Long-Term Venous Complications After Full-Size and Segmental Pediatric Liver Transplantation

Abstract

ObjectiveTo assess the long-term incidence of venous complications, including portal vein and hepatic vein stenoses, in both whole cadaveric and reduced-size cadaveric and living related liver transplants in a pediatric population, and to assess the therapeutic modalities in the treatment of these lesions. Summary Background DataA shortage in appropriate-sized liver grafts for pediatric patients led to the use of segmental liver grafts, which became the predominant graft used in 325 of 600 (54%) transplants at the authors' institution. To assess the long-term impact of this strategy, the authors examined the incidence of late (Ͼ90 days) venous complications and the efficacy of all therapeutic interventions. MethodsSix hundred pediatric liver transplants were performed in 325 patients, with reduced-size or split (RSS; n ϭ 207), living related (LRD; n ϭ 118), or full-size cadaveric grafts (FS; n ϭ 275) from 1988 to 2000. All transplants identified with late portal vein or vena caval stenoses or thromboses from a cohort of 524 grafts with survival greater than 90 days were reviewed for demographics, symptoms, therapeutic intervention, recurrence, morbidity, and mortality. ResultsFifty lesions were identified in 49 patients (38 portal vein and 12 hepatic vein-cava stenoses). Sex distribution was similar between portal vein and hepatic vein to cava, as was the mean patient age. Portal vein stenoses occurred in 32 LRD, 3 RSS, and 3 FS, while hepatic vein-cava stenoses occurred in 2 LRD, 8 RSS, and 2 FS. In the 38 portal vein stenoses, 9 had prior perioperative portal vein and/or 5 hepatic artery thrombectomies. Portal vein stenoses were identified after bleeding (17/38), ascites (6/38), increased liver function tests (6/38), splenomegaly (5/38), or screening ultrasound (4/38). Portal vein stenosis was associated most often with cryopreserved vein for portal conduits. Excluding conduits, the incidence of late portal vein complications was reduced to 1%. Lesions became symptomatic at a mean of 50.8 Ϯ 184.2 months posttransplant. All patients underwent venous angioplasty with a 66% (25/38) success rate, while 7 of 25 required further angioplasty and stenting. In the 13 unsuccessful angioplasties, 8 required surgical shunts for complete portal vein thrombosis. Recurrence occurred in 9 patients: all were amenable to stenting. Nine patients (24%) eventually died of sepsis (4) and surgical deaths at shunt or retransplant (5). Hepatic vein-cava stenoses occurred after a mean of 37.2 Ϯ 35.2 months, presenting with ascites (n ϭ 10), increased liver function tests (n ϭ 2), and splenomegaly (n ϭ 2). All patients were diagnosed by venogram and managed by balloon dilatation alone (n ϭ 6) or stented (n ϭ 4), with an 80% (10/12) success, with two late recurrences amenable to repeat angioplasty or stenting. Long-term survival was 80% at 1 year. ConclusionsThe use of segmental grafts without venous conduits is not associated with a significant rate of long-term venous complication. When late venous complications do occur, venous angiop...

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

“…A graft for smaller children, even if it is an LLS, becomes relatively large for size, and this compromises the hepatic venous outflow because of compression. 14, 15 Buell et al 16 noted that HVOO predominantly presented in patients of younger ages and lower weights. The present study did not reveal any significant increase in the risk for younger patients or patients of lower weights.…”

“…There have been several studies focused on stent placement for HVOO. 9,13,15,16,25,26 Buell et al 16 reported a 72% success rate for stent placement. However, most of these reports have noted hesitation in performing stent placement in pediatric cases for several reasons.…”

Interventional radiology for post-transplant anastomotic complications

“…Although HVOO is an uncommon complication after liver transplantation, it is still an important cause of graft failures after liver transplantation [2] . The incidence of HVOO after orthotropic liver transplantation is reported to be about 1% and that after LDLT is reported to be about 2-4% [11,12] .…”

“…The recent advances in surgical techniques and immunosuppression have led to improvements of post-transplant outcomes but various complications including bleeding, infections, rejection, vascular complications at the anastomotic site, and biliary complication will occur after liver transplantations [2,3] . Although deceased donor liver transplantation is considered a standard procedure, living donor liver transplantation (LDLT) has been widely performed owing to the shortage of donors [4] .…”

The perspective of liver transplantation for cholangiocarcinoma

“…34,35 In pediatric LDLT, the risk of portal vein stenoses has been reported to be as high as 27% when cryopreserved veins are used for portal conduits. 36 When conduits were excluded, the incidence of late portal vein complications was reduced to 1%.…”