Successful Intraoperative Use of Recombinant Tissue Plasminogen Activator During Liver Transplantation Complicated by Massive Intracardiac/Pulmonary Thrombosis

Jackson, Douglas; Botea, Andrei; Gubenko, Yuriy; Delphin, Ellise; Bennett, Henry L.

doi:10.1213/01.ane.0000197779.03866.ad

Cited by 54 publications

(45 citation statements)

References 24 publications

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“…4,7,9,10,12,13,17,18 Others are inherent to the OLT procedure: excessive activation of the coagulation system, venous stasis during clamping of the portal vein and inferior vena cava, and release of activators from the liver graft. 6,7,9 In addition, other conditions such as heparin-induced thrombocytopenia, factor V Leiden, and antithrombin deficiency can contribute to thrombosis and possibly ICTs during OLT. Finally, intraoperative management may play an important role: PA catheter placement; the administration of antifibrinolytics, anti-hepatitis B immunoglobulin, and blood products; and the intraoperative utilization of continuous venovenous filtration.…”

Section: Discussionmentioning

confidence: 99%

“…Finally, intraoperative management may play an important role: PA catheter placement; the administration of antifibrinolytics, anti-hepatitis B immunoglobulin, and blood products; and the intraoperative utilization of continuous venovenous filtration. 2,4,7,8,[10][11][12][13][14][18][19][20] Risk factor analysis for ICTs during OLT has proved to be difficult because of the relatively low incidence. In this study, we showed that symptomatic and/or surgically treated portal hypertension and intraoperative hemodialysis were independent risk factors for the development of incidental ICTs during OLT.…”

Section: Discussionmentioning

confidence: 99%

“…The thromboemboli in these cases are usually described as large, massive, severe, or fatal; these terms refer to the clot size, the impact on hemodynamics, or the patient outcomes (the term massive is used throughout this report). [3][4][5][6][7][8][9][10][11][12][13][14] The diagnosis of massive thromboemboli can be made on the basis of a typical clinical presentation with or without transesophageal echocardiography (TEE) evidence. Several strategies have been reported for the management of massive thromboemboli during OLT.…”

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confidence: 99%

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Incidental intracardiac thromboemboli during liver transplantation: Incidence, risk factors, and management

Xia

Nourmand

et al. 2010

Liver Transpl

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Even though numerous cases of massive thromboemboli have been reported in the literature, intracardiac thromboemboli (ICTs) incidentally found during orthotopic liver transplantation (OLT) have not been examined. In this study, we retrospectively examined the incidence, risk factors, and management of incidental ICTs during OLT. After institutional review board approval, adult patients who underwent OLT between January 2004 and December 2008 at our center were reviewed. ICTs were identified and confirmed by the examination of OLT datasheets, anesthesia records, and recorded transesophageal echocardiography (TEE) clips. The clinical presentation, management, and outcomes of the patients with ICTs were reviewed. Risk factors were analyzed by multivariate logistic regression. During the study period, 426 of the 936 adult OLT patients (45.5%) underwent intraoperative TEE monitoring. Incidental ICTs were identified in 8 of these 426 patients (1.9%). Two ICTs occurred before reperfusion, and 6 ICTs occurred after reperfusion. The treatment was at the discretion of the treating physicians; however, none of the patients received an anticoagulant or thrombolytics. Multivariate analysis identified 2 independent risk factors for intraoperative incidental ICTs: the presence of symptomatic or surgically treated portal hypertension (a history of gastrointestinal bleeding, a transjugular intrahepatic portosystemic shunt procedure, or portocaval shunt surgery) before OLT and intraoperative hemodialysis (odds ratios of 4.05 and 7.29, respectively; P < 0.05 for both). In conclusion, incidental ICTs during OLT occurred at a rate of 1.9% and were associated with several preoperative and intraoperative risk factors. The use of TEE allows early identification, which may be important. Our management for incidental ICTs is described; however, no conclusions can be made about the optimal therapy.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Incidental intracardiac thromboemboli during liver transplantation: Incidence, risk factors, and management

