We report a case of extensive acute portal vein thrombosis (PVT) presenting with severe diffuse abdominal pain and impending small bowel infarction. The patient was successfully treated with ultrasound-accelerated catheter-directed thrombolysis (EKOS endowave system; Covidien, Mansfield, Massachusetts), which resulted in prompt recanalization of his portal vein (PV) and its tributaries. The patient eventually had ischemic stricture that necessitated bowel resection. However, we believe that our technique was successful in rapidly restoring the patency of the PV and its tributaries, and therefore, avoiding a life-threatening complication of more extensive bowel infarction. To our knowledge, the use of ultrasound-accelerated thrombolysis in treatment of PVT has not been previously described in the literature.

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Background and AimsContrast‐enhanced cross‐sectional imaging is the cornerstone in the diagnosis, staging, and management of HCC, including eligibility for liver transplantation (LT). Radiological‐histopathological discordance may lead to improper staging and may impact patient outcomes. We aimed to assess the radiological‐histopathological discordance at the time of LT in HCC patients and its impact on the post‐LT outcomes.MethodsWe analyzed further the effect of 6‐month waiting policy on the discordance. Using United Network for Organ Sharing—Organ Procurement and Transplantation Network (UNOS‐OPTN) database, we examined the discordance between pre‐LT imaging and explant histopathology for all adult HCC patients who received liver transplants from deceased donors between April 2012 and December 2017. Kaplan–Meier methods and Cox regression analyses were used to evaluate the impact of discordance on 3‐year HCC recurrence and mortality.ResultsOf 6842 patients included in the study, 66.7% were within Milan criteria on both imaging and explant histopathology, and 33.3% were within the Milan based on imaging but extended beyond Milan on explant histopathology. Male gender, increasing numbers of tumors, bilobar distribution, larger tumor size, and increasing AFP are associated with increased discordance. Post‐LT HCC recurrence and death were significantly higher in patients who were discordant, with histopathology beyond Milan (adj HR 1.86, 95% CI 1.32–2.63 for mortality and 1.32, 95% CI 1.03–1.70 for recurrence). Graft allocation policy with 6‐month waiting time led to increased discordance (OR 1.19, CI 1.01–1.41), although it did not impact post‐LT outcome.ConclusionCurrent practice for staging of HCC based on radiological imaging features alone results in underestimation of HCC burden in one out of three patients with HCC. This discordance is associated with a higher risk of post‐LT HCC recurrence and mortality. These patients will need enhanced surveillance to optimize patient selection and aggressive LRT to reduce post‐LT recurrence and increase survival.

Since the first liver transplantation operation (LT) in 1967 by Thomas Starzl, efforts to increase survival and prevent rejection have taken place. The development of calcineurin inhibitors (CNIs) in the 1980s led to a surge in survival post-transplantation, and since then, strategies to prevent graft loss and preserve long-term graft function have been prioritized. Allograft rejection is mediated by the host immune response to donor antigens. Prevention of rejection can be achieved through either immunosuppression or induction of tolerance. This leads to a clinical dilemma, as the choice of an immunosuppressive agent is not an easy task, with considerable patient and graft-related morbidities. On the other hand, the induction of graft tolerance remains a challenge. Despite the fact that the liver exhibits less rejection than any other transplanted organs, spontaneous graft tolerance is rare. Most immunosuppressive medications have been incriminated in renal, cardiovascular, and neurological complications, relapse of viral hepatitis, and recurrence of HCC and other cancers. Efforts to minimize immunosuppression are directed toward decreasing medication side effects, increasing cost effectiveness, and decreasing economic burden without increasing the risk of rejection. In this article, we will discuss recent advances in strategies for improving immunosuppression following liver transplantation.