Outcome of percutaneous transhepatic venoplasty for hepatic venous outflow obstruction after living donor liver transplantation

Interventions in Budd-Chiari syndrome: an updated review

Budd Chiari syndrome is a potentially treatable disease, and imaging is the key to its diagnosis. Clinical presentations may vary, ranging from asymptomatic to fulminant disease. Subacute BCS is the most common type encountered in clinical practice, characterized by ascites, hepatosplenomegaly, dilated abdominal wall veins, and varicosities in the lower limb and scrotum. While hepatic vein thrombosis is the leading cause in the West, membranous and short segmental occlusion are predominant in the Asian populations. These geographical variations have an impact on the treatment algorithm in managing BCS. Anticoagulation alone often fails to prevent disease progression, demanding further interventional therapy. Interventional therapy carries a lower morbidity and mortality than surgery. Anatomical recanalization and portosystemic shunting form the basis of endovascular management. Membranous or short-segment occlusion are best treated by angioplasty, which restores the physiological venous outflow and possibly disease reversal. Suboptimal results with angioplasty require stenting. Transjugular intrahepatic shunt (TIPS) or direct IVC to portal vein shunt (DIPS) decompresses the portal pressure and reduces the sinusoidal congestion, which in turn diminishes hepatocellular damage and hepatic fibrosis. Despite its ability to modify the disease course, TIPS carries several procedure and shunt-related complications, mainly hepatic encephalopathy. Thus, anatomical recanalization precedes TIPS in the traditional step-up approach in managing BCS. However, this concept is challenged by some authors, necessitating future reseach. TIPS is a valid bridge therapy in BCS with acute live failure awaiting liver transplantation. Despite all, interventional therapies fail in a subset of BCS patients, leaving them with only option of liver transplantation.

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.

Venous outflow obstruction in pediatric left lateral segment split liver transplantation

BACKGROUND

Venous outflow obstruction (VOO) is a known cause of graft and patient loss after pediatric liver transplantation (LT). We analyzed the incidence, risk factors, diagnosis, management, and outcome of VOO in a large, consecutive series of left lateral segment (LLS) split LT with end-to-side triangular venous anastomosis.

METHODS

We evaluated data collected in our prospective databases relative to all consecutive pediatric liver transplants performed from January 2006 to December 2021. We included in this study children undergoing LLS split liver transplant with end-to-side triangular anastomosis. Diagnosis of VOO was based on clinical suspicion and radiological confirmation.

RESULTS

VOO occurred in 24/279 transplants (8.6%), and it was associated with lower graft weight (p = .04), re-transplantation (p = .008), and presence of two hepatic veins (p < .0001). In presence of two segmental veins' orifices, the type of reconstruction (single anastomosis after venoplasty or double anastomosis) was not significantly related to VOO (p = .87). Multivariable analysis indicated VOO as a risk factor for graft lost (hazard ratio 3.21, 95% confidence interval 1.22-8.46; p = .01). Percutaneous Transluminal Angioplasty (PTA) was effective in 17/22 (77%) transplants. Surgical anastomosis was redone in one case. Overall six grafts (25%) were lost.

CONCLUSION

VOO after LLS split LT with end-to-side triangular anastomosis is an unusual but critical complication leading to graft loss in a quarter of cases. The occurrence of VOO was associated with lower graft weight, re-transplantation, and presence of two hepatic veins. PTA was safe and effective to restore proper venous outflow in most cases.

Approach to persistent ascites after liver transplantation

Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.

Back table Preparation of the Right Lobe Live Donor Liver Allograft: A Crucial Part of the Adult Live Donor Liver Transplant Procedure

INTRODUCTION

We aimed to describe our procedure for vascular reconstruction and back table bench preparation for the right lobe live donor allograft. Live donor liver transplantation (LDLT) remains an important option for the expansion of the donor pool. The procedure has been widely used, and its success is dependent on a technically perfect operation with appropriate inflow and outflow of the allograft. Adequate preparation of the right lobe (RL) allograft prior to implantation remains a vital part of the procedure.

METHODS

Our technique of back table vascular reconstruction of the RL allograft has been performed using a hepatic vein patch venoplasty, inferior hepatic vein inclusion, portal vein reconstruction, and segment V and VIII reconstruction for all of our LDLTs.

RESULTS

Between March 2009 and January 2020, 321 consecutive adult LDLTs were performed and underwent back table reconstruction with the techniques described. During that time period, no patients had hepatic insufficiency. There was a single thrombosis of a superior mesenteric vein (SMV) to PV jump conduit.

CONCLUSIONS

Our technique of back table reconstruction of the LDLT right lobe graft remains a crucial part of the operative procedure. Our experience with RL grafts without middle hepatic vein (MHV) and our systematic approach for inflow and outflow reconstruction has yielded excellent results with no technical outflow issues and minimal inflow complications.

Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplant: Single Center Experience

OBJECTIVES

In this study, we share our approach for care of patients with hepatic venous outlet obstruction after living-donor liver transplant.

MATERIALS AND METHODS

We retrospectively examined the demographic, clinical, and radiologic data of 35 patients who developed hepatic venous outlet obstruction after living-donor liver transplant. Patients were subgrouped on the basis of onset (8 patients with early onset [< 30 days posttransplant] and 27 patients with late onset [≥ 30 days posttransplant]) and postoperative survival (24 survivors, 11 nonsurvivors).