Xia

Nourmand

et al. 2010

Liver Transpl

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“…Infectious conditions, however, are a well-defined and strong risk factor for thrombotic events, and this effect may last for weeks after the septic episode [55,56]. Other suggested risk factors are certain drugs and blood products, such as hepatitis B immunoglobulin [24,31,34], the combination of aprotinin and octreotide [37], solvent-detergent plasma [36], and large volumes of cryoprecipitate, fresh frozen plasma or platelet concentrates [20,21,23]. The potential role of acquired and congenital thrombophilia disorders, such as protein C, protein S, or antithrombin III deficiencies or factor (F) V Leiden mutation, has been investigated in only a small number of patients [17,27,29,32].…”

Section: Discussionmentioning

confidence: 99%

“…The most frequently described risk factors were venovenous bypass [13,15,18,[23][24][25]29,30,32,[34][35][36][38][39][40]45] and the use of antifibrinolytic medication [13,17,19,21,23,25,26,[28][29][30][31][32][34][35][36][37][38][39][42][43][44]. However, PE and ICT have been reported in almost an identical number of patients with or without these two putative risk factors (Table 3).…”

Section: Putative Risk Factorsmentioning

confidence: 99%

Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review

Warnaar¹,

Molenaar²,

Colquhoun³

et al. 2008

J Thromb Haemost

122

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Summary. Background: Pulmonary embolism (PE) and intracardiac thrombosis (ICT) are rare but potentially lethal complications during orthotopic liver transplantation (OLT). Methods: We aimed to review clinical and pathological correlates of PE and ICT in patients undergoing OLT. A systematic review of the literature was conducted using MEDLINE and ISI Web of Science. Results: Seventy-four cases of intraoperative PE and/or ICT were identified; PE alone in 32 patients (43%) and a combination of PE and ICT in 42 patients (57%). Most frequent clinical symptoms included systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse. PE and ICT occurred in every stage of the operation and were reported equally in patients with or without the use of venovenous bypass or antifibrinolytics. A large variety of putative risk factors have been suggested in the literature, including the use of pulmonary artery catheters or certain blood products. Nineteen patients underwent urgent thrombectomy or thrombolysis. Overall mortality was 68% (50/74) and 41 patients (82%) died intraoperatively. Conclusion: Mortality was significantly higher in patients with an isolated PE, compared to patients with a combination of PE and ICT (91% and 50%, respectively; P < 0.001). Intraoperative PE and ICT during OLT appear to have multiple etiologies and may occur unexpectedly at any time during the procedure.

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Intracardiac thrombosis during liver transplant: A 17‐year single‐institution study

Peiris¹,

Pai²,

Aniskevich³

et al. 2015

Liver Transpl

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Intracardiac thrombosis (ICT) during orthotopic liver transplantation (OLT) is an uncommon event. However, it is a devastating complication with high mortality when it occurs. This study aimed to identify possible predisposing factors for ICT during OLT. We retrospectively identified the cases of all patients with ICT during OLT at our institution from 1998 to 2014. Of 2750 OLTs performed, 10 patients had ICT intraoperatively. The patients' immediate prethrombosis intraoperative hemodynamic and coagulation values and thromboelastography (TEG) data were reviewed. Preexisting venous thrombosis, atrial fibrillation, and the prior placement of a transjugular intrahepatic portosystemic shunt for portal hypertension were noted in several patients and may be related to ICT during OLT. A high Model of End-Stage Liver Disease score, low cardiac output, and sepsis did not appear to be associated with ICT. ICT occurred in some patients without the administration of antifibrinolytic agents. TEG and coagulation parameters did not appear to be helpful in predicting the onset of ICT. Four patients had ICT in both right-and left-sided heart chambers; none of these 4 patients survived. All 6 patients with only right-sided thrombus survived. In those who survived, improved hemodynamics and clot disappearance on transesophageal echocardiography (TEE) occurred over time, even without the use of thrombolytics. Whether this is because of endogenous thrombolysis or distal clot propagation into the pulmonary vasculature, or both, is unclear. Tissue plasminogen activator may have a role in the resuscitation procedure. In conclusion, without the routine use of TEE during OLT, the incidence of ICT will remain an under-recognized event.

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Successful Intraoperative Use of Recombinant Tissue Plasminogen Activator During Liver Transplantation Complicated by Massive Intracardiac/Pulmonary Thrombosis

Cited by 54 publications

References 24 publications

Incidental intracardiac thromboemboli during liver transplantation: Incidence, risk factors, and management

Incidental intracardiac thromboemboli during liver transplantation: Incidence, risk factors, and management

Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review

Intracardiac thrombosis during liver transplant: A 17‐year single‐institution study

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