Ligating coronary vein varices: An effective treatment of “coronary vein steal” to increase portal flow in liver transplantation

Gupta, Amar; Klintmalm, Göran B.; Kim, Peter T. W.

doi:10.1002/lt.24448

Cited by 14 publications

(12 citation statements)

References 6 publications

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“…In cases where there are large coronary vein varices present (>1 cm in diameter), ligating these may increase the PV flow significantly. This prevents the “steal” by the coronary vein . Even in the setting of adequate PV flow at the time of transplant, any large varices should be ligated because they will divert PV flow in the postoperative period if the compliance of the liver increases due to rejection, volume overload, or recurrent hepatitis C. A large splenorenal shunt can be addressed by percutaneous embolization or ligation of the left renal vein …”

Section: Discussionmentioning

confidence: 99%

“…This prevents the "steal" by the coronary vein. (26) Even in the setting of adequate PV flow at the time of transplant, any large varices should be ligated because they will divert PV flow in the postoperative period if the compliance of the liver increases due to rejection, volume overload, or recurrent hepatitis C. A large splenorenal shunt can be addressed by percutaneous embolization or ligation of the left renal vein. (27,28) If the PV flow is inadequate even after aforementioned maneuvers, an intraoperative portogram (IOP) may be considered.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis

Draoua¹,

Titze²,

Gupta

et al. 2017

Liver Transpl

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Adequate portal vein (PV) flow in liver transplantation is essential for a good outcome, and it may be compromised in patients with portal vein thrombosis (PVT). This study evaluated the impact of intraoperatively measured PV flow after PV thrombendvenectomy on outcomes after deceased donor liver transplantation (DDLT). The study included 77 patients over a 16-year period who underwent PV thrombendvenectomy with complete flow data. Patients were classified into 2 groups: high PV flow (>1300 mL/minute; n = 55) and low PV flow (≤1300 mL/minute; n = 22). Postoperative complications and graft survival were analyzed according to the PV flow. The 2 groups were similar in demographic characteristics. Low PV flow was associated with higher cumulative rates of biliary strictures (P = 0.02) and lower 1-, 2-, and 5-year graft survival (89%, 85%, and 68% versus 64%, 55%, and 38%, respectively; P = 0.002). There was no difference in the incidence of postoperative PVT between the groups (1.8% versus 9.1%; P = 0.19). No biliary leaks or hepatic artery thromboses were reported in either group. By multivariate analyses, age >60 years (hazard ratio [HR], 3.04, 95% confidence interval [CI], 1.36-6.82; P = 0.007) and low portal flow (HR, 2.31; 95% CI, 1.15-4.65; P = 0.02) were associated with worse survival. In conclusion, PV flow <1300 mL/minute after PV thrombendvenectomy for PVT during DDLT was associated with higher rates of biliary strictures and worse graft survival. Consideration should be given to identifying reasons for low flow and performing maneuvers to increase PV flow when intraoperative PV flows are <1300 mL/minute. Liver Transplantation 23 1032-1039 2017 AASLD.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis

Draoua¹,

Titze²,

Gupta

et al. 2017

Liver Transpl

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“…On the basis of this experience, we would like to emphasize 2 points in addition to the statements made by Gupta et al (1) First, we believe that in patients with baseline PVF > 1000 mL and CVV > 1 cm, PVF measurement must be performed after a PSS clamping test to verify the absence of portal hyperperfusion (ie, PVF > 250 mL/minute per 100 g of liver weight), (2) especially for smaller grafts. In our series, the patient for whom CVV ligation was abandoned due to portal hyperperfusion had a satisfactory postoperative course, whereas it could be hypothesized that he would have developed small-for-size syndrome in the case of a shunt ligation.…”

Section: To the Editormentioning

confidence: 87%

“…We read with great interest the article by Gupta et al, (1) which reported 3 cases of liver transplantation (LT) in recipients with large coronary vein varices (CVVs). On the basis of their findings, the authors recommended routine portal vein flow (PVF) measurement after reperfusion, followed by shunt ligation in case of PVF < 1000 mL/minute or shunt diameter of >1 cm.…”

Section: To the Editormentioning

confidence: 99%

Ligating coronary vein varices: An effective treatment of “coronary vein steal” to increase portal flow in liver transplantation

Mohkam

Aurelus²,

Ducerf³

et al. 2016

Liver Transpl

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“…In cases where there are large coronary vein varices are present (>1 cm in diameter), ligating these may increase the PV flow by 55-140% depending on the relative size of the varix. This prevents the "steal" by the coronary vein, and diverts the flow to the main PV [23]. Large splenorenal shunt can be addressed by percutaneous embolization or ligation of the left renal vein [24,25].…”

Section: Portal Vein Flowmentioning

confidence: 99%

Importance of Hepatic Flows in Liver Transplantation

Ptw¹,

Gb²

2016

J Hepatol Gastroint Dis

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Establishing appropriate dual blood supply in liver transplant is important to ensure optimal graft survival and post-operative outcomes. The hemodynamic changes in cirrhotic patients render the patients with hyperdynamic circulation and this environment raises the portal venous flow through the graft immediately after transplant. In deceased donor liver transplantation, lower hepatic flows are associated with detrimental outcomes. Lower measured hepatic artery flow has been associated with lower graft survival and higher rate of arterial complications. Lower portal venous flow of less than 1-1.3 L/min has been associated with lower graft survival. Lower hepatic artery flow is associated with increased rate of biliary complications after deceased donor transplantation. In live donor liver transplantation, portal hyperperfusion is implicated in small for size syndrome. Maneuvers to decrease portal venous flow such as splenic artery ligation, splenectomy or portacaval shunt have been associated with improved outcomes after live donor liver transplantation. It appears that relationship between higher portal flows and poor outcomes is not yet firmly established in that the live donor liver graft may tolerate higher PV flows when the outflow of the graft is well established and if the higher PV flow is not accompanied by portal hypertension. The importance of blood flow in liver transplantation is undeniable. Further studies are required to establish the relationship between the portal and hepatic arterial flows to biliary and arterial complications after liver transplantation.

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Ligating coronary vein varices: An effective treatment of “coronary vein steal” to increase portal flow in liver transplantation

Cited by 14 publications

References 6 publications

Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis

Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis

Ligating coronary vein varices: An effective treatment of “coronary vein steal” to increase portal flow in liver transplantation

Importance of Hepatic Flows in Liver Transplantation

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