RESULTS

Patients ranged in age from 1 to 61 years (24 adults and 11 children). All adult patients had undergone right lobe living-donor liver transplant. In the pediatric group, 8 had undergone left lateral segment and 3 had undergone left lobe living-donor liver transplant. Nineteen adult patients and all 11 pediatric patients underwent hepatic venous reconstruction, with all procedures based on common large-opening drainage models using various vascular graft materials. Development of hepatic venous outlet obstruction occurred at mean posttransplant day 233 ± 298.5 in the adult patients and mean posttransplant day 139 ± 97.8 in the pediatric patients. After development of obstruction, the patients underwent 1-6 sessions (1.5 ± 1.1 sessions) of balloon angioplasty. After the first balloon angioplasty procedure, 25% of the adults and 36.3% of the pediatric patients developed recurrence. The early-onset and late-onset subgroups showed statistically significant differences in serum albumin (P = .01), underlying causes (P < .001), time from transplant to obstruction (P = .02), and time from transplant to last visit (P = .02). The survivor and nonsurvivor subgroups showed statistically significant differences in total bilirubin (P = .03) and time from transplant to last visit (P = .03).

CONCLUSIONS

Common large-opening reconstruction minimizes hepatic venous outlet obstruction development after living-donor liver transplant. Balloon angioplasty and/or stenting is almost always the first option in the care of this complication.

The Application of Interventional Radiology in Living-Donor Liver Transplantation

Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.

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.

Endovascular stent placement for venous complications following pediatric liver transplantation: outcomes and indications

PURPOSE

Advances in interventional radiology (IVR) treatment have notably improved the prognosis of hepatic vein (HV) and portal vein (PV) complications following pediatric living donor liver transplantation (LDLT); however, graft failure may develop in refractory cases. Although endovascular stent placement is considered for recurrent stenosis, its indications are controversial.

METHODS

We enrolled 282 patients who underwent pediatric LDLT in our department from May 2001 to September 2016.

RESULTS

22 (7.8%) HV complications occurred after LDLT. Recurrence was observed in 45.5% of the patients after the initial treatment, and 2 patients (9.1%) underwent endovascular stent placement. The stents were inserted at 8 months and 3.8 years following LDLT, respectively. After stent placement, both patients developed thrombotic obstruction and are currently being considered for re-transplantation. 40 (14.2%) PV complications occurred after LDLT. Recurrence occurred in 27.5% of the patients after the initial treatment, and 4 patients (10.0%) underwent endovascular stent treatment. The stents of all the patients remained patent, with an average patency duration of 41 months.

CONCLUSION

Endovascular stent placement is an effective treatment for intractable PV complications following pediatric LDLT. However, endovascular stent placement for HV complications should be carefully performed because of the risk of intrastent thrombotic occlusion and the possibility of immunological venous injury.

Efficacy of repeated balloon venoplasty for treatment of hepatic venous outflow obstruction after pediatric living-donor liver transplantation: A single-institution experience

HVOO is a rare complication after LT and an important cause of graft failure. Balloon venoplasty is the first-line treatment for HVOO, but the effect of repeated balloon venoplasty and stent placement for HVOO recurrence after pediatric LDLT remains unclear. Between 1998 and 2016, 147 pediatric patients underwent LDLT in our institution. Among them, the incidence of HVOO and the therapeutic strategy were retrospectively reviewed. Ten patients were diagnosed with HVOO. All the patients underwent LLS grafts. Median age at the initial endovascular intervention was 2.7 years (range, 5 months-8 years). The median interval between the LDLT and the initial interventional radiology was 2.7 months (range, 29 days-35.7 months). Four patients experienced no recurrence after a single balloon venoplasty; 6 underwent balloon venoplasty more than 3 times because of HVOO recurrence; and 2 underwent stent placement due to the failure of repeated balloon venoplasty. All patients are alive with no symptoms of HVOO. The HVOO recurrence-free period after the last intervention ranged from 20 days to 15.5 years (median, 8.9 years). Repeated balloon venoplasty may prevent unnecessary stent placement to treat recurrent HVOO after pediatric LDLT.

Diagnostic accuracy of magnetic resonance angiography for Budd-Chiari syndrome: A meta-analysis

In recent years, the role of magnetic resonance angiography (MRA) in the diagnosis of Budd-Chiari Syndrome (BCS) has been the focus of various clinical studies. The purpose of the present study was to perform a meta-analysis of the diagnostic performance of MRA in patients with BCS by using digital subtraction angiography as a reference method. The search strategy for relevant research articles was based on the Cochrane Handbook for Systematic Reviews, and literature databases (including PubMed, Medline and China National Knowledge Infrastructure) and reference lists of retrieved studies published from 2000 to 2016 were searched. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess the methodological quality of these research studies by two reviewers independently. Summary estimates of the sensitivity, specificity, positive/negative likelihood ratio (LR+/-), diagnostic odds ratio (DOR) and the summary receiver operating characteristic (SROC) curve of MRA in identifying BCS were obtained. The pooled MRA estimates had a sensitivity of 97.6% [95% confidence interval (CI), 95.1-99.0%], a specificity of 70.7% (95% CI, 54.5-83.9%), an LR+ of 3.163 (95% CI, 2.03-4.94) and an LR- of 0.045 (95% CI, 0.02-0.09). The overall DOR was 94.053 (95% CI, 32.71-270.41). The area under the SROC curve was 0.972. In conclusion, MRA is an accurate modality for evaluating BCS.

Diagnosis, treatment and outcome of hepatic venous outflow obstruction in paediatric liver transplantation: 24-year experience at a single centre

BACKGROUND

Hepatic venous outflow obstruction after paediatric liver transplantation is an unusual but critical complication.

