LIVER TRANSPLANTATION 21:132–134, 2015
LETTERS FROM THE FRONTLINE
Management of Portal Vein Thrombosis After Liver Transplantation With a Combined Open and Endovascular Approach Received May 22, 2014; accepted September 14, 2014. TO THE EDITORS: Vascular complications after orthotopic liver transplantation (OLT) are rare but devastating complications. Graft survival is significantly reduced by hepatic artery thrombosis and portal vein thrombosis (PVT). PVT can be more detrimental to graft and patient survival than hepatic artery thrombosis.1 PVT is a complication for up to 3% to 7% of patients undergoing OLT, and as many as 50% of patients with PVT will require retransplantation.1,2 The risk factors reported to be associated with PVT include the following: technical issues (eg, redundancy in the donor-recipient vein length), preoperative PVT in the recipient requiring intraoperative thrombectomy, small portal vein diameter, prior splenectomy, pediatric transplantation, and the need for intraoperative portal vein reconstruction with a vein conduit.1,3,4 PVT disrupts the allograft’s blood supply, and this leads to early graft dysfunction, long-term graft failure, or death; this highlights the importance of the diagnosis and the development of a comprehensive management and treatment plan for this unusual complication. PVT is a difficult complication to treat after liver transplantation because an alternative portal inflow is difficult to establish. We describe a unique thrombolytic-based treatment option with a transmesenteric approach to the portal system to be considered when more conventional PVT treatment options are not successful. A 67-year-old male veteran with a medical history significant for end-stage liver disease due to reformed ethanol abuse underwent OLT after a transjugular intrahepatic portosystemic shunt (TIPS). The patient’s preoperative Model for End-Stage Liver Disease score
was 25. The patient was discharged on postoperative day (POD) 3 after an uneventful initial postoperative course. His first clinic visit on POD 6 was unremarkable, and he was progressing well with resolving liver function tests. The patient presented on POD 9 with increasing abdominal pain, abdominal distension, and fluid retention. His laboratory work was notable for elevated transaminases (aspartate aminotransferase, 1078 IU/L; alanine aminotransferase, 1140 IU/ L). Duplex ultrasound was performed, and it demonstrated an absence of flow in the portal system consistent with PVT (notably, the hepatic artery was patent). The sonographic findings were subsequently confirmed by computed tomography venography (CTV; see Fig. 1). Anticoagulation with heparin was initiated at therapeutic dosing. With systemic anticoagulation, the patient’s liver function tests trended down slightly; however, his subjective complaints of abdominal pain and edema did not improve. Over the course of 48 hours, percutaneous transhepatic and transjugular portal venous cannulation for the initiation of locoregional thrombolytic therapy was attempted. However, percutaneous portal access could not be established because of a diffuse thrombus in the portal system. Forty-eight hours after the initiation of systemic heparin therapy, repeat imaging did not show thrombus resolution or adequate portal venous flow. Because of unsuccessful attempts at percutaneous access to the portal system, the decision was made to proceed to the operating room for exploratory laparotomy. Intraoperatively, the portal vein and the anastomosis were inspected, and there was no stenosis or technical concern. Because of the preoperative imaging and the intraoperative findings, thrombectomy of the principle portal vein branches was unlikely to establish adequate venous outflow on account of the significant clot burden within the small
Potential conflict of interest: Nothing to report. Address reprint requests to Clark D. Kensinger, M.D., Department of General Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, D4313 MCN, Nashville, TN 37232. Telephone: 937-248-9213; FAX: 615-322-0689; E-mail: [email protected] DOI 10.1002/lt.24011 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LIVER TRANSPLANTATION, Vol. 21, No. 1, 2015
Figure 1. Representative coronal image of preoperative CTV demonstrating PVT with extension into the intrahepatic portal vein branches. The timing of the study shows contrast in the retroperitoneal varices and the proximal portal vein with a lack of peripheral hepatic enhancement secondary to diffuse portal system thrombosis. The expected hepatic vein washout at the inferior vena cava confluence from the arterial phase further highlights the lack of parenchymal enhancement during the portal venous phase. The thick arrow indicates PVT, the dashed arrow indicates retroperitoneal varices, and the small arrow indicates hepatic vein washout from the arterial phase.
