Cavoportal hemitransposition for unrecognized spontaneous mesocaval shunt after liver transplantation: a case report

Abstract

SummarySpontaneous portosystemic shunts can steal the blood away from the portal system. This may result in graft dysfunction or even loss following liver transplantation and can be sorted by shunt occlusion based on intraoperative flow measurements. Herein, we present an alternative technique with cavoportal hemitransposition performed for unrecognized spontaneous mesocaval shunt with 'portal steal' syndrome and primary graft nonfunction diagnosed first day following the transplant. This was chosen as a rescue strategy because an attempt to locate the shunt during relaparotomy was unsuccessful. As there was no improvement, emergency liver retransplantation with preservation of the cavoportal hemitransposition was performed on the fourth day after the primary transplant with good long-term outcome. We conclude that cavoportal hemitransposition during or after liver transplantation can be used to provide an adequate inflow into the donor portal vein if the shunting vessels responsible for the steal cannot be located and dealt with at surgery.

Unusual spontaneous porto‐systemic shunt: The importance of diagnosing non‐anatomical porto‐systemic shunts to improve portal flow in pediatric living–related liver transplantation. Case report

“…A triple‐phase CT angiography with vascular reconstruction can identify the shunt; if it is performed prior to LT, it would allow a planned search to identify and ligate the shunt after or during the engraftment. Routine intraoperative portal vein flow measurements can provide the opportunity of identifying venous anomalies and to act accordingly during the transplant surgery . Unfortunately, in some instances, these shunts are not identified preoperatively and cannot be assessed during surgery, or do not become clinically evident until the post‐transplant period, as seen in the case reported here.…”

“…The importance of identifying those dominant collaterals during the pretransplant evaluation has been very well described in adults, as well as the subsequent need for post‐transplant occlusion, but there is scattered information in this regard in pediatrics. In most cases, after a successful liver transplant, these large shunts tend to disappear due the low portal resistance present in the new liver; nevertheless, the spontaneous closure might be slow, delayed, or might not occur . In such extreme cases, the persistence of the spontaneous shunts can cause “steal flow syndrome” into the new liver.…”

“…living donor liver transplantation, portal thrombosis, porto-systemic shunt might be slow, delayed, or might not occur. 4,5 In such extreme cases, the persistence of the spontaneous shunts can cause "steal flow syndrome" into the new liver. Therefore, an early diagnosis of main portal flow reduction is mandatory to ligate or embolize the shunts, even in the operating room at the end of the case.…”

Radiologic evaluation of portal steal phenomenon in recipients of liver transplantation

“…1) (4,22,24). While intrahepatic shunts and some extrahepatic shunts such as portophrenic or para-umbilical shunts can be eliminated with harvest of the native liver in the recipients, gastrorenal shunts, splenorenal shunts, mesocaval shunts, gastrophrenic shunts, and other minor non-removable shunts may persist and potentially contribute to portal steal following liver transplantation (4,14,25). Splenorenal shunt is one of the major concerns due to their higher prevalence and tendency to grow larger (4,26).…”