Interventional percutaneous trans-splenic approach in the management of portal venous occlusion after living donor liver transplantation

Abstract

A 2-year-old Chinese boy with progressive familial intrahepatic cholestasis type II-related end-stage liver disease underwent living donor liver transplantation (LDLT) using a left lateral segment graft from his mother. Preoperative computed tomography angiography showed that the hepatic artery, inferior vena cava, and portal vein were patent. The left portal vein of the graft was connected to the recipient's right anterior portal vein. The left hepatic vein of the graft was connected to the recipient's hepatic veins with triple venoplasty. The left hepatic artery of the graft was connected to the recipient's right hepatic artery. The left hepatic duct of the graft was connected to the recipient's common hepatic duct with a microsurgical technique.After the operation, the infant underwent reworking of the hepatic artery anastomosis twice because of early hepatic artery thrombosis. He also underwent revision of the biliary reconstruction to Roux-en-Y hepaticojejunostomy because of biliary anastomotic stricture. At 18 months post-transplant, there was poor visualization of the intrahepatic portal vein, but there was hepatofugal flow inside the left portal vein during Doppler ultrasound follow-up studies. Splenomegaly and minimal ascites were also noted by ultrasound. The computed tomography angiography study showed mild intrahepatic bile duct dilatation, marked splenomegaly, and occlusion of the transverse portion of the portal vein with collateral vessels also noted. The patient was subsequently referred for a possible interventional radiological procedure as initial management for the occluded portal vein.The patient underwent vascular catheter intervention under general anesthesia. The percutaneous transsplenic approach was performed to puncture the splenic vein with a 21-gauge Chiba needle (Cook, Bloomington, IN) under ultrasonographic and fluoroscopic guidance. The needle was changed to a 4-French coaxial dilator and a 7-French sheath (Terumo, Tokyo, Japan) over a 0.035-inch angled hydrophilic guide wire (Terumo) after confirmation that the needle was in the splenic vein. Direct main portal venography and the pressure gradient across the stenosis were then obtained. Portography showed total occlusion of the portal vein at its umbilical portion (Fig. 1). The coronary vein was prominent, and gastroesophageal varices were also noted. The extrahepatic portal pressure was 18 mm Hg, and the intrahepatic portal pressure was 18 mm Hg. Hence, there was no pressure gradient across the area of stenosis. A 0.035-inch guide wire and a 4-French J curve catheter (Terumo) were used to traverse the area of portal vein stenosis (Fig. 2). A wall stent (9.0 mm ϫ 5.0 cm; Boston Scientific, Natick, MA) was placed to bypass the area of stenosis from the umbilical portion up to the visualized segment 3 portal vein. A second similarly sized wall stent was placed from the mid portion of the native main portal vein to the splenic vein.Balloon angioplasty (6.0-40 mm, 80 cm; Wanda, BosAbbreviation: LDLT, living donor liver transplantati...

Vascular Stents in the Management of Portal Venous Complications in Living Donor Liver Transplantation

“…The procedure is conventionally performed through the percutaneous transhepatic approach. However, transjugular, transsplenic and intraoperative mesenteric vein approaches were also reported (13–16).…”

“…Engorgement of intraparenchymal HA with prominent DUS arterial flow is usually seen in poor portal flow patients, especially in complete PV vein occlusion. A small‐sized PV without visualized flow is difficult to approach and may need several attempts to puncture (16). In this situation, parenchymal HA pseudoaneurysm can be the complication in pediatric LT during PV intervention (17).…”

Recanalization of post‐transplant late‐onset long segmental portal vein thrombosis with bidirectional transhepatic and transmesenteric approach

“…After introduction of percutaneous PV venoplasty, utility of this technique is confirmed by other reports including long‐term patency as well as efficacy of metallic stents in the cases with elastic stenosis . Although utility of transileocolic approach as well as trans‐splenic approach is reported, majority of PV venoplasty is performed with percutaneous transhepatic retrograde fashion .…”

Outcomes of Liver Transplantation in Small Infants

“…(36,38,40) Interventional radiology (balloon angioplasty, stent replacement) is used to treat, and recanalization with stent placement is limited to cases that need repeat balloon dilatation for PVS recurrence. (36,38,40) Access for PV angioplasty and stent placement is typically via a percutaneous transhepatic approach, (40) but a percutaneous transsplenic (41) or transileocolic approach by minilaparotomy (42) has been described.…”