vessels of the liver periphery. Therefore, the decision was made to access the portal system via the middle colic vein for the local delivery of thrombolytic therapy. A 6-Fr, 25-cm sheath was placed into the middle colic vein, through which a 5-Fr, 20-cm infusion length (total catheter length, 90 cm) was positioned in the portal system under fluoroscopy guidance. The initial portovenogram was consistent with the preoperative CTV and showed complete thrombosis of the main portal vein and intrahepatic branches. The catheter was secured, and the abdomen was closed with an occlusive negative-pressure dressing. The patient remained stable and was managed in the surgical intensive care unit. Over the next 72 hours, a tissue plasminogen activator was infused via the catheter, whereas continuous heparin was infused via the sheath. To evaluate the progress of the treatment, serial venograms were performed daily for 3 days, and they demonstrated progressive clearing of the thrombus on each examination. Minor manipulations of the catheter were made to maximize the exposure of the thrombus to the tissue plasminogen activator. Venography 72 hours after the initiation of the thrombolytic infusion showed the portal system to be widely patent with complete thrombus resolution and satisfactory flow into the liver periphery (see Fig. 2). There was still significant competitive outflow via a cluster of retroperitoneal portosystemic varices, which were embolized under fluoroscopy in an attempt to drive flow to the main portal vein to increase the likelihood of durable portal vein patency. Final venography demonstrated a widely patent flow through the portal system, and the patient’s abdomen was subsequently closed. Postoperatively, the patient’s liver function tests normalized, and his abdominal complaints were resolved. The patient was discharged on systemic anticoagulation with warfarin. At the time of this writing, the patient was more than 10 months from this interven-
133
Figure 2. Venogram demonstrating portal thrombus resolution with adequate intrahepatic portal perfusion. The solid arrow indicates the patent portal vein, the dashed arrow indicates the infusion catheter for local thrombolytic therapy delivery via the middle colic vein, and the dotted arrow indicates the enteric feeding tube.
tion. Serial imaging confirmed that the portal vein remained patent without further issues. The patient had no additional complications and was doing well. The uniqueness of this case is highlighted by the successful treatment strategy for accessing the portal system in a postoperative liver transplant patient by antegrade cannulation of the middle colic vein for locoregional thrombolytic therapy. This represents an alternative strategy when more conventional PV access is unsuccessful. Treatment strategies for PVT range from systemic anticoagulation to catheterbased thrombolytic therapy to portosystemic shunting to retransplantation. Endovascular-based options are attractive alternatives to operative anastomotic revision, open thrombectomy, or retransplantation. Local delivery of thrombolytic therapy is more desirable because it avoids the need for anastomotic revision when there is no narrowing and allows complete lysis of intrahepatic portal clots in a smaller vasculature and ensures satisfactory portal vein outflow. The 3 percutaneous options presented in the literature include transhepatic portal vein angioplasty,3,4 percutaneous thrombolytic therapy via TIPS creation,3,5 and a transplenic approach. The benefit of local intraclot administration of low-dose thrombolytic therapy can be accomplished with limited risk of systemic bleeding complications.3 Furthermore, the use of the TIPS-type approach has the advantage over transhepatic or transplenic cannulation in patients with ascites, splenomegaly, or coagulopathy.3 However, the success of catheter-based therapies is limited by the technical difficulty with percutaneous access and cannulation of a thrombosed portal vein. In addition, percutaneous cannulation can be risky in the early posttransplant period because of the potential for anastomotic disruption. The approach described in this case report should be considered when both percutaneous access to the
134