OBJECTIVES

To review the incidence, diagnosis and therapeutic modalities of hepatic venous outflow obstruction from a large national liver transplant unit.

MATERIALS AND METHODS

During the period from October 1992 to March 2016, 917 liver transplant procedures were performed with all types of grafts in 792 children. Transplants suspected to have early or delayed venous outflow obstruction were confirmed by percutaneous venography or surgical revision findings. Therapeutic intervention, recurrence and outcome were evaluated.

RESULTS

Twenty-six of 792 children (3.3%) experienced post-transplant hepatic venous outflow obstruction. These patients had been diagnosed from 1 day to 8.75 years after transplantation. Six occurred during the early post-transplant period; in three of them, the graft was lost. Seventeen patients were initially treated by balloon angioplasty with success; 11 of these experienced recurrences. Four stents were implanted; one was complicated by definitive occlusion. Three of the five surgical revisions were successful. The initial stenosis involved the inferior vena cava in 10 grafts, in isolation or associated with hepatic vein involvement. Mean follow-up was 79 months after transplantation. Eight grafts were lost.

CONCLUSION

Acute postoperative hepatic venous outflow obstruction was associated with poor prognosis. Diagnostic venography should be performed if there is any suspicion of venous outflow obstruction, even if first-line examinations are normal. Stenosis frequently involved the inferior vena cava. Angioplasty was a safe and efficient treatment for venous outflow obstruction despite frequent recurrence.

Balloon dilatation for treatment of hepatic venous outflow obstruction following pediatric liver transplantation

AIM

To assess the efficacy and safety of balloon dilatation for the treatment of hepatic venous outflow obstruction (HVOO) following pediatric liver transplantation.

METHODS

A total of 246 pediatric patients underwent liver transplantation at our hospital between June 2013 and September 2016. Among these patients, five were ultimately diagnosed with HVOO. Seven procedures (two patients underwent two balloon dilatation procedures) were included in this analysis. The demographic data, types of donor and liver transplant, interventional examination and therapeutic outcomes of these five children were analyzed. The median interval time between pediatric liver transplantation and balloon dilatation procedures was 9.8 mo (range: 1-32).

RESULTS

Five children with HVOO were successfully treated by balloon angioplasty without stent placement, with seven procedures performed for six stenotic lesions. All children underwent successful percutaneous intervention. Among these five patients, four were treated by single balloon angioplasty, and these patients did not develop recurrent stenosis. In seven episodes of balloon angioplasty across the stenosis, the pressure gradient was 12.0 ± 8.8 mmHg before balloon dilatation and 1.1 ± 1.5 mmHg after the procedures, which revealed a statistically significant reduction (P < 0.05). The overall technical success rate among these seven procedures was 100% (7/7), and clinical success was achieved in all five patients (100%). The patients were followed for 4-33 mo (median: 15 mo). No significant procedural complications or procedure-related deaths occurred.

CONCLUSION

Balloon dilatation is an effective and safe therapeutic option for HVOO in children undergoing pediatric liver transplantation. Venous angioplasty is also recommended in cases with recurrent HVOO.

Interventional radiology in the management of the liver transplant patient

Liver transplantation (LT) is commonly used to treat patients with end-stage liver disease. The evolution of surgical techniques, endovascular methods, and medical care has led to a progressive decrease in posttransplant morbidity and mortality. Despite these improvements, a multidisciplinary approach to each patient remains essential as the early diagnosis and treatment of the complications of transplantation influence graft and patient survival. The critical role of interventional radiology in the collaborative approach to the care of the LT patient will be reviewed. Liver Transplantation 23 1328-1341 2017 AASLD.

Efficacy and patency of primary stenting for hepatic venous outflow obstruction after living donor liver transplantation

BACKGROUND

Hepatic venous outflow is important for graft survival in living donor liver transplantation (LDLT). If hepatic venous outflow obstruction occurs, hepatic vein stenting is considered to restore the patency.

PURPOSE

To retrospectively evaluate the efficacy and patency of primary hepatic vein stenting for hepatic venous outflow obstruction (HVOO) after LDLT.

MATERIAL AND METHODS

Percutaneous interventions, including hepatic vein stent placement with or without balloon angioplasty, were performed in 21 patients who had undergone LDLT and had HVOO confirmed through hepatic venography or manometry, including the patients who had a structural abnormality. Two stents each were inserted in four patients; therefore, the total number of treated anastomoses was 25. Technical success, patency rates, and pressure gradients between hepatic veins and the right atrium were evaluated in 19 patients each.

RESULTS

Technical success was achieved in 25 of 26 vessels (96%). The mean interval between operation and stenting was 43 days. After the procedure, the follow-up period was a mean 530 days. The mean pressure gradient decreased from 8.5 mmHg to 2.1 mmHg after treatment (P < 0.01). The patency rates of the 25 vessels were 80% at 1, 2, and 3 years after stent placement. However, middle hepatic vein stenting revealed a low patency rate (all were 36%). Three of seven stents (43%) in the middle hepatic vein occluded during follow-up.

CONCLUSION

Percutaneous primary hepatic vein stent replacement is an effective treatment for HVOO after LDLT.

