Eversion thromboendovenectomy in organized portal vein thrombosis during liver transplantation

Abstract

Portal thrombosis is no longer considered a contraindication for transplantation because of the technical experience acquired in the field of liver transplantation and the development of various surgical techniques. All the same, the results obtained in portal thrombosis patients are at times suboptimal, and the surgical technique used (thromboendovenectomy or veno-venous bypass) is also controversial. Between May 1988 and December 2001, 455 liver transplants were performed, of which 32 (7%) presented portal vein thrombosis. Of these, eight belonged to the first 227 transplants (group I), and 24 to the other 228 (group II). Of the 32 cases with portal thrombosis, 20 (62%) were type Ib, seven (22%) type II/III and five (16%) type IV. Twenty-two were males (69%), with a mean age of 50 yr (range: 30-70 yr); the thrombosis in all cases developed over a cirrhotic liver: 15 cases of an ethanolic origin, 11 because of hepatitis C virus, two cases of autoimmune aetiology, one case of primary biliary cirrhosis, one case because of hepatitis B virus and two cases of a cryptogenic origin. Five cases had a history of surgical treatment for portal hypertension. The surgical method in all cases consisted of an eversion thromboendovenectomy (ETEV) under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. Once re-canalization was achieved, we performed local heparinization and end-to-end portal anastomosis. In no case was systemic post-operative heparinization performed. In the 32 cases in which thrombectomy was attempted it was achieved in 31 of them (96%), failing only in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis re-thrombosed. The 5-yr survival rate of the patients in the series was 69%, with 10 patients dying, of whom only two from causes related to the thrombosis and the thrombosis treatment, both with type IV thrombosis. The ideal treatment for portal thrombosis during liver transplantation is controversial and depends on its extension and the experience of the surgeon. In our experience, ETEV resolves most thromboses (types I, II and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal haemitransposition.

Living-Donor Liver Transplantation with Renoportal Anastomosis for Patients with Large Spontaneous Splenorenal Shunts

“…Since the successful bypass of thrombotic segments using vein grafts (11) many authors have reported that liver transplantations are feasible even in the presence of portal vein thrombosis (1)(2)(3)(4)12). Nevertheless, the incidence of re-thrombosis in the portal vein after liver transplantation has been reported to be as high as 6.6 % (30 cases of re-thrombosis out of 452 cases with portal vein thrombosis) with high mortality rate by a meta-analysis (4).…”

“…Although various techniques, mainly low dissections, thrombectomy of the recipient portal vein, or interposition of venous graft between the donor portal vein and the recipient SMV, have made it feasible to perform liver transplantations in patients with portal vein thrombosis, these procedures are associated with a possibility of rethrombosis and a high mortality rate (1)(2)(3)(4). Patients with a complete occlusion of the portal vein and large splenorenal collaterals, a special type of portal vein thrombosis, are not uncommon, but it is sometimes technically difficult to restore portal vein flow to the graft using conventional portal vein reconstruction techniques, a portal vein thrombectomy, or the ligation of collaterals with/without a splenectomy.…”

Hemostatic balance in patients with liver cirrhosis: Report of a consensus conference

“…PVT is frequent in cirrhosis [35,48,[179][180][181][182][183][184][185][186][187][188][189][190], with a 1-year incidence of 4.6-16.7% (Table 4), and prevalence of 1.4-26.1% (Table 5). Prevalence increases with the severity of cirrhosis [186,190], with rates of up to 44.4% in patients with hepatocellular carcinoma.…”

Single center experience of 39 patients with preoperative portal vein thrombosis among 404 adult living donor liver transplantations

“…Surgical innovations have been reported for hilum dissection, thrombectomy and portal vein reconstruction using vein grafts in deceased liver transplantation. [1][2][3][4][5][6][7][8][9][10][11][12][13] In living donor liver transplantation (LDLT), there are technical difficulties due to these challenges for preexisting PVT patients; necessity of distal dissection of vascular pedicle of the hilum and restricted availability of a vein graft. The presence of PVT in the recipient has frequently been presented as a relative or absolute contraindication in LDLT by numerous groups.…”