Transjugular intrahepatic portosystemic shunt approach and local thrombolysis for treatment of early posttransplant portal vein thrombosis

Thrombotic complications post liver transplantation: Etiology and management

Liver transplantation (LT) is the life saving therapeutic option for patients with acute and chronic end stage liver disease. This is a routine procedure with excellent outcomes in terms of patient survival and quality of life post LT. Orthotopic LT (OLT) patients require a critical care as they are prone to variety of post-operative vascular, cardiovascular, biliary, pulmonary and abdominal complications. Thrombotic complications (both arterial and venous) are not uncommon post liver transplant surgery. Such vascular problems lead to increased morbidity and mortality in both donor and graft recipient. Although thromboprophylaxis is recommended in general surgery patients, no such standards exist for liver transplant patients. Drastic advancements of surgical and anesthetic procedures have improvised survival rates of patients post OLT. Despite these, haemostatic imbalance leading to thrombotic events post OLT cause significant graft loss and morbidity and even lead to patient’s death. Thus it is extremely important to understand pathophysiology of thrombosis in LT patients and shorten the timing of its diagnosis to avoid morbidity and mortality in both donor and graft recipient. Present review summarizes the current knowledge of vascular complications associated with LT to highlight their impact on short and long-term morbidity and mortality post LT. Also, present report discusses the lacunae existing in the literature regarding the risk factors leading to arterial and venous thrombosis in LT patients.

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.

Approach to different thrombolysis techniques and timing of thrombolysis in the management of portal vein thrombosis in cirrhotic patients

Thrombolysis is not currently recommended in cirrhotic patients with acute portal vein thrombosis (PVT) in most guidelines, because of the exceedingly limited data and the perceived high risk of bleeding adverse events. However, in the few studies including patients with cirrhosis, the rate of success was high and that of adverse events was similar in patients with or without cirrhosis. Hence, thrombolysis might be a rescue therapeutic option in patients with cirrhosis and acute, symptomatic thrombosis of the portal venous system, unresponsive to anticoagulation, provided a suitable timing is kept, less than 30 days and, if possible, less than 14 days from the acute onset of portal vein thrombosis. In this review perspective article, I discuss the several potential approaches of thrombolysis, either local or systemic, alone or combined with mechanical procedures for thrombus removal, or as a complement to Transjugular Intrahepatic Portosystemic Shunt placement, with a focus on the more suitable timing of thrombolysis. However, the very limited available data preclude from performing firm recommendations, and decision to carry out thrombolysis must take into account both the occurrence of major contraindications and the current critical clinical setting. In the next future, large high-quality multicentre studies will hopefully be able to settle more firm indications and preferable techniques.

The Management of Portal Vein Thrombosis after Adult Liver Transplantation: A Case Series and Review of the Literature

Background: Portal vein thrombosis (PVT) after adult liver transplantation (LT) is a rare but serious complication with no consensus on the ideal treatment. We report a case series and a comprehensive review of the literature on PVT after LT to discuss the therapeutic options. Methods: The clinical data of 360 adult patients (≥18 years of age) who underwent LT from January 2017 to January 2020 were reviewed, and a comprehensive search of PubMed and Web of Science was conducted. Patients diagnosed with PVT after LT were identified, and relevant risk factors and therapies were analyzed. Results: Among the 360 patients, 7 (1.94%) developed PVT after LT. Onset of PVT within one week after LT was found in six patients (85.71%). Four of the seven patients with PVT received systemic anticoagulation (low molecular weight heparin and warfarin) therapy. Minimally invasive interventional therapies combined with systemic anticoagulation (heparin and warfarin) were applied for three patients, two of whom died because of severe abdominal hemorrhage and liver failure. Of the 33 cases reported in the literature, minimally invasive interventional therapy combined with systematic anticoagulation or sclerotherapy were the most-used methods (20/33). Systemic anticoagulation was administered to four patients, and surgical operation (thrombectomy; portosystemic shunt and retransplantation) was performed for nine patients. Among these 33 patients, 4 eventually died. Conclusions: Interventional therapy combined with systemic anticoagulation is a good choice for the management of PVT after LT, and in our experience, systemic anticoagulation alone can also have a positive effect for early PVT patients.