Longterm outcomes of stent placement for hepatic venous outflow obstruction in adult liver transplantation recipients

The purpose of this study was to evaluate the longterm outcomes of stent placement for a hepatic venous outflow obstruction in adult liver transplantation recipients. From June 2002 to March 2014, 23 patients were confirmed to have a hepatic venous outflow obstruction after liver transplantation (18 of 789 living donors [2.3%] and 5 of 449 deceased donors [1.1%]) at our institute. Among these patients, stent placement was needed for 16 stenotic lesions in 15 patients (12 males, 3 females; mean age, 51.7 years). The parameters that were documented retrospectively were technical success, clinical success, complications, recurrence, and the patency of the stent. The technical success rate was 100% (16/16). Clinical success was achieved in 11 of the 15 patients (73.3%). A major complication occurred in only 1 patient-a hepatic vein laceration during the navigation of the occluded segment. The median follow-up period was 33.5 months (range, 0.5-129.3 months), and the overall 1-, 3-, and 5-year primary patency rates of the stent were all 93.8%. One case of occlusion of the stent without clinical signs and symptoms was observed 5 days after the initial procedure. In this patient, the stent was recanalized by balloon angioplasty and showed patent lumen for 48 months of the subsequent follow-up period. In conclusion, stent placement is a safe and effective treatment modality with favorable longterm outcomes to treat hepatic venous outflow obstruction in adult liver transplantation recipients. Liver Transplantation 22 1554-1561 2016 AASLD.

Left lobe graft poses a potential risk of hepatic venous outflow obstruction in adult living donor liver transplantation

Hepatic venous outflow obstruction (HVOO) is a critical complication after living donor liver transplantation (LDLT). This study aimed to evaluate the incidence of HVOO and the risk factors for HVOO in adults. From 2005 to 2015, 430 adult LDLT patients (right lobe [RL] graft, 270 patients; left lobe [LL] graft, 160 patients) were enrolled and divided into no HVOO (n = 413) and HVOO (n = 17) groups. Patient demographics and surgical data were compared, and risk factors for HVOO were analyzed. Furthermore, the longterm outcomes of percutaneous interventions as treatment for HVOO were assessed. HVOO occurred in 17 (4.0%) patients. The incidence of HVOO in patients receiving a LL graft was significantly higher than in those receiving a RL graft (8.1% versus 1.5%; P = 0.001). The body weight and caliber of hepatic vein anastomosis in the HVOO group were significantly lower compared with the no HVOO group (P = 0.02 and P = 0.008, respectively). Multivariate analysis revealed that only LL graft was an independent risk factor for HVOO (OR, 4.782; 95% CI, 1.387-16.488; P = 0.01). Among 17 patients with HVOO, 7 patients were treated with single balloon angioplasty, and 9 patients who developed recurrence were treated with repeated interventions. Overall, 6 patients underwent stent placement: 1 at the initial procedure, 3 at the second procedure for early recurrence, and 2 following repeated balloon angioplasty (≥3 interventions). These 6 patients experienced no recurrence. Overall graft survival was not significantly different between the HVOO and no HVOO groups (P = 0.99). In conclusion, the use of a LL graft was associated with HVOO, and percutaneous interventions were effective for treating adult HVOO after LDLT. Liver Transplantation 22 785-795 2016 AASLD.

Long-term safety and outcome of percutaneous transhepatic venous balloon angioplasty for Budd-Chiari syndrome

BACKGROUND AND AIMS

The restenosis following percutaneous transluminal balloon angioplasty (PTBA) is high for Budd-Chiari syndrome (BCS) patients with hepatic venous obstruction (HVO). We aim to evaluate the safety and long-term outcome of PTBA with a large balloon catheter in a large series of patients with HVO.

METHODS

Between January 2005 and December 2013, 93 consecutive BCS patients with HVO were referred for PTBA and subsequently underwent color Doppler ultrasonography or angiography follow-up. Data were retrospectively collected, and follow-up observations were performed at 1-, 2-, 2- to 5-, and 5- to 8-years postoperatively.

RESULTS

Percutaneous transluminal balloon angioplasty was technically successful in all patients. Ninety-one patients (97.85%) were treated with PTBA and two with PTBA and stent. Major procedure-related complications occurred in six of the 93 patients (6.45%). The cumulative 1-, 2-, 2- to 5-, and 5- to 8-year primary patency rates were 97.5%, 92.9%, 90%, and 86.5%, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year secondary patency rates were 100%, 100%, 98.6%, and 97.3%, respectively. Mean and median primary patency rates were 51.50 ± 3.01 months and 55.0 ± 3.63 months, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year survival rates were 98.75%, 98.6%, 100%, and 100%, respectively. Mean and median survival times were 53.10 ± 3.04 months and 55.0 ± 3.64 months, respectively.

CONCLUSION

Percutaneous transluminal balloon angioplasty with a large balloon is a safe and effective treatment that could provide excellent rates of long-term patency and survival for the majority of Chinese patients with BCS and HVO.

Imaging Diagnosis of Splanchnic Venous Thrombosis

Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach.

Long-term outcome of endovascular intervention in hepatic venous outflow obstruction following pediatric liver transplantation

The purpose of our study was to address the long-term outcome of angioplasty and stent placement for hepatic venous outflow obstruction following pediatric liver transplantation. From October 1999 to December 2011, 20 stenotic lesions were confirmed to constitute hepatic venous outflow obstruction in 18 pediatric patients (13 boys, 5 girls) among 152 pediatric patients following liver transplantation and were managed with endovascular intervention. Stent placement was favored over additional angioplasty in patients of preadolescent or adolescent age (>8 years old), after 1 or 2 sessions of balloon angioplasty. The primary patency and assisted primary patency were estimated using the Kaplan-Meier method. A total of 32 procedures (24 balloon angioplasties, 8 stent placements) were conducted. The technical success rate was 90.6% (29/32). Clinical success was achieved in 15 of 18 patients (clinical success rate of 83.3%). Major complications did not occur in our study. Median follow-up was 91.5 months (interquartile range, 54.7-137.3 months) for the 18 patients. The 1-year, 3-year, 5-year, and 10-year primary patencies of the 20 treated lesions were 63.5%, 57.8%, 57.8%, and 57.8%, respectively. The 1-year, 3-year, 5-year, and 10-year assisted-primary patencies of the lesions were 100%, 100%, 100%, and 100%, respectively. Of the 6 patients of preadolescent or adolescent age, 5 patients underwent stent placement procedures, and the stents were patent during the follow-up period of 57.3-162.5 months (median, 72.7 months). In conclusion, endovascular intervention is very effective in hepatic venous outflow obstruction following pediatric liver transplantation. In addition, early stent placement in patients of preadolescent or adolescent age can provide a safe and favorable long-term outcome.

