Portal Revascularization in the Setting of Cavernous Transformation Through a Paracholedocal Vein: A Case Report

Abstract

Diffuse thrombosis of the entire portal system (PVT) and cavernomatous transformation of the portal vein (CTPV) represents a demanding challenge in liver transplantation. We present the case of a patient with nodular regenerative hyperplasia and recurrent episodes of type B hepatic encephalopathy concomitant with PVT as well as CTPV, successfully treated with orthotopic liver transplantation. The portal inflow to the graft was carried out through the confluence of 2 thin paracholedochal varicose veins, obtaining good early graft function and recovery of the encephalopatic episodes. This alternative should be kept in mind as an option to assure hepatopetal splanchnic flow in those cases of diffuse thrombosis and cavernomatous transformation of portal vein.H T E COMPLICATIONS of diffuse portal-splenic and superior mesenteric vein thrombosis (PVT) with subsequent cavernous transformation of the portal vein (CTPV) in noncirrhotic patients represent a clinical challenge. When the medical and interventional procedures fail, liver transplantation (OLT) or combined liver-small bowel transplantation remain the ultimate option.1,2 Although several surgical alternatives have been described to overcome PVT and CTPV in clinical series, the absence of portal flow remains a challenge in OLT, for it increases the morbidity and mortality of the procedure.3,4 Herein we have presented a case of a successful OLT in a patient with PVT and CTPV. The portal inflow of the graft was achieved through the confluence of two pericholedochal veins (Petren's veins). CASE REPORTA 54-year-old man with complete thrombosis of the portal vein and nodular regenerative hyperplasia (NRH) was referred for a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The diagnosis of PVT due to antiphospholipid antibody syndrome had been previously established during 2 episodes of abdominal pain. Doppler ultrasound and computed tomography confirmed the PVT diagnosis. The patient later developed esophageal varices and bled on 3 ocasions despite /3-blocker administration, requiring sclerotherapy sessions.Six months after the TIPS procedure, he suffered several episodes of portosystemic encephalopathy (PSE). The patient was treated with conservative medical therapy, administration of lactulose nonabsorbable antibiotics, and a low-protein diet. However, the encephalopathy symptoms persisted, and he underwent an endovascular shunt reduction without clinical improvement.5 OLT was indicated due to the progressively debilitating PSE.

The paracholedochal vein: a feasible option as portal inflow in living donor liver transplantation

“…However, several surgical techniques have been developed for deceased donor liver transplantation (DDLT), such as thrombectomy, interposition or a jump graft between the donor and recipient PV, cavoportal hemitransposition (CPHT), renoportal anastomosis (RPA), and PV arterializations [1,2]. With these surgical innovations, the results of DDLT for patients with PVT have been comparable to those of patients without PVT [1,6].…”

“…Although various surgical techniques and approaches to PVT has been introduced to overcome PVT, the absence of portal flow remains a surgically demanding challenge in the setting of LDLT because it has an obvious influence on surgical complexity, morbidity and mortality rates [1,2,3]. Furthermore, portal vein (PV) reconstruction is a very difficult procedure in LDLT with extensive PVT with CTPV in the setting of decreasing portal hypertension and providing adequate portal inflow [3,4].…”

The collateral caval shunt as an alternative to classical shunt procedures in patients with recurrent duodenal varices and extrahepatic portal vein thrombosis

“…Management of disease complications such as varices of the gastrointestinal system plays an important role in therapy progress [3,4]. …”

“…Endoscopic sclerotherapy and endoscopic variceal ligation replaced open surgical portosystemic shunt operations as first-line treatment modalities in patients with upper gastrointestinal variceal bleedings related to portal hypertension [1-4,7]. Nevertheless, in case of endoscopic treatment failure (15% of cases in total), a portosystemic shunt operation represents the therapy option of choice [1,2,4,5,8].…”

“…Nevertheless, in case of endoscopic treatment failure (15% of cases in total), a portosystemic shunt operation represents the therapy option of choice [1,2,4,5,8]. In these cases a surgical shunt procedure was indicated for patients with a Child-Pugh A cirrhosis to reduce the incidence of re-bleeding, maintain hepatic function and provide structural stability.…”