Vascular complications in living donor liver transplantation at a high-volume center: Evolving protocols and trends observed over 10 years

Vascular complications continue to have a devastating effect on liver transplantation recipients, even though their nature, incidence, and outcome might have actually changed with increasing experience and proficiency in high-volume centers. The aim of this study was to analyze the trends observed in vascular complications with changing protocols in adult and pediatric living donor liver transplantation over 10 years in 2 time frames in terms of nature, incidence, and outcome. It is a retrospective analysis of 391 (group 1, January 2006 to December 2010) and 741 (group 2, January 2011 to October 2013) patients. With a minimum follow-up of 2 years, incidence of hepatic artery thrombosis (HAT) in adults has reduced significantly from 2.2% in group 1 to 0.5% in group 2 (P = 0.02). In group 2, nonsignificantly, more adult patients (75% with HAT) could be salvaged compared with only 25% patients in group 1 (P = 0.12). However, HAT in children had 100% mortality. Incidence of portal vein thrombosis (PVT) in complicated transplants in 2 eras remained the same (P = 0.2) and so has its mortality. The thrombosis rate of the neo-middle hepatic vein was significantly reduced in group 2 (P = 0.01). The incidence of HAT, particularly in adults, has decreased significantly though PVT has continued to puzzle surgeons in complicated transplants. In high-volume centers, increasing proficiency, technical modifications, early diagnosis, and multimodality of treatment is the key to decrease overall morbidity and mortality due to vascular complications. Liver Transplantation 23 457-464 2017 AASLD.

Nontumoral portal vein thrombosis in patients awaiting liver transplantation

Portal vein thrombosis (PVT) occurs in approximately 2%-26% of the patients awaiting liver transplantation (LT) and is no longer an absolute contraindication for LT. Nearly half of PVT cases are accidentally found during the LT procedure. The most important risk factor for PVT development in cirrhosis may be the severity of liver disease and reduced portal blood flow. Whether other inherited or acquired coagulation disorders also play a role is not yet clear. The development of PVT may have no effect on the liver disease progression, especially when it is nonocclusive. PVT may not increase the risk of wait-list mortality, but it is a risk factor for poor early post-LT mortality. Anticoagulation and transjugular intrahepatic portosystemic shunt (TIPS) are 2 major treatment strategies for patients with PVT on the waiting list. The complete recanalization rate after anticoagulation is approximately 40%. The role of TIPS to maintain PV patency for LT as the primary indication has been reported, but the safety and efficacy should be further evaluated. PVT extension and degree may determine the surgical technique to be used during LT. If a "conventional" end-to-end portal anastomotic technique is used, there is not a major impact on post-LT survival. Post-LT PVT can significantly reduce both graft and patient survival after LT and can preclude future options for re-LT.

Transjugular intrahepatic portosystemic shunts in liver transplant recipients

The insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure used to relieve the signs and symptoms of portal hypertension in patients with liver disease. The most common indications for placement are refractory ascites and variceal hemorrhage. In properly selected candidates, TIPS placement can serve as a bridge to liver transplantation. Expertise in TIPS placement after transplantation has significantly increased, which has allowed the procedure to become a viable option for retransplant candidates suffering the consequences of recurrent portal hypertension due to portal vein thrombosis, recurrent liver disease, or hepatic venous outflow obstruction (HVOO). However, TIPSs in liver transplant recipients are associated with a lower clinical response rate and a higher rate of complications in comparison with patients with native liver disease, and they are, therefore, generally reserved for patients with a Model for End-Stage Liver Disease (MELD) score ≤ 15 and ≤ 12 in patients with HCV. The role of TIPS placement in nonliver transplant recipients has been well studied in large trials, and it translates well into clinical applicability to candidates for orthotopic liver transplantation (OLT). However, the experience with OLT recipients is heterogeneous and restricted to small series. Thus, we focus here on reviewing the current literature and discussing the proper use of TIPSs in liver transplant recipients.

Portal interventions in liver transplant recipients

Portal vein interventions in liver transplant recipients represent a group of interventions in the management of several disease entities including portal vein stenosis, portal vein thrombosis, and recurrent liver cirrhosis with portal hypertension with and without gastric varices. The procedures performed in these patient populations include portal vein angioplasty with or without stent placement for portal vein stenosis, portal vein thrombolysis with or without stent placement for portal vein thrombosis, transjugular intrahepatic portosystemic shunts or splenic embolization for cirrhosis, and balloon-occluded retrograde transvenous obliteration for gastric varices. This article discusses these disease entities and the minimal invasive procedures used in their management.