Utility of liver biopsy in predicting clinical outcomes after percutaneous angioplasty for hepatic venous obstruction in liver transplant patients

AIM: To determine utility of transplant liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty (PTA) for hepatic venous obstruction (HVOO).

METHODS: Adult liver transplant patients treated with PTA for HVOO (2003-2013) at a single institution were reviewed for pre/post-PTA imaging findings, manometry (gradient with right atrium), presence of HVOO on pre-PTA and post-PTA early and late biopsy (EB and LB, < or > 60 d after PTA), and clinical outcome, defined as good (no clinical issues, non-HVOO-related death) or poor (surgical correction, recurrent HVOO, or HVOO-related death).

RESULTS: Fifteen patients meeting inclusion criteria underwent 21 PTA, 658 ± 1293 d after transplant. In procedures with pre-PTA biopsy (n = 19), no difference was seen between pre-PTA gradient in 13/19 procedures with HVOO on biopsy and 6/19 procedures without HVOO (8 ± 2.4 mmHg vs 6.8 ± 4.3 mmHg; P = 0.35). Post-PTA, 10/21 livers had EB (29 ± 21 d) and 9/21 livers had LB (153 ± 81 d). On clinical follow-up (392 ± 773 d), HVOO on LB resulted in poor outcomes and absence of HVOO on LB resulted good outcomes. Patients with HVOO on EB (3/7 good, 4/7 poor) and no HVOO on EB (2/3 good, 1/3 poor) had mixed outcomes.

CONCLUSION: Negative liver biopsy greater than 60 d after PTA accurately identifies patients with good clinical outcomes.

[Arterial and portal venous complications after HPB surgical procedures: Interdisciplinary management]

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (<5 %) of these procedures could be reduced; nonetheless, postoperative complications still occur in 41.2 % of cases. Compared with hepatobiliary procedures, pancreatic surgery shows an increased rate of complications. Postoperative bleeding has a major effect on the outcome and the incidence is 6.7 % after pancreatic surgery and 3.2 % after hepatobiliary surgery. The major causes of early postoperative hemorrhage are related to technical difficulties in surgery whereas late onset postoperative hemorrhage is linked to anastomosis insufficiency, formation of fistulae or abscesses due to vascular arrosion or formation of pseudoaneurysms. In many cases, delayed hemorrhage is preceded by a self-limiting sentinel bleeding. The treatment is dependent on the point in time, location and severity of the hemorrhage. The majority of early postoperative hemorrhages require surgical treatment. Late onset hemorrhage in hemodynamically stable patients is preferably treated by radiological interventions. After interventional hemostatic therapy 8.2 % of patients require secondary procedures. In the case of hemodynamic instability or development of sepsis, a relaparotomy is necessary. The treatment concept includes surgical or interventional remediation of the underlying cause of the hemorrhage. Other causes of postoperative morbidity and mortality are arterial and portal venous stenosis and thrombosis. Following liver resection, thrombosis of the portal vein occurs in 8.5-9.1 % and in 11.6 % following pancreatic resection with vascular involvement. Interventional surgical procedures or conservative treatment are suitable therapeutic options depending on the time of diagnosis and clinical symptoms. The risk of morbidity and mortality after HPB surgery can be reduced only in close interdisciplinary cooperation, which is particularly true for vascular complications.

Better innovate than compromise: a novel hepatic outflow reconstruction technique in pediatric living donor liver transplantation

Pediatric LDLT using donors with unfavorable vascular anatomy is challenging in terms of donor safety, and complexity of reconstruction in the recipient. We describe an innovative technique of hepatic venous outflow reconstruction involving the recipient RHV, in the presence of a rudimentary RHV in the donor. The postoperative course of the donor and recipient was uneventful with satisfactory venous outflow in both. This technique avoided the use of prosthetic material, an important consideration given the recipient age and requirement for growth. This shows that donors previously considered unsuitable for donation can be utilized safely as long as principles of vascular anastomosis are adhered to. Moreover, it highlights that innovation is sometimes necessary to avoid compromise in donor safety.

Balloon venoplasty for liver failure due to stenosis of the left hepatic vein after right tri-segmentectomy

A 41-year-old male patient with hepatitis B underwent right tri-segmentectomy and total caudate lobectomy for a huge hepatocellular carcinoma associated with complete occlusion of the inferior vena cava with thrombosis of the infrahepatic inferior vena cava due to tumor compression. Five months later, he was readmitted for ascites and hyperbilirubinemia. Venography revealed stenosis and tortuosity of the left hepatic vein and the inferior vena cava, for which balloon angioplasty of the left hepatic vein and the inferior vena cava was performed using an 8-mm and 10-mm balloon, respectively. The left hepatic venous pressure decreased from 65 mmHg to 25 mmHg after dilatation. The patient made a satisfactory recovery thereafter and remains well with normal liver functions and without ascites. Balloon angioplasty may be useful for liver failure due to hepatic vein stenosis after hepatic resection.

