Our evolution in the treatment of hepatic artery and portal vein thrombosis in pediatric liver transplantation: Success with catheter‐directed therapies

Abstract

Background:In pediatric liver transplant recipients, hepatic artery thrombosis and portal vein thrombosis are major causes of acute graft failure and mortality within 30 days of transplantation. There is, however, a strong possibility of graft salvage if flow can be re-established to reduce ischemic injury. The current standard treatment is surgical revascularization, and if unsuccessful, retransplantation.Due to our success in treating these complications with catheter-directed therapies, we sought to summarize and publish the outcomes of all patients who experienced hepatic artery thrombosis or portal vein thrombosis within 30 days of liver transplantation. Methods:We conducted a retrospective cohort analysis of 27 pediatric liver transplant recipients who experienced hepatic artery thrombosis (n = 13), portal vein thrombosis (n = 9), or both (n = 5) between September 2012 and March 2021. We collected and tabulated data on the patients and therapies performed to treat them, including success rates, primary and secondary patency, and clinical outcomes.Results: Among these patients, 6 were managed with anticoagulation and relisting for transplant and 21 had a primary revascularization attempt. Surgical recanalization was attempted in 7 patients of which 3 had successful recanalization (43%) and catheter-directed recanalization was attempted in 14 patients with 100% success in re-establishing blood flow to the graft. Additionally, patency was increased, and mortality was decreased in patients treated with catheter-directed recanalization compared to surgical revascularization or anticoagulation alone. Conclusion:This data illustrates the need to further investigate catheter-directed thrombolysis as a potential first-line treatment for postoperative HAT and PVT in pediatric liver transplant recipients. How to cite this article: Moreno NF, Hernandez JA, Huang C-S, et al. Our evolution in the treatment of hepatic artery and portal vein thrombosis in pediatric liver transplantation: Success with catheter-directed therapies.

Redo hepatic artery reconstruction for thrombosis without retransplantation in 1355 adult living donor liver transplantations

“…Endovascular procedures, including intra-arterial thrombectomy/thrombolysis, balloon angioplasty, and intraluminal stenting, are evolving and are preferred in some groups because they are less invasive 8,18,19 . Endovascular treatment is sometimes more feasible as the first approach in very small pediatric patients with small partial living donor grafts 10,20 . The overall success rate of endovascular procedures for HAT is reported to be 45%–55%.…”

“…[8,18,19] Endovascular treatment is sometimes more feasible as the first approach in very small pediatric patients with small partial living donor grafts. [10,20] The overall success rate of endovascular procedures for HAT is reported to be 45%-55%. In particular, the interventional approach is not recommended in the immediate postoperative period due to incomplete recovery of patients' coagulation function.…”

Global research on portal vein thrombosis and liver transplantation: A bibliometric and visualized study

“…[35] When PVT occurs, catheter thrombolysis and anticoagulation with stent placement have improved patency rates compared to conventional therapy and are now the preferred treatment for PVT in children. [36] Therefore, the current analysis of catheterization results in other areas and the treatment of portal vein thrombosis in pediatric liver transplantation suggests that catheter thrombolysis will be the most effective treatment for pediatric patients with portal vein thrombosis.…”

“Long‐term” is getting longer for children receiving liver transplantation grafts

“…Once HAT has been diagnosed, increased IR technical expertise with endovascular thrombolysis and angioplasty of stenoses can maintain good graft function, delaying or eliminating the need for retransplantation. [6] Finally, it should be noted that the percentage of living donor LT (LDLT) has decreased in the recent era, from 17.3% to 15.5% overall. [1] Based on the Scientific Registry of Transplant Recipients report of all LTs in 2019 in the United States, only 5.3% of adults and 14.3% of children received a graft from a living donor (LD).…”

“…Once HAT has been diagnosed, increased IR technical expertise with endovascular thrombolysis and angioplasty of stenoses can maintain good graft function, delaying or eliminating the need for retransplantation. [ 6 ]…”