Venous outflow obstruction after orthotopic liver transplantation: use of a breast implant to maintain graft position

Treatment of acute intraoperative Budd-Chiari syndrome by placement of silicone prosthesis

Complete liver mobilization for major resections sometimes causes liver tilting due to the release of the suspensory elements of the liver. Rarely this may take to a liver abnormal position with acute obstruction to venous flow at the suprahepatic level (Budd-Chiari syndrome). To avoid this complication, techniques such as post-operative stent implantation have been described. The case of a patient who underwent a complete mobilization of the liver for resection of the inferior venous cava and a right renal tumor, was reported. After that, an acute Budd-Chiari Syndrome was observed caused of the liver malposition, which was solved with the placement of two silicone prostheses in the liver cell.

Positional outflow obstruction as a cause of early refractory ascites post-pediatric living donor liver transplantation

Refractory ascites post-liver transplantation can be a challenging problem. Causes of refractory ascites include venous outflow anastomotic stenosis, vessel kinking by the regenerating liver, pre-existing graft disease, and positional outflow obstruction. We present a case report of a child presenting with high drain output and refractory ascites post-LDLT secondary to a positional kinking. Repeating the Doppler studies with patients both supine and sitting may be helpful.

Breast implant during orthotopic liver transplant to avoid hepatic outflow obstruction

Donor-recipient size mismatch in liver transplantation is a recognized but uncommon situation. It can lead to a partial or complete obstruction of the inferior vena cava with subsequent hepatic outflow obstruction. Placement of a breast implant in the right upper quadrant of the abdomen during liver transplantation is a technically easy resource and can protect the liver graft from kinking or rotation.

Hepatic venous outflow obstruction after whole liver transplantation of large-for-size graft: versatile intra-operative management

Backgrounds/Aims

Preservation of the native inferior vena cava using a large graft during adult whole liver transplantation is associated with a potential risk of hepatic venous outflow compression/obstruction, which may adversely affect both graft and short-term patient outcomes. Intraoperative placement of materials to restore adequate hepatic venous outflow can overcome this complication.

Methods

Data of patients who underwent liver transplantation between 2011 and 2016 were retrospectively reviewed. All cases of hepatic venous outflow obstruction due to large graft size managed via intraoperative intervention were analyzed. The literature was searched for studies reporting adult cases of hepatic venous outflow obstruction following whole liver transplantation managed extrahepatically.

Results

Three patients diagnosed with intraoperative hepatic venous outflow obstruction due to large graft size were managed via retro-hepatic placement of breast implants (2 cases) or abdominal pads (1 case). It was successfully carried out in all cases. Four studies including 15 patients were identified in the literature search. Different types of materials such as inflatable materials (Foley catheter, Blakemore balloon), surgical gloves or breast implants, were used.

Conclusions

Placement of inflatable materials leads to gradual deflation in the postoperative period, which might obviate the need for reoperation. Breast implants could be left in place indefinitely due to their bio-inert nature.

Novel use of percutaneous thrombosuction to rescue the early thrombosis of the conduit vein graft after living donor liver transplantation

A 54-year-old woman with liver cirrhosis and hepatocellular carcinoma received a living donor liver transplant. Thrombosis of the segmental hepatic vein occurred on postoperative day 7. We undertook percutaneous catheter thrombosuction under local anesthesia to extract the thrombus successfully without re-exploration. Thrombosuction has been used for thrombosis of the cardiovascular system, limbs, and brain. We first used it in hepatic venous thrombus after liver transplantation. This procedure is simple, less invasive, feasible, safe, repeatable, and effective.

Ultrasound-accelerated, catheter-directed thrombolysis for inferior vena cava thrombosis after an orthotopic liver transplant

Inferior vena cava thrombosis is a rare occurrence after an orthotopic liver transplant that is associated with a high rate of retransplant and mortality. There is no consensus regarding the optimal therapeutic strategy. Surgical management, including thrombectomy with revision of the cavocaval anastomosis, has been described. With the use of endovascular therapies, several minimally invasive approaches are available that are effective and avoid the high morbidity associated with reoperative surgery. We describe our successful experience using an approach after a liver transplant in which the inferior vena cava thrombosis in a patient presenting with acute renal failure, anorexia, weight loss, and fatigue using an ultrasound-accelerated, catheter-directed thrombolysis platform in conjunction with systemic anticoagulation.