Sequential venoplasty for treatment of inferior vena cava stenosis following liver transplant

Obstruction of the inferior vena cava (IVC) is a rare complication of liver transplantation with significant consequences including intractable ascites and hepatic dysfunction. Although venoplasty and stenting are effective in many cases, patients who fail first-line treatment may require surgical intervention or re-transplantation. Scheduled sequential balloon dilation, an approach frequently used to treat fibrotic, benign biliary strictures, but less commonly vascular lesions, may avert the need for such high-risk alternatives while achieving favorable clinical and angiographic response. Herein, we report the case of a 36-year-old woman with transplant-related, initially angioplasty-resistant IVC stenosis that was successfully treated with sequential balloon dilation.

Interventional radiology in living donor liver transplant

The shortage of deceased donor liver grafts led to the use of living donor liver transplant (LDLT). Patients who undergo LDLT have a higher risk of complications than those who undergo deceased donor liver transplantation (LT). Interventional radiology has acquired a key role in every LT program by treating the majority of vascular and non-vascular post-transplant complications, improving graft and patient survival and avoiding, in the majority of cases, surgical revision and/or re-transplant. The aim of this paper is to review indications, diagnostic modalities, technical considerations, achievements and potential complications of interventional radiology procedures after LDLT.

Hepatic venous outflow obstruction after transplantation: outcomes for treatment with self-expanding stents

OBJECTIVES

To evaluate the safety and patency of self-expanding stents to treat hepatic venous outflow obstruction after orthotopic liver transplantation. To evaluate differences in the response between patients with early obstruction and patients with late obstruction.

MATERIAL AND METHODS

This is a retrospective analysis of 16 patients with hepatic venous outflow obstruction after liver transplantation treated with stents (1996-2011). Follow-up included venography/manometry, ultrasonography, CT, and laboratory tests. We did a descriptive statistical analysis of the survival of patients and stents, technical and clinical success of the procedure, recurrence of obstruction, and complications of the procedure. We also did an inferential statistical analysis of the differences between patients with early and late obstruction.

RESULTS

The mean follow-up period was 3.34 years (21-5,331 days). The technical success rate was 93.7%, and the clinical success rate was 81.2%. The rate of complications was 25%. The survival rates were 87.5% for patients and 92.5% for stents. The rate of recurrence was 12.5%. The rate of primary patency was 0.96 (95% CI 0.91-1) at 3 months, 0.96 (95% CI 0.91-1) at 6 months, 0.87 (95% CI 0.73-1) at 12 months, and 0.87 (95% CI 0.73-1) at 60 months. There were no significant differences between patients with early and late obstruction, although there was a trend toward higher rates of primary patency in patients with early obstruction (P=.091).

CONCLUSIONS

Treating hepatic venous outflow obstruction after orthotopic transplantation with self-expanding stents is effective, durable, and effective. There are no significant differences between patients with early obstruction and those with late obstruction.

Long-term outcome of percutaneous interventions for hepatic venous outflow obstruction after pediatric living donor liver transplantation: experience from a single institute

PURPOSE

To evaluate retrospectively the long-term outcome of percutaneous interventions for hepatic venous outflow obstruction (HVOO) occurring after pediatric living donor liver transplantation (LDLT).

MATERIALS AND METHODS

Between October 1997 and December 2012, 48 patients (24 boys, 24 girls; median age, 6 y) who had undergone LDLT were confirmed to have HVOO using percutaneous hepatic venography and manometry. All patients underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, patency rates, stent placement, and major complications were evaluated.

RESULTS

Technical success was achieved in 92 of 93 sessions (99.0%) and in 47 of 48 patients (97.9%), and clinical success was achieved in 41 of 48 patients (85.4%). During the follow-up period (range, 1-182 mo; median, 51.5 mo), 28 patients were treated with a single session of balloon angioplasty, and 20 patients who developed recurrent stenosis were treated with repeated percutaneous interventions. The rates of primary and primary-assisted patency at 1, 3, 5, and 10 years after balloon angioplasty were 64%, 57%, 57%, and 52% (primary patency) and 98%, 95%, 95%, and 95% (primary-assisted patency). Of six patients with stent placement, four had no recurrent HVOO after the stent placement, but two developed recurrent stenosis. The stent migrated to the right atrium in one patient.

CONCLUSIONS

Percutaneous interventions were effective treatments for HVOO after LDLT.

Successful recanalization of occluded intrahepatic inferior vena cava in post-liver transplant Budd-Chiari syndrome

Budd-Chiari syndrome following a liver transplant is an uncommon phenomenon. We present a case of endovascular management of a focal circumferential inferior vena cava (IVC) occlusion at the anastomosis that developed 10 years after orthotopic liver transplantation. It was successfully recanalized using the stiff end of the guidewire and percutaneous transluminal angioplasty with a high-pressure balloon. During a 14-month follow up, the IVC remained patent and did not require further intervention.

Long-term outcomes of percutaneous venoplasty and Gianturco stent placement to treat obstruction of the inferior vena cava complicating liver transplantation

PURPOSE

Evaluation of long-term outcomes of venoplasty and Gianturco stents to treat inferior vena cava (IVC) obstruction after liver transplantation.

METHODS

We retrospectively analyzed records from 33 consecutive adult patients referred with the intent to treat suspected IVC obstruction after liver transplantation. Treatment was performed for occlusion or stenosis with a gradient exceeding 3 mmHg. The primary treatment was venoplasty and, if refractory, Gianturco stent placement. Recurrence prompted repeat venoplasty or stent placement.