portal system is not technically successful and thrombectomy of the main portal vein would not establish adequate venous outflow as a result of a persistent clot burden within the liver periphery. Judicious local delivery of thrombolytic therapy versus systemic therapy has a significant advantage because it avoids the risks of systemic bleeding in post–liver transplant patients. The costs associated with this procedure, chosen because more standard therapies were not effective, were lower than the cost of retransplantation. Furthermore, because the patient did not require retransplantation, another liver graft was not taken from the limited pool of donor organs. Innovative management strategies that maximize treatment success and limit graft loss, such as the approach discussed in this report, should be explored in patients when more conventional salvage treatment options are not successful in order to improve long-term hepatic function and decrease the need for retransplantation. Clark D. Kensinger, M.D.1 Kevin W. Sexton, M.D.1 Christopher M. Baron, M.D.2 Andrew J. Lipnik, M.D.2 Steven G. Meranze, M.D.2 D. Lee Gorden, M.D.1 Departments of 1Surgery and 2Radiology and Radiological Sciences Vanderbilt University Medical Center Nashville, TN
LIVER TRANSPLANTATION, January 2015
REFERENCES 1. Duffy JP, Hong JC, Farmer DG, Ghobrial RM, Yersiz H, Hiatt JR, Bussuttil RW. Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg 2009;208:896-903. L, Fabregat J, Castellote J, Ramos E, Torras J, 2. Llado Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant 2007;21:716-721. 3. Cherukuri R, Haskal ZJ, Naji A, Shaked A. Percutaneous thrombolysis and stent placement for the treatment of portal vein thrombosis after liver transplantation: long-term follow-up. Transplantation 1998;65: 1124-1126. 4. Durham JD, LaBerge JM, Altman S, Kam I, Everson GT, Gordon RL, Kumpe DA. Portal vein thrombolysis and closure of competitive shunts following liver transplantation. J Vasc Interv Radiol 1994;5:611-615. 5. Olcott EW, Ring EJ, Roberts JP, Ascher NL, Lake JR, Gordon RL. Percutaneous transhepatic portal vein angioplasty and stent placement after liver transplantation: early experience. J Vasc Interv Radiol 1990;1:17-22.
LETTERS FROM THE FRONTLINE
Management of Portal Vein Thrombosis After Liver Transplantation With a Combined Open and Endovascular Approach Received May 22, 2014; accepted September 14, 2014. TO THE EDITORS: Vascular complications after orthotopic liver transplantation (OLT) are rare but devastating complications. Graft survival is significantly reduced by hepatic artery thrombosis and portal vein thrombosis (PVT). PVT can be more detrimental to graft and patient survival than hepatic artery thrombosis.1 PVT is a complication for up to 3% to 7% of patients undergoing OLT, and as many as 50% of patients with PVT will require retransplantation.1,2 The risk factors reported to be associated with PVT include the following: technical issues (eg, redundancy in the donor-recipient vein length), preoperative PVT in the recipient requiring intraoperative thrombectomy, small portal vein diameter, prior splenectomy, pediatric transplantation, and the need for intraoperative portal vein reconstruction with a vein conduit.1,3,4 PVT disrupts the allograft’s blood supply, and this leads to early graft dysfunction, long-term graft failure, or death; this highlights the importance of the diagnosis and the development of a comprehensive management and treatment plan for this unusual complication. PVT is a difficult complication to treat after liver transplantation because an alternative portal inflow is difficult to establish. We describe a unique thrombolytic-based treatment option with a transmesenteric approach to the portal system to be considered when more conventional PVT treatment options are not successful. A 67-year-old male veteran with a medical history significant for end-stage liver disease due to reformed ethanol abuse underwent OLT after a transjugular intrahepatic portosystemic shunt (TIPS). The patient’s preoperative Model for End-Stage Liver Disease score
was 25. The patient was discharged on postoperative day (POD) 3 after an uneventful initial postoperative course. His first clinic visit on POD 6 was unremarkable, and he was progressing well with resolving liver function tests. The patient presented on POD 9 with increasing abdominal pain, abdominal distension, and fluid retention. His laboratory work was notable for elevated transaminases (aspartate aminotransferase, 1078 IU/L; alanine aminotransferase, 1140 IU/ L). Duplex ultrasound was performed, and it demonstrated an absence of flow in the portal system consistent with PVT (notably, the hepatic artery was patent). The sonographic findings were subsequently confirmed by computed tomography venography (CTV; see Fig. 1). Anticoagulation