Transjugular intrahepatic portosystemic shunt in the treatment of portal vein thrombosis: a critical review of literature

Reports of successful transjugular intrahepatic portosystemic shunt (TIPS) surgery in patients with portal vein thrombosis (PVT) are considered anecdotal owing to the technical difficulty of the procedure and potential procedure-related complications. A literature review was undertaken to determine the feasibility and safety of TIPS in the treatment of PVT. All studies in which TIPS was attempted in patients with PVT were identified by searching through the PUBMED and MEDLINE databases. A total of 424 PVT patients undergoing TIPS were reported in 54 articles. The success rate of TIPS insertion was 67-100% in 19 case series. Further, 85 patients with portal cavernoma underwent successful TIPS insertions. Three therapeutic strategies of TIPS placement were used: (1) TIPS placement followed by portal vein recanalization via the shunt, (2) portal vein recanalization via percutaneous approaches followed by TIPS placement, and (3) TIPS insertion between a hepatic vein and a large collateral vessel without portal vein recanalization. Four approaches were used to access the portal vein: transjugular, transhepatic, transsplenic, and transmesenteric. Intra-abdominal hemorrhage secondary to hepatic capsule perforation was lethal in only three patients. No episode of pulmonary embolism was reported. Other procedure-related complications were reversible. The overall incidence of shunt dysfunction and hepatic encephalopathy was 8-33% and 0-50%, respectively. In conclusion, the reviewed studies uniformly support the feasibility and safety of TIPS for PVT even in the presence of portal cavernoma. Further, several major issues that remain unresolved are discussed.

Portal vein thrombosis: Insight into physiopathology, diagnosis, and treatment

Portal vein thrombosis (PVT) is a relatively common complication in patients with liver cirrhosis, but might also occur in absence of an overt liver disease. Several causes, either local or systemic, might play an important role in PVT pathogenesis. Frequently, more than one risk factor could be identified; however, occasionally no single factor is discernable. Clinical examination, laboratory investigations, and imaging are helpful to provide a quick diagnosis, as prompt treatment might greatly affect a patient’s outcome. In this review, we analyze the physiopathological mechanisms of PVT development, together with the hemodynamic and functional alterations related to this condition. Moreover, we describe the principal factors most frequently involved in PVT development and the recent knowledge concerning diagnostic and therapeutic procedures. Finally, we analyze the implications of PVT in the setting of liver transplantation and its possible influence on patients’ future prognoses.

Use of splenic artery embolization to relieve tense ascites following liver transplantation in a patient with paroxysmal nocturnal hemoglobinuria

Recurrent venous thrombosis following liver transplantation for Budd-Chiari syndrome is common, particularly in the setting of an underlying myeloproliferative disorder. We describe a patient who developed refractory ascites due to portal vein thrombosis following liver transplantation for Budd-Chiari syndrome in the setting of paroxysmal nocturnal hemoglobinuria. Extensive portal vein thrombosis, dense abdominal adhesions, and portosystemic collaterals precluded the use of a transjugular intrahepatic portosystemic shunt or surgical portosystemic shunt to manage the patient's ascites. Splenic artery embolization to decrease portal hypertension was performed, and this resulted in complete resolution of ascites. This case demonstrates the successful use of splenic artery embolization to manage ascites due to portal vein thrombosis following liver transplantation. Splenic artery embolization may be considered as an alternative option for the management of refractory ascites due to portal hypertension in patients who are unable to undergo safe transjugular intrahepatic portosystemic shunt or surgical shunt placement.

Successful percutaneous pulse spray thrombolysis of extensive acute portocaval hemitransposition thrombosis

We report a case of extensive acute thrombosis of portal vein and cava in a portocaval hemitransposition liver graft that was treated successfully with percutaneous pulse spray thrombolysis through a femoral vein access. The patient subsequently developed descending and sigmoid colon ischemic necrosis because of the venous thrombosis necessitating emergency colon resection. The patient had prolonged postoperative intensive care stay, but was eventually discharged in a good condition with normal liver function. Three month follow up demonstrated persistent normalization of hepatic function and normal duplex ultrasound.

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation

BACKGROUND

Treatment options for patients with portal vein thrombosis are limited.

AIM

To evaluate the feasibility and efficacy of transjugular intrahepatic portosystemic shunt for portal vein thrombosis with/without cavernomatous transformation.

METHODS

A survey of such patients, referred for transjugular intrahepatic portosystemic shunt between 1994 and 2005, was performed. Success rates, complications, transjugular intrahepatic portosystemic shunt patency and clinical progression were examined.