RESULTS

Of the 33 patients, 25 (aged 46.9 ± 12.2 years) required treatment at a mean of 2.3 years (14 days to 20.3 years) after transplantation. For technically successful cases, primary treatment was venoplasty alone (14) or with stent placement (10). Technical success was 96 % (24 of 25) reflecting failure to cross one occlusion. Clinical success was 88 % (22 of 25) reflecting the technical failure and two that died of unrelated complications within 5 weeks. Cumulative primary patencies were 57.1 % at 6 months (n = 21) and 51.4 % at 1 (n = 10), 3 (n = 7), 5 (n = 6), and 7 (n = 5) years. Cumulative primary assisted patency was 95.2 % at 6 months (n = 21) and at 1 (n = 15), 3 (n = 9), 5 (n = 8), and 7 (n = 8) years. The 17 patients stented for refractory (n = 10) or recurrent (n = 7) stenosis had cumulative primary and primary assisted patencies of 86.0 and 100 %, respectively, from 6 months (n = 14) to 7 years (n = 3). No major complications occurred; one fractured stent was observed after 11.6 years.

CONCLUSION

For IVC obstruction following liver transplantation, excellent long-term outcomes can be achieved by venoplasty and Gianturco stent placement.

Interventional radiological treatment of perihepatic vascular stenosis or occlusion in pediatric patients after liver transplantation

PURPOSE

Evaluation of the efficacy and safety of percutaneous treatment of vascular stenoses and occlusions in pediatric liver transplant recipients.

METHODS

Fifteen children (mean age 8.3 years) underwent interventional procedures for 18 vascular complications after liver transplantation. Patients had stenoses or occlusions of portal veins (n = 8), hepatic veins (n = 3), inferior vena cava (IVC; n = 2) or hepatic arteries (n = 5). Technical and clinical success rates were evaluated.

RESULTS

Stent angioplasty was performed in seven cases (portal vein, hepatic artery and IVC), and sole balloon angioplasty was performed in eight cases. One child underwent thrombolysis (hepatic artery). Clinical and technical success was achieved in 14 of 18 cases of vascular stenoses or occlusions (mean follow-up 710 days).

CONCLUSION

Pediatric interventional radiology allows effective and safe treatment of vascular stenoses after pediatric liver transplantation (PLT). Individualized treatment with special concepts for each pediatric patient is necessary. The variety, the characteristics, and the individuality of interventional management of all kinds of possible vascular stenoses or occlusions after PLT are shown.

The Role of Interventional Radiology in Treating Complications following Liver Transplantation

Liver transplantation (LT) is used to treat both adult and pediatric patients with end-stage liver disease or acute liver failure. It has become more prevalent as both the surgical technique and postoperative care have improved resulting in a reduced morbidity and mortality. As a result, there are more patients surviving longer after liver transplantation. Despite this, there remain serious complications from the procedure that have a significant outcome on the patient and may result in retransplantation. At the same time, there have been significant advances in the field of interventional radiology both in terms of technology and how these apply to the patients. In this paper, we review the commonest complications, diagnostic tests, and interventional management options available.

A novel approach to endovascular treatment of severe hepatic vein stenoses following liver transplant in children

Hepatic vein stenoses are a rare but serious complication of liver transplants in children. Restoration of flow by radiological methods often provides a viable treatment option. This technique relies on the interventional radiologist's ability to advance a guide wire across the obstruction, thus allowing for balloon dilatation and other necessary interventions. Failure to cross the stenosis reduces graft survival and increases patient morbidity. We report two cases with tight hepatic vein stenosis where the guide wire could not be advanced in a conventional approach across the upper end of the stenosis. Utilizing prominent intrahepatic collateral vessels, the stenoses were able to be crossed, facilitating successful PTA with good clinical outcome.

Standard hepatic vein reconstruction with patch plasty using the native portal vein in adult living donor liver transplantation

An outflow obstruction of the hepatic vein is a critical complication after living donor liver transplantation (LDLT) and occasionally leads to hepatic failure. Here we introduce a simple method for preventing outflow obstructions by patch plasty in adult LDLT. Between September 2001 and May 2010, 468 adult LDLT procedures were performed at Kyoto University Hospital. We harvested each recipient's portal vein (PV) from the extirpated liver for a patch. We intended to re-form several orifices of the hepatic veins into a single, large orifice. The patch was attached to the anterior wall of the re-formed orifice on the bench. After we put in the liver graft, the procedure for the hepatic vein anastomosis to the inferior vena cava was simple enough that the warm ischemia time was reduced. Three of the 468 cases were diagnosed with an outflow obstruction. All 3 cases underwent hepatic vein reconstruction without patch plasty. In contrast, none of the 159 cases that underwent LDLT with patch plasty suffered from an outflow obstruction, regardless of the liver graft type. The procedure for hepatic vein plasty using a patch from the native PV is simple and elegant and results in excellent outcomes. We propose this as the standard procedure for hepatic vein reconstruction in adult LDLT.

