Balloon dilatation for treatment of hepatic venous outflow obstruction following pediatric liver transplantation

Abstract

AIMTo assess the efficacy and safety of balloon dilatation for the treatment of hepatic venous outflow obstruction (HVOO) following pediatric liver transplantation.METHODSA total of 246 pediatric patients underwent liver transplantation at our hospital between June 2013 and September 2016. Among these patients, five were ultimately diagnosed with HVOO. Seven procedures (two patients underwent two balloon dilatation procedures) were included in this analysis. The demographic data, types of donor and liver transplant, interventional examination and therapeutic outcomes of these five children were analyzed. The median interval time between pediatric liver transplantation and balloon dilatation procedures was 9.8 mo (range: 1-32).RESULTSFive children with HVOO were successfully treated by balloon angioplasty without stent placement, with seven procedures performed for six stenotic lesions. All children underwent successful percutaneous intervention. Among these five patients, four were treated by single balloon angioplasty, and these patients did not develop recurrent stenosis. In seven episodes of balloon angioplasty across the stenosis, the pressure gradient was 12.0 ± 8.8 mmHg before balloon dilatation and 1.1 ± 1.5 mmHg after the procedures, which revealed a statistically significant reduction (P < 0.05). The overall technical success rate among these seven procedures was 100% (7/7), and clinical success was achieved in all five patients (100%). The patients were followed for 4-33 mo (median: 15 mo). No significant procedural complications or procedure-related deaths occurred.CONCLUSIONBalloon dilatation is an effective and safe therapeutic option for HVOO in children undergoing pediatric liver transplantation. Venous angioplasty is also recommended in cases with recurrent HVOO.

Tailored techniques of graft outflow vein reconstruction in pediatric liver transplantation at Asan Medical Center

“…Secure graft outflow vein reconstruction is the most important step for successful pediatric LT. Once HVOO occurs, it is difficult to treat it effectively [1][2][3][4] and the sequences of treatment are often intractable. Endovascular stenting in infant patients should be the last life-saving procedure because it can induce stent-associated vascular insufficiency according to physical growth of the recipient from infant to adolescent [5,6].…”

“…Various innovative surgical techniques have been proposed to improve outcomes of pediatric liver transplantation (LT) because vascular complications can occur in a not negligible proportion of pediatric LT recipients. Pediat-ric recipients, especially infants, are vulnerable to vascular complications because their graft and recipient vessels are much smaller than those of adult LT. Once graft inflow or outflow vein stenosis occurs, it is difficult to treat it effectively [1][2][3][4]. Insertion of an endovascular stent can be a rescue treatment in pediatric patients, but such a stent may not expand sufficiently during physical growth of the recipient from infant to adolescent [5].…”

Graft outflow vein unification venoplasty with superficial left hepatic vein branch in pediatric living donor liver transplantation using a left lateral section graft

“…Once an anastomotic stenosis of the graft hepatic vein develops, it is not easily treated through the use of a percutaneous radiological angioplasty, because the connective tissues around the vascular structures are hardened through the prolonged inflammatory process whereby repetitive interventional procedures are often needed. 4 - 7 Note that the insertion of a wall stent into the hepatic vein anastomosis is regarded as a life-saving procedure to cope with hepatic vein outflow obstruction with an anticipation of late retransplantation, because such use of a vascular wall stent may not be expanded enough to follow the long-term physical growth timeframe characteristic of a patient from the years of an infant to a forming adolescent. 8 Therefore, it is critical that an evidence-based secure surgical design is essential for hepatic vein reconstruction in pediatric LDLT.…”

Third retransplantation using a whole liver graft for late graft failure from hepatic vein stent stenosis in a pediatric patient who underwent split liver retransplantation

“…1 It is difficult to treat stent-associated hepatic or portal vein stenosis through percutaneous angioplasty. [2][3][4][5][6] As a result, endovascular stenting performed in infants can cause intractable vascular insufficiency, which can lead to progressive graft liver failure and late retransplantation. We present a case of third retransplantation using a whole liver graft in a pediatric patient who had suffered graft failure following split liver retransplantation with endovascular stenting of the hepatic and portal veins.…”