experience with transjugular intrahepatic portosystemic shunt (TIPSS) procedures for children with resistant portal hypertension (PHTN).

METHODS

Retrospective review of all children that had a TIPSS performed at Birmingham Children's Hospital from January 1, 1995 to January 1, 2015.

RESULTS

Forty children underwent 42 attempted TIPSS for resistant PHTN with recurrent variceal bleeding (n = 35), refractory ascites (n = 4), and hypersplenism (n = 1). Median age at operation was 12 years (range 7 months-17 years). Thirty-four procedures were elective and 8 were emergency cases. TIPSS was established in 33 cases (79%). Median portal venous pressure reduction was 10 mmHg. Variceal bleeding ceased in 27 (96%) and ascites improved in all. Clinical improvement following TIPSS enabled 7 children to be bridged to transplantation and 7 others to become suitable for transplantation. The 1-year and 5-year survival with TIPSS was 57% and 35%, respectively. Child-Pugh score C was an independent risk factor for adverse outcome (Likelihood ratio (LR) = 8.0; 95% confidence interval (CI) 2.7 to 23.5; P = 0.001). There were 6 major complications: hepatic artery thrombosis and infarction (n = 1), hepatic artery pseudoaneurysm (n = 1), bile leak (n = 1), and hepatic encephalopathy (n = 3). Encephalopathy was resistant to medical treatment in 2 cases, necessitating staged closure in 1. Ten patients (30%) required intervention to maintain TIPSS patency. The 1-year and 5-year freedom from reintervention was 71% and 55%, respectively.

CONCLUSIONS

A TIPSS is highly successful in controlling symptoms in children with resistant PHTN and facilitating liver transplantation. It is technically demanding and not without risk. Patients must be appropriately selected and counselled.

Laparotomy-Assisted Endoscopic Injection of Jejunal Varices for Overt Small Bowel Bleeding

A 54-year old male liver transplant recipient with Roux-en-Y choledochojejunostomy was admitted for symptomatic anemia. Despite endoscopies and a bleeding scan, active bleeding was not visualized. Angiography and abdominal computed tomography demonstrated possible jejunal varices at the choledochojejunal anastomosis. Double-balloon enteroscopy demonstrated varices with overlying clots in the Roux limb at the anastomosis. Due to the extensive loop formation and unstable position of the endoscope, therapeutic intervention could not be performed. Operative enterotomy and intraoperative endoscopy were subsequently required. A varix in the jejunum with venous flow on Doppler was injected twice with cyanoacrylate and successfully obturated.

Correction of extrahepatic portal hypertension in pediatric patient after liver transplantation

Introduction. Liver transplantation is a multi-component and complex type of operative treatment. Patients undergoing such a treatment sometimes are getting various complications. One of these complications is a portal hypertension associated with portal vein stenosis.

Materials and methods. In 6 years after the left lateral section transplantation from living donor in a pediatric patient the signs of portal hypertension were observed. Stenosis of the portal vein was revealed. Due to this fact percutaneous transhepatic correction of portal vein stenosis was performed.

Results. As a result of the correction of portal blood flow in the patient a positive trend was noted. According to the laboratory and instrumental methods of examination the graft had a normal function, portal blood flow was adequate. In order to control the stent patency Doppler ultrasound and MSCT of the abdominal cavity with intravenous bolus contrasting were performed. Due to these examinations the stent function was good, the rate of blood flow in the portal vein due to Doppler data has reached 80 cm/sec, and a decrease of the spleen size was noted.

Conclusion. Diagnosis and timely detection of portal vein stenosis in patients after liver transplantation are very important for the preservation of graft function and for the prevention of portal hypertension. In order to do that, ultrasound Doppler fluorimetry examination needs to be performed to each patient after liver transplantation. In cases of violation of the blood flow in the portal vein CT angiography performance is needed. Percutaneous transhepatic stenting of portal vein is a minimally invasive and highly effective method of correction of portal hypertension. Antiplatelet therapy and platelet aggregation control are the prerequisites for successful stent function.

Thrombolysis and Transjugular Intrahepatic Portosystemic Shunt Creation for Acute and Subacute Portal Vein Thrombosis

Catheter-based interventional therapy offers a safe and effective option for treatment of symptomatic portomesenteric venous thrombosis refractory to medical therapy. Various techniques and approaches have been described for thrombolysis and thrombectomy and re-establishing the portal venous flow for select populations. Early diagnosis and prompt treatment based on clinical presentation, imaging, and underlying anatomy are necessary to prevent long-term complications. This article describes various catheter-based approaches for treatment of acute and subacute portal vein thrombosis.

Pediatric liver transplant portal vein anastomotic stenosis: correlation between ultrasound and transhepatic portal venography

The objective of this study was to determine which transabdominal ultrasound parameters correlate with portal vein stenosis (PVS) on percutaneous transhepatic portal venography in pediatric liver transplant patients. A retrospective review was performed of percutaneous transhepatic portal venograms performed between 2005 and 2013. The findings were compared to those from ultrasounds performed before venography and at the baseline. Patients were stratified on the basis of the presence of significant PVS (group 1, >50% stenosis; group 2, ≤50% stenosis) on portal venography. Findings were compared to those for age-matched controls. Twenty portal venograms were performed for 12 pediatric patients. Thirteen of the 20 patients (65%) demonstrated significant PVS (>50%). The mean peak anastomotic velocity (PAV) was 253.6±96 cm/s in group 1, 169.7±48 cm/s in group 2, and 51.3±20 cm/s in the control group. PAV (r=0.672, P=0.002) was the only ultrasound variable that correlated with the presence of significant PVS. A receiver operating characteristic curve was generated from PAV and PVS data (area under the curve=0.75, P=0.08). A threshold velocity of 180 cm/s led to a sensitivity of 83% and a specificity of 71% in predicting significant PVS on portal venography. At the baseline, the mean PAV was 155.8±90 cm/s for group 1 and 69.5±33 cm/s for group 2 (P=0.08); for control subjects, it was 78.9±53 cm/s (P=0.06). PAV is the only measured ultrasound parameter that correlates with significant PVS on portal venography in pediatric liver transplant patients. An elevated baseline PAV may increase the risk of developing PVS.

Postoperative doppler evaluation of liver transplants

Doppler ultrasound plays an important role in the postoperative management of hepatic transplantation, by enabling early detection and treatment of various vascular complications. This article describes the normal Doppler findings following liver transplantation and reviews the imaging appearances of various vascular complications associated with it. The article also discusses transient waveform abnormalities, often seen on a post-transplant Doppler examination, and the importance of differentiating them from findings suggestive of ominous vascular complications.