Hepatic venous outflow obstruction in pediatric living donor liver transplantation using left-sided lobe grafts: Kyoto University experience

The goals of this study were to evaluate the incidence of hepatic venous outflow obstruction (HVOO) in pediatric patients after living donor liver transplantation (LDLT) using left-sided lobe grafts and to assess the therapeutic modalities used for the treatment of this complication at a single center. Four hundred thirteen primary LDLT procedures were performed with left-sided lobe grafts between 1996 and 2006. All transplants identified with HVOO from a cohort of 380 grafts with survival greater than 90 days were evaluated with respect to the patient demographics, therapeutic intervention, recurrence, and outcome. Seventeen cases (4.5%) were identified with HVOO. Eight patients experienced recurrence after the initial balloon venoplasty. Two patients finally required stent placement after they experienced recurrence shortly after the initial balloon venoplasty. A univariate analysis revealed that a smaller recipient-to-donor body weight ratio and the use of reduced grafts were statistically significant risk factors. The cases with grafts with multiple hepatic veins had a higher incidence of HVOO. In conclusion, the necessity of repeated balloon venoplasty and stent placement was related to poor graft survival. Therefore, the prevention of HVOO should be a high priority in LDLT. When grafts with multiple hepatic veins and/or significant donor-recipient size mismatching are encountered, the use of a patch graft is recommended. Stent placement should be carefully considered because of the absence of data on the long-term patency of stents and stent-related complications. New stenting devices, such as drug-eluting and biodegradable stents, may be promising for the management of HVOO.

Incidence, impact, and treatment of portal and hepatic venous complications following pediatric liver transplantation: a single-center 12 year experience

PVT or PVS and HVOO are known causes of graft and patient loss after pediatric liver transplantation. Increased incidences of these complications have been reported in partial livers including DDSLT or LDLT. From 1997 to 2008, 241 consecutive pediatric patients received 271 hepatic grafts at a single center. Median follow-up is 1856 days. Surgical technique, demographics, lab values, and radiologic imaging procedures were obtained utilizing OTTR to evaluate the relationship of portal and hepatic complications with risk factors, patient and graft survival. Grafts were composed of 115/271 (42.4%) partial livers of which 90 (33.2%) were DDSLT and 25 (9.2%) LDLT. Of 271 patients, 156 (57.6%) received whole-sized grafts. There were six PVC in five patients with one patient requiring retransplantation (0.34%) and no patient deaths. Utilizing all three hepatic vein orifices on the recipient hepatic vena cava and the donor hepatic vein cut short enables a wide hepatic outflow tract unlikely to twist. None of the 241 patients developed early or late complications of the hepatic vein. None of the last 128 consecutive patients who received 144 grafts over seven and a half yr have developed either early or late complications of the hepatic or portal vein. Partial-graft actuarial survival was similar to whole-graft survival (87.2% vs. 85.3% at one yr; 76.6% vs. 80.2 at three yr; p = 0.488). Likewise, patient survival was similar between partial grafts and whole grafts (93.8% vs. 93.1% at one yr; 89.8% vs. 87.2% at three yr; p = 0.688) with median follow-up of 1822 (+/-1334) days. Patients receiving partial livers were significantly younger and smaller than patients receiving whole livers (p < 0.001). Portal and hepatic venous complications may have negative effects on patient or graft survival after pediatric liver transplantation. In our series, there was one graft and no patient loss related to portal or hepatic venous complications after pediatric liver transplantation over 12 yr.

Percutaneous transluminal venoplasty after venous pressure measurement in patients with hepatic venous outflow obstruction after living donor liver transplantation

PURPOSE

The aim of this study was to evaluate retrospectively the outcome of percutaneous transluminal venoplasty (PTV) after venous pressure measurement in patients with hepatic venous outflow obstruction following living donor liver transplantation (LDLT).

MATERIALS AND METHODS

We studied 24 consecutive patients suspected of having hepatic venous outflow obstruction after LDLT. Pressure gradients were measured proximal and distal to the lesion, and gradient values >3 mmHg were considered hemodynamically significant. We evaluated the technical success, complications, outcome of venoplasty and recurrence, and the patency rate.

RESULTS

In all, 11 female patients manifested a pressure gradient >3 mmHg across the anastomotic site; they underwent subsequent PVT. The initial balloon venoplasty procedure was technically successful in 10 of the 11 patients (91%), and the pressure gradient was reduced from 5.8 to 1.1 mmHg (P < 0.01). Clinical improvement was observed in 9 of these 10 patients; one patient failed to improve and underwent retransplantation. Recurrent obstruction occurred in four patients; they underwent PTV with (n = 2) or without (n = 2) stent placement. There were no major procedural complications.

CONCLUSION

PTV following venous pressure measurement is an effective and safe treatment for venous outflow obstruction in patients subjected to LDLT. In patients with recurrent obstruction, re-venoplasty is recommended.

Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation

BACKGROUND

Hepatic outflow block is one of the major complications leading to severe graft dysfunction after left lobe living donor liver transplantation (LDLT).

METHODS

Medical records of 46 recipients of a left lobe LDLT were reviewed. The method of outflow reconstruction and post-transplant morphological changes of hepatic veins were investigated. The subjects were followed up until September 2008, with a median follow-up period of 2.0 yr (range: 0.5-5.9 yr).

RESULTS

There were no multiple outflow tracts to be reconstructed, and the median caliber of the single orifices with or without venoplasty was 32.0 mm. The difference between the angle of hepatic veins to the sagittal plane measured on computed tomography was calculated for pre-operative donors and post-operative recipients a month after LDLT. Both left and middle hepatic veins showed a significantly greater change in angle than the right hepatic vein. Both left and middle hepatic veins more frequently showed a nearly flat wave form on Doppler study one month after LDLT. In the 46 recipients of left lobe grafts, three developed outflow block (6.5%).

CONCLUSIONS

The middle and left hepatic veins tend to distort and stretch during graft regeneration. These characteristics seem to be associated with outflow disturbances.