Obstruction of the portal vein may be related to constriction by malignant tumors or thrombosis associated with liver disease. We herein have reported our experience with patients undergoing liver transplantation with portal vein thrombosis (PVT) whose diagnosis was made intraoperatively. From September 1991 to May 2009, we studied 27/419 (6.4%) patients with PVT who were evaluated according to the presence of esophagogastric varices, underlying disease, malignancy, and if there was previous surgery, review of medical records on data collected prospectively. We observed 24 (88.9%) patients with PVT grade 1, 2 (7.4%) with grade 2, and 1 (3.7%) with grade 3. The average age of the PVT patients was 47.5 years; the average model for End-Stage Liver Discase score was 18.3, and the predominant diagnosis, hepatitis C cirrhosis. Eighteen underwent a sclerotherapy/ligature. The sensitivity of ultrasound for grade 1 thrombosis was 39.1%; for grade 2, 50%; and for grade 3, 100%. Portal vein thrombectomy was performed in 24 patients. In other patients (grade 2), we performed an anastomosis of the donor portal vein to the recipient gastric vein or to a greater splanchnic collateral vein. In only 1 patient was the graft performed using the donor portal vein-donor iliac vein-recipient superior mesenteric vein. None of the patients displayed PVT in the immediate postoperative period. Actuarial survivals at the years 1, 3, and 5 were 85%, 74%, and 63%, respectively. We concluded that PVT cannot be considered to be a contraindication for liver transplantation.
Portal vein thrombosis (PVT) was for a long time considered a barrier to liver transplantation. The aim of this study is to demonstrate the surgical technical options for portal vein reconstruction during liver transplantation in patients with PVT in which thrombectomy was not possible. Between September 1991 and March 2009, 420 liver transplanted patients were retrospectively analyzed, identifying 29 cases with PVT (6.9%). Preoperative diagnosis, preoperative risk factors, surgical technique options to treat various forms (grades) of PVT, postoperative recurrence and actuarial survival rates were studied. In three cases of PVT grade II and in one case PVT grade III the thrombectomy was insufficient, requiring some surgical technique options (13.79%). In two cases placement of iliac vein graft was performed, in one an anastomosis of the portal vein with collateral splenorenal vein and in the other with left gastric varicose. The actuarial survival rate for patients without PVT and patients with PVT and effective thrombectomy was 73.8% while those with PVT who needed some type of surgical option was 75%. Our results suggest that actuarial survival rates were similar among patients with PVT or PVT with effective thrombectomy when compared with PVT that required some surgical options
Introdução: A trombose de artéria hepática é uma complicação frequente no pós-transplante hepático (varia de 2,0- 20%), ocorrendo precocemente (30 dias após transplante) em 46,7% das vezes, e necessitando novo transplante em aproximadamente metade dos casos (53,1%). A síndrome antifosfolípide é definida como presença de trombose arterial e/ou venosa associada a anticorpos contra fosfolipídios. A incidência de SAF foi estimada em cinco novos casos/ 100000 pessoas/ ano. A ocorrência de trombose precoce de artéria hepática pós-transplante secundária à síndrome antifosfolípide é evento raro. Métodos: Relato de caso de um paciente submetido a três transplantes hepáticos por trombose de artéria associada à positividade de anticorpo anticardiolipina. Resultados: Paciente masculino, 49 anos, cirrótico por vírus C, sem antecedentes pessoais trombóticos, incluído em lista de transplante hepático por apresentar à tomografia computadorizada, nódulo de 4,2cm no segmento VI hepático compatível com Carcinoma Hepatocelular. Submetido a transplante hepático sob a técnica de Piggy Back. Apresentou ao Ultrassom Doppler de controle, ausência de f luxo em artéria hepática, confirmado por angiotomografia. Submetido a novo transplante no 13º dia pós-operatório. Nova tomografia de abdome não identificou f luxo arterial intra-hepático, e evidenciou extensa área de infarto no terceiro pós-operatório. Iniciada investigação de trombofilias, com positividade para pesquisa do anticorpo anticardiolipina. Submetido a terceiro transplante hepático, quando foi optado pela confecção de anastomose aorto-íliaco-hepática, através da interposição de enxerto de artéria ilíaca do doador. Paciente com boa evolução clínica, apresentando f luxo arterial intra-hepático aos exames de imagem de controle. Recebeu alta hospitalar no 10º dia pós-operatório. Discussão e Conclusão: Mortalidade por trombose precoce de artéria hepática de 33,3%; tempo médio de diagnóstico em torno de sete dias; principais fatores de risco (tempo operatório prolongado, baixo peso do receptor, discordância entre sorologia do doador e receptor para CMV). Encontrada correlação entre IgM anticardiolipina e eventos trombóticos (p= 0.004). Achados sugerem que a anticardiolipina está elevada em pacientes com insuficiência hepática e pode estar associada à patogênese da trombose arterial. Não há na literatura consenso sobre o uso profilático de anticoagulantes nesses casos.
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