with heparin was initiated at therapeutic dosing. With systemic anticoagulation, the patient’s liver function tests trended down slightly; however, his subjective complaints of abdominal pain and edema did not improve. Over the course of 48 hours, percutaneous transhepatic and transjugular portal venous cannulation for the initiation of locoregional thrombolytic therapy was attempted. However, percutaneous portal access could not be established because of a diffuse thrombus in the portal system. Forty-eight hours after the initiation of systemic heparin therapy, repeat imaging did not show thrombus resolution or adequate portal venous flow. Because of unsuccessful attempts at percutaneous access to the portal system, the decision was made to proceed to the operating room for exploratory laparotomy. Intraoperatively, the portal vein and the anastomosis were inspected, and there was no stenosis or technical concern. Because of the preoperative imaging and the intraoperative findings, thrombectomy of the principle portal vein branches was unlikely to establish adequate venous outflow on account of the significant clot burden within the small
Potential conflict of interest: Nothing to report. Address reprint requests to Clark D. Kensinger, M.D., Department of General Surgery, Vanderbilt University Medical Center, 1161 21st Avenue South, D4313 MCN, Nashville, TN 37232. Telephone: 937-248-9213; FAX: 615-322-0689; E-mail: [email protected] DOI 10.1002/lt.24011 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LIVER TRANSPLANTATION, Vol. 21, No. 1, 2015
Figure 1. Representative coronal image of preoperative CTV demonstrating PVT with extension into the intrahepatic portal vein branches. The timing of the study shows contrast in the retroperitoneal varices and the proximal portal vein with a lack of peripheral hepatic enhancement secondary to diffuse portal system thrombosis. The expected hepatic vein washout at the inferior vena cava confluence from the arterial phase further highlights the lack of parenchymal enhancement during the portal venous phase. The thick arrow indicates PVT, the dashed arrow indicates retroperitoneal varices, and the small arrow indicates hepatic vein washout from the arterial phase.
vessels of the liver periphery. Therefore, the decision was made to access the portal system via the middle colic vein for the local delivery of thrombolytic therapy. A 6-Fr, 25-cm sheath was placed into the middle colic vein, through which a 5-Fr, 20-cm infusion length (total catheter length, 90 cm) was positioned in the portal system under fluoroscopy guidance. The initial portovenogram was consistent with the preoperative CTV and showed complete thrombosis of the main portal vein and intrahepatic branches. The catheter was secured, and the abdomen was closed with an occlusive negative-pressure dressing. The patient remained stable and was managed in the surgical intensive care unit. Over the next 72 hours, a tissue plasminogen activator was infused via the catheter, whereas continuous heparin was infused via the sheath. To evaluate the progress of the treatment, serial venograms were performed daily for 3 days, and they demonstrated progressive clearing of the thrombus on each examination. Minor manipulations of the catheter were made to maximize the exposure of the thrombus to the tissue plasminogen activator. Venography 72 hours after the initiation of the thrombolytic infusion showed the portal system to be widely patent with complete thrombus resolution and satisfactory flow into the liver periphery (see Fig. 2). There was still significant competitive outflow via a cluster of retroperitoneal portosystemic varices, which were embolized under fluoroscopy in an attempt to drive flow to the main portal vein to increase the likelihood of durable portal vein patency. Final venography demonstrated a widely patent flow through the portal system, and the patient’s abdomen was subsequently closed. Postoperatively, the patient’s liver function tests normalized, and his abdominal complaints were resolved. The patient was discharged on systemic anticoagulation with warfarin. At the time of this writing, the patient was more than 10 months from this interven-
133
Figure 2. Venogram demonstrating portal thrombus resolution with adequate intrahepatic portal perfusion. The solid arrow indicates the patent portal vein, the dashed arrow indicates the infusion catheter for local thrombolytic therapy delivery via the middle colic vein, and the dotted arrow indicates the enteric feeding tube.
