Thrombolysis of portal vein thrombosis after splenectomy following liver transplantation

Abstract

TO THE EDITORSSplenectomy is indicated after orthotopic liver transplantation (OLT) for various reasons, including leftsided portal hypertension, trauma, and hemorrhage prevention in patients with splenic artery aneurysms. Complications of splenectomy may include infections, bleeding, and portal vein thrombosis (PVT). The incidence of symptomatic postsplenectomy PVT ranges from 0.7% to 2%, 1,2 whereas the incidence of asymptomatic PVT can reach 7% to 10%. 3 There is, however, limited literature pertaining to postsplenectomy PVT in recipients of OLT. The sequelae of PVT are particularly serious in OLT recipients. The reduction of the portal vein flow severely compromises allograft and patient survival. 4,5 In patients who have not undergone OLT, acute portal or mesenteric vein thrombosis is usually managed with anticoagulation alone, and this leads to recanalization in more than 90% of patients. 6 Alternatively, thrombolysis or thrombectomy is performed, but this has not been widely reported and is not the standard of care. 7 There are few studies addressing the management of postsplenectomy PVT in OLT recipients.Here we describe a case of acute postsplenectomy PVT in an OLT recipient who was successfully treated with both mechanical thrombolysis and directed and systemic anticoagulation.The patient was a 54-year-old male who suffered from end-stage liver disease secondary to complications from hepatitis C and alcohol abuse. He underwent OLT on March 5, 2007. The piggyback technique was used with a biliary duct-to-duct anastomosis. The operation and the postoperative course both went well without complications.Approximately 2 years later, he presented with increasing left upper quadrant pain. A computed tomography (CT) scan revealed an enlarged spleen with a calcified cyst that measured 17 cm. Therapeutic options were discussed with the patient, and splenectomy was planned. He received subcutaneous heparin perioperatively as deep venous thrombosis prophylaxis. The operation lasted 2 hours and was performed through an extension of the left subcostal incision from the initial OLT. An Endo GIA stapler was used to divide the hilum. Pathology revealed a 960-g spleen measuring 18.2 cm 3 14.3 cm 3 10.2 cm with capsular fibrosis indicating perisplenitis.Postoperative laboratory tests revealed a 5-fold rise in transaminase levels. An ultrasound examination of the liver was performed and revealed an absence of flow in the portal vein. Dual-phase CT of the liver showed complete thrombosis of the splenic and portal veins with extension into both right and left portal vein branches. The superior mesenteric vein was spared. An intravenous infusion of heparin was initiated. Complete thrombosis of the intrahepatic portal vein branches precluded percutaneous transhepatic cannulation of the portal system. The patient was taken immediately to the operating room in an attempt to salvage the hepatic allograft. A peripheral mesenteric venous branch was located and cannulated with a 5-Fr Fogarty catheter. An initial portogram confirmed...

The Management of Portal Vein Thrombosis after Adult Liver Transplantation: A Case Series and Review of the Literature

“…A total of 25 articles reported one or more cases, for a total of 33 cases of post-LT PVT formation in adult LT recipients [ 2 , 3 , 10 , 11 , 12 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. The characteristics of the reported cases are summarized in Table 2 .…”

The Management of Portal Vein Thrombosis after Adult Liver Transplantation: A Case Series and Review of the Literature

“…A total of 21 articles that reported one or more cases, which included a total of twenty-nine cases of post-LT PVT formation in adult LT recipients [2,3,[10][11][12][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]. The characteristics of the reported cases are summarized in Table 2.…”

Portal vein thrombosis in cirrhosis: exploring the uncharted waters

“…4 Another study also documented no differences in survival post-LT, although the presence of PVT did increase intraoperative blood product use and theater time. 5 The natural history of PVT in cirrhosis, as stated by the authors, is dependent on multiple variables-MELD status, serum albumin levels, and presence of collaterals among other factors. In addition, the effect of PVT on the natural history of cirrhosis is also highly variable and it is perhaps the progression of PVT that could significantly affect liver function and not the mere presence of PVT.…”