RESULTS

Transjugular intrahepatic portosystemic shunt was attempted in 28 patients (13 cirrhotics). Indications were: presurgery/transplantation (2), worsening of ascites (2), variceal bleeding (15 - 8 elective), refractory ascites (3), portal biliopathy (3) and portal vein thrombosis complicating Budd-Chiari syndrome (2). Transjugular intrahepatic portosystemic shunt was placed successfully in 19 of 28 (73%); 23 of 28 had complete portal vein thrombosis and 9 of 23 had cavernous transformation and transjugular intrahepatic portosystemic shunt was successfully placed in six of these. In the 19 patients with transjugular intrahepatic portosystemic shunt, the mean follow-up was 18.1 months (range 5-70): six patients had stent revisions; three had liver transplantation, one died of bleeding. Most cirrhotic patients had an improvement in the Child-Pugh score. In the failed transjugular intrahepatic portosystemic shunt group, two of nine died, and three had further bleeding.

CONCLUSIONS

Transjugular intrahepatic portosystemic shunt should be considered for selected patients with symptomatic complete portal vein thrombosis with/without cavernous transformation, as clinical improvement and less rebleeding occur when transjugular intrahepatic portosystemic shunt placement is successful.

Interventional radiology in liver transplantation

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation.

Transjugular Intrahepatic Portosystemic Shunt Placement in Liver Transplant Recipients: Experiences with Pediatric and Adult Patients

OBJECTIVE

The purpose of our study was to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in pediatric and adult liver transplant recipients. A retrospective review of six TIPS placed in six liver transplant recipients-a pediatric patient with a split liver transplant, a pediatric patient with left lateral segment transplant, and four adult patients-was performed.

CONCLUSION

TIPS placement in both pediatric and adult liver transplant recipients is feasible. In liver transplant patients who are recipients of a left lateral segment or a split liver transplant, knowledge of the liver transplant anatomy is critical in the placement of TIPS. TIPS placement is a treatment option and a bridge to retransplantation for patients who have undergone liver transplantation and develop sequelae of portal hypertension.

Review article: portal vein thrombosis -- new insights into aetiology and management

Portal vein thrombosis may occur in the presence or absence of underlying liver disease, and a combination of local and systemic factors are increasingly recognized to be important in its development. Acute and chronic portal vein thrombosis have traditionally been considered separately, although a clear clinical distinction may be difficult. Gastrooesophageal varices are an important complication of portal vein thrombosis, but they follow a different natural history to those with portal hypertension related to cirrhosis. Consensus on optimal treatment continues to be hampered by a lack of randomized trials, but recent studies demonstrate the efficacy of thrombolytic therapy in acute thrombosis, and the apparent safety and benefit of anticoagulation in patients with chronic portal vein thrombosis.

Role of interventional radiology in the management of vascular complications after liver transplantation

The purpose of this study is to review the role of the percutaneous interventional procedures in the treatment of vascular complications after orthotopic liver transplantations (OLT). Vascular complications, such as arterial stenosis and venous thrombosis, which occur in approximately 1% to 10% of liver transplant patients, are associated with a higher risk of graft dysfunction. Percutaneous interventional procedures, including angioplasty, local thrombolysis, and embolization, are useful to manage these complications. A reduced blood loss and a low incidence of procedural complications allow for rapid recovery. Hepatic arterial and portal vein anastomotic stenosis can be treated effectively by means of balloon dilation; stenting has also been proposed, particularly for venous complications. Infusional local thrombolysis may be useful in venous thrombosis. Arteriovenous fistulas, occurring at the level of the anastomosis or after liver biopsy, require intraarterial embolization using microcoils or gelfoam. Timing of the intervention for the treatment of ischemic complications is of outmost importance to guarantee liver functional recovery and avoid irreversible parenchymal injuries. Other interventional procedures may be extremely useful to manage portal hypertension after OLT; for example, by creation of transjugular portosystemic shunts, or, in the case of associated hypersplenism, transarterial embolization of the splenic artery. Finally, in patients with recurrent hepatitis, the transjugular approach has been shown to be safe and effective for liver biopsy, whereas transarterial chemoembolization may be extremely useful to treat recurrent hepatocarcinoma.

