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A: donor common bile duct; B: donor-recipient arterial anastomosis; C: gastroportal anastomosis; D: left gastric vein distal neck.
Source publication
Portal vein thrombosis is observed in up to 10% of liver transplant candidates, hindering execution of the procedure. A dilated gastric vein is an alternative to portal vein reconstruction and decompression of splanchnic bed. We present two cases of patients with portal cavernoma and dilated left gastric vein draining splanchnic bed who underwent l...
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Citations
... According to the medical literature, the anatomic requirement for vascular anastomosis is an optimization of anastomotic openings in size and preparation. 26 Anastomosis with as large a diameter as possible is required for portal vein reconstruction to obtain good portal ow. 27 According to our reports, using LGV shows the feasibility of this unusual approach and even allows the dispensing of venous grafts. ...
Introduction
The most relevant limiting factor for performing end-to-end anastomosis is portal vein thrombosis (PVT), which leads to challenging vascular reconstructions. This study aimed to analyze a single center’s experience using the left gastric vein (LGV) for portal flow reconstruction in liver transplantation (LT).
Methods
This retrospective observational study reviewed laboratory and imaging tests, a description of the surgical technique, and outpatient follow-up of patients with portal system thrombosis undergoing LT with portal flow reconstruction using the LGV. This study was conducted at a single transplant reference center in the northeast region of Brazil from January 2016 to December 2021.
Results
Between January 2016 and December 2021, 848 transplants were performed at our center. Eighty-two patients (9.7%) presented with PVT, most of whom were treated with thrombectomy. Nine patients (1.1% with PVT) had extensive thrombosis of the portal system (Yerdel III or IV), which required end-to-side anastomosis between the portal vein and the LGV without graft, and had no intraoperative complications. All patients had successful portal flow in Doppler ultrasound control evaluations.
Discussion
The goal was to reestablish physiological flow to the graft. A surgical strategy includes using the LGV graft. According to our reports, using LGV fulfilled the requirements for excellent vascular anastomosis and even allowed the dispensing of venous grafts. This is the largest case series in a single center of reconstruction of portal flow with direct anastomosis with the LGV without needing a vascular graft.
... The portal vein-variceal anastomosis is a challenging physiological non-anatomical technique of portal vein inflow reconstruction used and described rarely. In those procedures, enlarged splanchnic varices [31][32][33][34], LGV [35][36][37][38], or pericholedochal varix [39,40] is used. Use of a splanchnic varix such as a dilated LGV necessitates a meticulous and very careful dissection in a hostile surrounding of other dilated fragile varices. ...
Background:
Portal vein thrombosis (PVT) is a frequent complication occurring in 5% to 26% of cirrhotic patients candidates for liver transplantation (LT). In cases of extensive portal and or mesenteric vein thrombosis, complex vascular reconstruction of the portal inflow may become necessary for a successful orthotopic LT (OLT).
Case summary:
A 54-year-old male with history of cirrhosis secondary to schistosomiasis complicated with extensive portal and mesenteric vein thrombosis and severe portal hypertension who underwent OLT with portal vein-left gastric vein anastomosis.
Conclusion:
We review the various types of PVT, the portal venous inflow reconstruction techniques.
... 8 The non-physiological inflow is associated with an increased risk of postoperative complications, especially those connected to portal re-thrombosis and gastrointestinal bleeding. 8 In presence of a complex portal vein thrombosis (CPVT) and of an enlarged left gastric vein (LGV) functioning as a spontaneous PSS, an anastomosis between the recipient LGV and the graft PV has been described in single case reports or small case series (median number of cases per publication = 2), having good long-term results but with a variable follow-up, as also indicated in the above-mentioned publication by Bhangui et al. 3,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] We report our series of 12 LT in patients with CPVT, where we restored the portal inflow with a lateral-terminal anastomosis between the graft PV and an enlarged LGV with a mean follow-up of 4 ± 4.8 years. CPVT and enlarged LGV were detected during preoperative radiological evaluation at CT scan and, in all cases, re-confirmed intraoperatively. ...
... 18 Among these, the literature reported 14 (37.8%) satisfactory long-term outcomes but the previous series mainly described one or two cases per study [8][9][10][11][12]16,[20][21][22] with short-term results. 13,14,18 In the end, only 14 liver transplantations In our experience, we have always detected CPVT and an LGV major than 1 cm of diameter at the preoperative abdominal CT, settling the surgical strategy as in Figure 3. ...
Introduction
post‐operative complications and worse prognosis still burden liver transplantations (LT) with complex portal vein thrombosis (CPVT). When an engorged left gastric vein (LGV) is present, the portal inflow is restorable with an anastomosis between the graft portal vein and the LGV of the recipient. We analyzed short and long‐term results of this procedure in 12 LT with CPVT.
Methods
Between 2005 and 2019, 55 patients with CPVT underwent LT. We applied this technique in 12 patients. In six cases, we placed a vascular graft to obtain a tension‐free structure. We evaluated patency, short and long‐term results.
Results
No intraoperative complication was observed. The median duration of LT, blood transfusion, deceased donor age and MELD score of the recipients were seven hours, 1250 mL, 72 years and 19. Seven patients were affected by hepatocellular carcinoma. No major complications or PVT recurrence were observed. One patient required a liver retransplantation for primary non‐functioning syndrome. The mean hospital stay was 20 days. The actuarial patient survival was 85% with a mean FU of 4 years. The two late deaths were due to hepatocellular carcinoma recurrence and sepsis for cholangitis.
