Thrombosis prophylaxis in pediatric liver transplantation: A systematic review

Abstract

AIMTo review current literature of thrombosis prophylaxis in pediatric liver transplantation (PLT) as thrombosis remains a critical complication.METHODSStudies were identified by electronic search of MEDLINE, EMBASE and Cochrane Library (CENTRAL) databases until March 2018. The search was supplemented by manually reviewing the references of included studies and the references of the main published systematic reviews on thrombosis and PLT. We excluded from this review case report, small case series, commentaries, conference abstracts, papers which describing less than 10 pediatric liver transplants/year and articles published before 1990. Two reviewers performed study selection independently, with disagreements solved through discussion and by the opinion of a third reviewer when necessary.RESULTSNine retrospective studies were included in this review. The overall quality of studies was poor. A pooled analysis of results from studies was not possible due to the retrospective design and heterogeneity of included studies. We found an incidence of portal vein thrombosis (PVT) ranging from 2% to 10% in pediatric living donor liver transplantation (LDLT) and from 4% to 33% in pediatric deceased donor liver transplantation (DDLT). Hepatic artery thrombosis (HAT) was observed mostly in mixed LDLT and DDLT pediatric population with an incidence ranging from 0% to 29%. In most of the studies Doppler ultrasonography was used as a first line diagnostic screening for thrombosis. Four different surgical techniques for portal vein anastomosis were reported with similar efficacy in terms of PVT reduction. Reduced size liver transplant was associated with a low risk of both PVT (incidence 4%) and HAT (incidence 0%, P < 0.05). Similarly, aortic arterial anastomosis without graft interposition and microsurgical hepatic arterial reconstruction were associated with a significant reduced HAT incidence (6% and 0%, respectively). According to our inclusion and exclusion criteria, we did not find eligible studies that evaluated pharmacological prevention of thrombosis.CONCLUSIONPoor quality retrospective studies show the use of tailored surgical strategies might be useful to reduce HAT and PVT after PLT; prospective studies are urgently needed.

Time is of the essence: A single‐center experience of hepatic arterial supply impairment management in pediatric liver transplant recipients

“…8,11,[19][20][21][22] Despite all measures to avoid graft arterial flow disruptions, arterial complication rate is still rarely lower than 3%-4%. 5,23 Our study was not an exception (the incidence of HAT, HAS, and SASS was 4.1%, 2.2%, and 1,4%, respectively). The consequences of these complications are often dramatic.…”

“…7,23 Most of the cases occur during the first two weeks of transplantation, which is noted in all studies without exception. 5,8,11,24 The crucial role of urgent arterial revascularization has been previously described. 7,24 DUS is the diagnostic modality of choice for early detection of hepatic arterial flow reduction.…”

“…Although improvements in surgical technique and pharmacological thrombosis prophylaxis have helped to decrease HAT rates, it is still one of the most frequent reasons for graft loss in pediatric recipients. 5,6 Therefore, the goal of arterial supply deterioration monitoring is to reduce morbidity and mortality. According to a few studies, timing is a crucial point in achieving this goal.…”

“…The incidence of HAT in pediatric patients is higher than that in adult patients, ranging from 2% to 10%. Although improvements in surgical technique and pharmacological thrombosis prophylaxis have helped to decrease HAT rates, it is still one of the most frequent reasons for graft loss in pediatric recipients 5,6 …”

Biliary reconstruction before clamp removal to avoid portal vein thrombosis in pediatric living‐donor liver transplantation using hyper‐reduced left lateral segment grafts: A novel technical strategy

“…In the Nacoti et al systematic review, the incidence of PVT in pediatric LDLT varies from 2% to 10% and from 4% to 33% in pediatric deceased donor LT with reduced grafts.…”