Surgical strategies for liver transplantation in the case of portal vein thrombosis – current role of cavoportal hemitransposition and renoportal anastomosis

Abstract

Portal vein thrombosis (PVT), a common complication of end stage liver disease, is no longer considered a definite contraindication for liver transplantation (LTx). The clinical decision to perform an LTx in the case of PVT depends on the degree of PVT and the experience of the surgeon. Eversion thromboendovenectomy was suggested by most authors as the surgical technique of choice for PVT grade 1, 2, and 3. If PVT obstructs more extended parts of the porto-mesenteric venous circulation, surgical options would include different types of venous jump graft reconstructions or arterialization of the portal vein. Combined liver and small bowel transplantation is another possible alternative. Cavoportal hemitransposition (CPHT) and renoportal anastomosis (RPA) were recently particularly advocated as creative surgical strategies in case of diffuse PVT. In this work, we focus on CPHT and RPA surgical techniques during LTx, which attempts to secure the portal flow to the liver graft in case of pre-existent diffuse PVT. We provide a review of all reported clinical experience at international clinical centers using these techniques. According to our meta-analysis a total of 15 studies were published on this topic between 1996 and 2005. In summary, a total of 56 orthotopic LTx have been performed in 53 patients (28 men, 25 women) combined with either CPHT or RPA, for the purpose of providing the donor graft with adequate inflow. Mean age was 44 yr including two patients who were infants, with the youngest recipient being two yr old. Main indications for LTx were liver cirrhosis caused by viral hepatitis, alcoholic cirrhosis and cryptogenic cirrhosis. CPHT was performed in 46 cases, and RPA in 10 cases. Thirty-five of 53 patients (66%) had surgery previous to LTx. Of these, 13 patients (37%) [corrected] presented with a history of other previous surgical procedures for decompression of portal hypertension or treatment of associated complications (portocaval shunts, splenectomy, etc). Ascites, renal dysfunction, lower extremity and torso edema and variceal bleeding were dominant post-operative complications after CPHT or RPA noted in 22 cases (41.5%), 18 cases (34%), 17 cases (32%) and 13 cases (24.5%) respectively. Patients' follow-up ranged from two to 48 months. Thirty nine of 53 patients [corrected] (74%) survived [corrected] and 14 patients died (26%) [corrected] during the course of observation. Based on the literature, we conclude that the ideal technique to overcome PVT during LTx is still controversial. Short-term follow-up results of both methods are promising, however, long-term results are unknown at present. Furthermore, clinical follow-up and basic experimental work is required to evaluate the influence of systemic venous inflow to the liver graft with respect to long-term liver function and liver regeneration.

Portal Vein Thrombosis in Cirrhosis

“…80 Rodriguez-Castro, in a recent systematic review, reported that among 49 patients with portocaval hemitransposition, 20% had episodes of variceal bleeding, 58% had persistent ascites, and 26% presented with renal dysfunction after LT. 81 An alternative to portocaval hemitransposition is reno-portal transposition, where the recipient portal vein is anastomosed to the left renal vein. 82 5. Multivisceral transplantation: combined liver and small bowel transplantation is an infrequently used alternative in cases of bowel ischemia, and when no other portal inflow is available.…”

Liver retransplantation with cavoportal hemitransposition after percutaneous mesocaval shunt creation

“…Four patients died during a follow-up period of 10 months. (2) Until 2011, 59 patients underwent CPHT in grade 4 PVT. (3) The largest single-center series so far reports the experience of 23 patients.…”

“…The 1-year survival rate was 60%, and the 5-year survival rate was 38%, compared to an average 1-year survival rate of 85%-90% in normal LT populations. (2,5) Lower limb edema and ascites were reported in 50% to 90% of patients with the development of renal insufficiency in approximately 50% of patients. (2,3,5) A major complication after CPHT is upper gastrointestinal bleeding given that portal hypertension is not addressed by the procedure.…”

“…(2,5) Lower limb edema and ascites were reported in 50% to 90% of patients with the development of renal insufficiency in approximately 50% of patients. (2,3,5) A major complication after CPHT is upper gastrointestinal bleeding given that portal hypertension is not addressed by the procedure. Bleeding is reported in up to 30% to 50% of patients after transplantation and is treated by endoscopic sclerotherapy, splenectomy, gastric desvascularization, and splenic artery embolization.…”

“…Common postoperative complications are ascites, renal dysfunction, and variceal bleeding. (2) In cases of treatment-resistant portal hypertension in combination with extensive PVT, a transjugular intrahepatic portosystemic shunt (TIPS) procedure is not feasible. If endoscopic sclerotherapy and surgical shunt formation are impossible, an interventional mesocaval shunt formation has been described.…”