Conclusions
this technique in presence of both CPVT and engorged LGV is feasible and safe for patients, with good short and long‐term results.
... The presence of PV thrombosis is a complex scenario in patients on a waiting list for liver transplantation, and it is observed in 10% of preoperative imaging in cirrhotic patients. 2 The cause of the occurrence of PV thrombosis is multifactorial, and it is probably related Figure 1. Computed tomography showing signs of segmental portal hypertension in the splenic, gastric, and esophagic areas due to portal vein cavernous transformation. ...
... Table 2 summarises the 37 reported cases (1990-2018) of LGV to portal anastomosis. 9,13,22,34,38,40,45,47,52,[68][69][70][71][72][73][74] All reports were single case reports or small case series (median ...
... Kim, 2011 45 3 Shunt patent, long term in 2, thrombosed in 1 patient, all patients well at last follow up Ravaioli, 2011 9 3 n.a., 1 patient died, 2 alive at last follow-up Hibi, 2014 47 1 n.a. Alexopoulos, 2014 71 5 All shunts patent (1 after surgical revision), all patients well, median follow up 2.3 years Wang, 2014 72 1 Patent, well, 1 year Teixeira, 2016 73 2 Patent, well, 5 years, 1 month Safwan, 2016 74 1 Patent, well, 3 months Gomez Gavara, 2018 53 3 Patent and well at 1, 2, 2 years n.a., not available; PVT, portal vein thrombosis; N, number of patients. ...
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
... Portal vein thrombosis (PVT) management still remains a challenge in liver transplantation (LT), and until recently it was a formal impairment for LT. When associated with splenorenal shunt it turns the transplant into a more complicated procedure considering the technical complexity [1,2]. Many surgical techniques have been proposed, such as thrombectomy, splenectomy, renal vein ligation, left gastric vein anastomosis, shunt ligation and more complex procedures like hemitransposition and even multi-visceral transplantation depending on the grade of thrombosis [1,2,3]. ...
... When associated with splenorenal shunt it turns the transplant into a more complicated procedure considering the technical complexity [1,2]. Many surgical techniques have been proposed, such as thrombectomy, splenectomy, renal vein ligation, left gastric vein anastomosis, shunt ligation and more complex procedures like hemitransposition and even multi-visceral transplantation depending on the grade of thrombosis [1,2,3]. ...
Portal vein thrombosis (PVT) is present in around 10% of transplant candidates, but its conduct still remains a challenge in liver transplantation
(LT). Therefore we present an innovative and less invasive option for PVT management, exemplified through an endovascular procedure realized
in a patient with Yerdel type III PVT and splenorenal shunt during an orthotopic liver transplantation (OLT).
... Portal vein thrombosis (PVT) management still remains a challenge in liver transplantation (LT), and until recently it was a formal impairment for LT. When associated with splenorenal shunt it turns the transplant into a more complicated procedure considering the technical complexity [1,2]. Many surgical techniques have been proposed, such as thrombectomy, splenectomy, renal vein ligation, left gastric vein anastomosis, shunt ligation and more complex procedures like hemitransposition and even multi-visceral transplantation depending on the grade of thrombosis [1,2,3]. ...
... When associated with splenorenal shunt it turns the transplant into a more complicated procedure considering the technical complexity [1,2]. Many surgical techniques have been proposed, such as thrombectomy, splenectomy, renal vein ligation, left gastric vein anastomosis, shunt ligation and more complex procedures like hemitransposition and even multi-visceral transplantation depending on the grade of thrombosis [1,2,3]. ...
Background
Portal vein thrombosis is a potentially devastating complication following pediatric liver transplantation. In rare instances of complete portomesenteric thrombosis, cavoportal hemitransposition may provide graft inflow. Here we describe long‐term results following a case of pediatric cavoportal hemitransposition during liver transplantation and review the current pediatric literature.
Methods
A 9‐month‐old female with a history of biliary atresia and failed Kasai portoenterostomy underwent living donor liver transplantation, which was complicated by portomesenteric venous thrombosis. The patient underwent retransplantation with cavoportal hemitransposition on postoperative day 12.
Outcome
The patient recovered without further complication, and 10 years later, she continues to do well, with normal graft function and no clinical sequelae of portal hypertension. CT scan with 3‐D vascular reconstruction demonstrated recanalization of the splanchnic system, with systemic drainage to the inferior vena cava via an inferior mesenteric vein shunt. The cavoportal anastomosis remains patent with hepatopetal flow. Of the 12 previously reported cases of pediatric cavoportal hemitransposition as portal inflow in liver transplantation, this is the longest‐known follow‐up with a viable allograft. Notably, sequelae of portal hypertension were also rare in the 12 previously reported cases, with no cases of long‐term renal dysfunction, lower extremity edema, or ascites.
Conclusions
Long‐term survival beyond 10 years with normal graft function is feasible following pediatric cavoportal hemitransposition. Complications related to portal hypertension were generally short‐lived, likely due to the development of robust collateral circulation. Additional reports of long‐term outcomes are necessary to facilitate informed decision making when considering pediatric cavoportal hemitransposition for liver graft inflow.
