Usability of intraoperative cine‐portogram during liver transplantation in young pediatric patients with biliary atresia

Abstract

Background Pediatric patients with biliary atresia (BA) often present liver cirrhosis‐associated portal hypertension and portal vein (PV) hypoplasia. For successful liver transplantation (LT), it is essential to maintain sufficient PV inflow through stenosis‐free PV reconstruction with effective ligation of collateral veins. The aim of this study was to assess the clinical usability of intraoperative cine‐portogram (IOCP) in young pediatric patients who underwent LT for BA. Methods Medical records of pediatric patients younger than 10 years who underwent primary LT for BA from 2018 to 2020 were reviewed. Results A total of 31 patients had undergone Kasai portoenterostomy soon after birth. Their median ages at Kasai portoenterostomy and LT were 1 and 11 months, respectively. Types of LT were living‐donor LT in 13, deceased‐donor split LT in 15, and deceased‐donor whole LT in three patients. PV interposition using an iliac vein homograft was performed in 28 patients receiving partial liver grafts. Side‐to‐side PV unification venoplasty was performed in three patients undergoing whole LT. All patients underwent ligation of collateral veins. IOCP was performed in 6 (19.4%) patients. Four showed no or faint residual venous collaterals. Collateral vein embolization and endovascular stenting were performed in one patient each. PV insufficiency‐free survival rate was 100% at 1 year and 93.8% at 3 years. All patients are currently alive with a median follow‐up period of 23 months. Conclusions Intraoperative cine‐portogram can be a useful method for identification and embolization of residual portosystemic collateral veins in young pediatric patients who undergo LT for biliary atresia.

Modified patch-conduit venoplasty for portal vein hypoplasia in pediatric liver transplantation

“…PV reconstruction with an iliac vein homograft conduit is an effective method of PV reconstruction in pediatric recipients with severe PV hypoplasia. We have preferentially used cold-preserved fresh iliofemoral vein homografts because of their high long-term patency rates [ 2 , 3 ]. However, the supply of these fresh homografts is very limited in most transplantation centers worldwide.…”

“…Portal vein (PV) hypoplasia is frequently accompanied by biliary atresia. Although various surgical techniques have been developed for the reconstruction of these stenotic PVs, PV complications can still occur [ 1 - 7 ]. Interposition of a homologous vein conduit has been found to be effective for PV reconstruction in pediatric patients with severe PV hypoplasia undergoing liver transplantation (LT) [ 1 , 3 ].…”

“…Interposition of a homologous vein conduit has been found to be effective for PV reconstruction in pediatric patients with severe PV hypoplasia undergoing liver transplantation (LT) [ 1 , 3 ]. Cold-preserved fresh iliofemoral vein homografts are the best material for interposition vein conduits, but their time of availability is very limited during LT, even in patients undergoing split LT [ 2 ]. Although cryopreserved iliac veins can be used as alternative interposition vein conduits for PV reconstruction, various conduit-associated complications, including aneurysm, stricture, and thrombosis, have been reported [ 8 - 10 ].…”

Living donor liver transplantation with proximal splenic vein ligation in a pediatric patient with congenital absence of the portal vein

“…After portal reperfusion, the second IOCP showed the presence of coronary collateral around the gastric lesser curvature, which was interrupted with coil embolization. IOCP is a useful method for identifying and embolizing residual portosystemic collateral veins in young pediatric patients who undergo LT [17].…”

Living donor liver transplantation in a pediatric patient having intrahepatic portocaval shunt with congenital absence of the intrahepatic portal vein

“…There was no development of the collateral veins, so intraoperative portogram was not performed. If there is evidence of portal hypertension with collateral formation, intraoperative portography is indicated because it is useful for identifying and embolizing the residual portosystemic collateral veins in young pediatric patients undergoing LT [14].…”