Antithrombotic management and thrombosis rates in children post–liver transplantation: A case series and literature review

Abstract

Thrombosis is a major postoperative complication in pediatric liver transplantation. There is marked heterogeneity in prophylactic antithrombotic therapies used, without established guidelines. This review summarizes current worldwide incidence of thrombotic events and compares antithrombotic therapies in children post–liver transplant, with comparison to our institution's experience. Of the twenty‐three articles with sufficient detail to compare antithrombotic regimens, the overall incidence of thrombosis ranged from 2.4% to 17.3%. Incidence of HAT ranged from 0% to 28.1%, of HVT from 0% to 4.7%, of PVT from 1.5% to 11.2%, and of IVC thrombosis from 0% to 2.8%. Re‐transplantation due to thrombosis ranged from 0% to 4.8%. Prophylactic antithrombotic therapies varied between studies, and bleeding complications were infrequently reported. Since 2010, 96 children underwent 100 liver transplants at our institution with thrombosis incidence comparable to international literature (HAT 6%, PVT 5%, IVC 1%, and HVT 0%). Re‐transplantation due to thrombosis occurred in 2% and major bleeding occurred in 10%. The prophylactic antithrombotic therapies used post–liver transplantation in children remain varied. Low rates of thrombosis have been reported with antiplatelet use both with and without anticoagulation. Standard definitions and consistent reporting of bleeding complications are required, in addition to thrombosis rates, so that true risk‐benefit assessment of reported regimes can be understood.

Hepatic artery reconstruction using an operating microscope in pediatric liver transplantation—Is it worth the effort?

“…Regardless of the considerably high HAT rates in the SL group, our data support the idea that HAT occurrence can be significantly reduced, or-as shown in this case-series-entirely avoided in pLT by using an OM. [7][8][9] Therefore, HAR performed by a plastic surgeon using an OM appears to be a logical step, and many authors suggest the use of an OM for HAR in pLT. 4,13,25,26 Still, its implementation has not fully been established in most pLT programs due to multiple reasons.…”

Pediatric liver transplantation

“…Risk is maximum in the first two weeks, with an estimated incidence of 6% -this number varies widely according to institutions and eras (27) . Post-transplantation thrombotic events, regardless of the vessel involved (arterial, portal or hepatic vein thrombosis), range from 2.4% to 17.3% (28) . In Spain, NTO data on urgent re-transplantation rates are broken down by healthcare institution, which represents an approximate indicator of AT.…”

“…Finally, all teams apply their own postoperative anticoagulation protocols, which greatly vary globally (28) . Most studies show a similar pattern, which initiates when INR levels go below 1.5-2.…”

Trasplante hepático pediátrico

“…Su riesgo es máximo en las primeras dos semanas y su incidencia se estima en el 6%, con un amplio rango según centros y épocas (27 ). El rango de fenómenos trombóticos postrasplante, independientemente del vaso afectado (arterial, portal o de venas hepáticas), oscila entre el 2,4 y el 17,3% (28) . En nuestro país la ONT ofrece desglosado por centro la tasa de retrasplante urgente, un estimador aproximado de la TA.…”

“…Por último, todos los equipos aplican protocolos de anticoagulación postoperatoria con una amplia variabilidad a nivel mundial (28) . La mayoría de los estudios muestran un patrón similar que se inicia cuando los niveles de INR disminuyen por debajo de 1,5-2.…”