Combined Mechanical and Pharmacologic Thrombolysis for Portal Vein Thrombosis in Liver-Graft Recipients and in Candidates for Liver Transplantation

Portal vein thrombosis (PVT) is an uncommon cause for presinusoidal portal hypertension and can occur even in liver-graft recipients. Interventional radiology by percutaneous approach may represent a valid and less invasive alternative to surgical treatment. We describe three cases of PVT (2 liver-transplant patients and a cirrhotic patient candidate for liver transplantation) treated by combined mechanical and pharmacologic thrombolysis. The Arrow-Trerotola device was used along with the infusion of urokinase by way of a percutaneous-transhepatic approach. In all cases, a recanalization of the portal system was obtained and maintained during the follow-up. The best result was achieved when mechanical thrombectomy was performed before urokinase infusion. The combined locoregional treatment with mechanical thrombectomy and pharmacologic thrombolysis appears to be a promising approach for PVT because of its rapid and durable effect and its ability to reduce the dose of urokinase required to achieve recanalization.

Liver transplantation in the presence of portal vein thrombosis: report from a single center

Portal vein thrombosis (PVT) is a frequent finding in liver transplantation, the management of which depends mainly on its extent. In cases of mild to moderate PVT, a low dissection of the portal trunk, a jump graft, or direct implantation of graft portal vein into large venous collaterals or thrombectomy offer alternatives. For severe PVT anecdotal reports suggest that cavoportal hemitransposition, portal arterialization, or combined liver and intestine transplantation may be attempted, although the results to date are not satisfactory. When extensive perivenous and venous inflammatory changes reach the infrapancreatic region, liver transplantation probably should not be performed due to the high mortality rate.

Pharmacological thrombolysis in Budd Chiari syndrome: a single centre experience and review of the literature

BACKGROUND/AIMS

To review our experience of thrombolytic therapy in patients with acute Budd Chiari syndrome (BCS).

METHODS

Records of 10 patients with BCS, treated by thrombolysis over a 12-year period were retrospectively analysed for demographics, clinical presentation/duration, primary disease, thrombolytic regimen, and follow-up. The same characteristics were also studied in previously reported patients. The agent used was recombinant tissue plasminogen activator (tPA) in all patients.

RESULTS

Thrombolysis was used 12 times in 10 patients. Infusion was made systemically in three patients, into the hepatic artery in one patient, locally into a hepatic vein and/or IVC in four patients and locally within TIPS/portal vein in two patients. Only one infusion made systemically was partially successful. Adjunctive balloon angioplasty and/or stent insertion was undertaken for all eight procedures (in six patients) where local infusion was into the hepatic vein or TIPS. Six of these were ultimately successful (in five patients) and two were unsuccessful. Thrombolysis was more likely to be successful in the presence of a short history of thrombosis, when the thrombolytic agent was locally infused and when it was combined with a successful radiological procedure. Mean follow-up was 4.5 years (range 1-10 years). No serious bleeding complication occurred.

CONCLUSIONS

We observed no benefit from thrombolysis when delivered systemically or arterially except in one case. Thrombolysis was useful in adjunctive management of BCS when the drug was infused locally into recently thrombosed veins that had appreciable flow following partial recanalisation. Thrombolysis was clearly of benefit in the repermeation of occluded/partially occluded hepatic veins/TIPS when early detection of new thrombus followed interventional procedures such as balloon angioplasty or stenting of hepatic veins.

A surgical solution to extrahepatic portal thrombosis and portal cavernoma: the splanchnic-intrahepatic portal bypass

Three cases of prehepatic portal vein thrombosis, complicated by the clinical manifestations of portal hypertension, were successfully treated by surgically created splanchnic-intrahepatic portal bypass. Two out of three patients had been previously submitted to liver transplantation. No significant morbidity was observed and long-term Doppler evaluations proved the patency of the venous grafts. Together with the technical aspects of the procedures, the possible role of this technique, primarily proposed by De Ville de Goyet in 1992, is discussed in relation to the available therapies for the extrahepatic portal vein thrombosis.

Hepatic circulatory diseases associated with chronic myeloid disorders

These liver diseases are diseases of the hepatic circulation. Myeloproliferative disorders are among the most common prothrombotic disorders that lead to Budd-Chiari syndrome and PVT. SOS, previously known as hepatic veno-occlusive disease, is mainly seen in North America and Western Europe as a complication of the conditioning regimen for hematopoietic stem cell transplantation. SOS is caused by damage to SECs, and the initiating circulatory blockage occurs because of the embolism of sinusoidal lining cells. Myeloproliferative disorders are an uncommon cause of NRH, which is believed to be caused by uneven perfusion of the liver at the venous or sinusoidal level. Peliosis hepatis is believed to result from damage to SECs and is seen mainly in immunosuppressed patients, patients with a wasting illness, or patients with a drug toxicity.