tion. Serial imaging confirmed that the portal vein remained patent without further issues. The patient had no additional complications and was doing well. The uniqueness of this case is highlighted by the successful treatment strategy for accessing the portal system in a postoperative liver transplant patient by antegrade cannulation of the middle colic vein for locoregional thrombolytic therapy. This represents an alternative strategy when more conventional PV access is unsuccessful. Treatment strategies for PVT range from systemic anticoagulation to catheterbased thrombolytic therapy to portosystemic shunting to retransplantation. Endovascular-based options are attractive alternatives to operative anastomotic revision, open thrombectomy, or retransplantation. Local delivery of thrombolytic therapy is more desirable because it avoids the need for anastomotic revision when there is no narrowing and allows complete lysis of intrahepatic portal clots in a smaller vasculature and ensures satisfactory portal vein outflow. The 3 percutaneous options presented in the literature include transhepatic portal vein angioplasty,3,4 percutaneous thrombolytic therapy via TIPS creation,3,5 and a transplenic approach. The benefit of local intraclot administration of low-dose thrombolytic therapy can be accomplished with limited risk of systemic bleeding complications.3 Furthermore, the use of the TIPS-type approach has the advantage over transhepatic or transplenic cannulation in patients with ascites, splenomegaly, or coagulopathy.3 However, the success of catheter-based therapies is limited by the technical difficulty with percutaneous access and cannulation of a thrombosed portal vein. In addition, percutaneous cannulation can be risky in the early posttransplant period because of the potential for anastomotic disruption. The approach described in this case report should be considered when both percutaneous access to the
134
portal system is not technically successful and thrombectomy of the main portal vein would not establish adequate venous outflow as a result of a persistent clot burden within the liver periphery. Judicious local delivery of thrombolytic therapy versus systemic therapy has a significant advantage because it avoids the risks of systemic bleeding in post–liver transplant patients. The costs associated with this procedure, chosen because more standard therapies were not effective, were lower than the cost of retransplantation. Furthermore, because the patient did not require retransplantation, another liver graft was not taken from the limited pool of donor organs. Innovative management strategies that maximize treatment success and limit graft loss, such as the approach discussed in this report, should be explored in patients when more conventional salvage treatment options are not successful in order to improve long-term hepatic function and decrease the need for retransplantation. Clark D. Kensinger, M.D.1 Kevin W. Sexton, M.D.1 Christopher M. Baron, M.D.2 Andrew J. Lipnik, M.D.2 Steven G. Meranze, M.D.2 D. Lee Gorden, M.D.1 Departments of 1Surgery and 2Radiology and Radiological Sciences Vanderbilt University Medical Center Nashville, TN
LIVER TRANSPLANTATION, January 2015
REFERENCES 1. Duffy JP, Hong JC, Farmer DG, Ghobrial RM, Yersiz H, Hiatt JR, Bussuttil RW. Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg 2009;208:896-903. L, Fabregat J, Castellote J, Ramos E, Torras J, 2. Llado Jorba R, et al. Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality. Clin Transplant 2007;21:716-721. 3. Cherukuri R, Haskal ZJ, Naji A, Shaked A. Percutaneous thrombolysis and stent placement for the treatment of portal vein thrombosis after liver transplantation: long-term follow-up. Transplantation 1998;65: 1124-1126. 4. Durham JD, LaBerge JM, Altman S, Kam I, Everson GT, Gordon RL, Kumpe DA. Portal vein thrombolysis and closure of competitive shunts following liver transplantation. J Vasc Interv Radiol 1994;5:611-615. 5. Olcott EW, Ring EJ, Roberts JP, Ascher NL, Lake JR, Gordon RL. Percutaneous transhepatic portal vein angioplasty and stent placement after liver transplantation: early experience. J Vasc Interv Radiol 1990;1:17-22.
