The Recipient With Portal Thrombosis and/or Previous Surgery

doi:10.1016/j.transproceed.2008.03.073

Transplantation Proceedings

Volume 40, Issue 4, May 2008, Pages 1183-1186

https://doi.org/10.1016/j.transproceed.2008.03.073 Get rights and content

Abstract

Introduction

Portal vein thrombosis (PVT) has been considered to be an absolute contraindication to liver transplantation (OLT) and previous upper abdominal surgery was considered to render it a high-risk procedure. Currently, these are only conditions considered risk factors increasing recipient morbidity and mortality. The objective of this study was to compare OLT perioperative morbidity, mortality, blood product consumption, and length of hospital stay among patients with or without PVT or with or without previous surgery.

Materials and methods

Among 366 OLTs performed between July 1999 and November 2007, 33 liver transplant recipients displayed previous PVT while 34 had undergone previous surgery. The two groups of marginal recipients were compared with a cohort of 33 patients without PVT or previous surgery.

Results

The groups were homogeneous in terms of epidemiological variables, surgical techniques, and donor-related variables. In the PVT group, all analyzed parameters were the same as the control group; surgical time, anhepatic phase duration, early surgical complication, intensive care unit and hospital length of stay, and overall mortality. The only significant difference was the incidence of portal rethrombosis (P < .035). Among the previous surgery group, we did not observe significant differences.

Conclusions

PVT and previous surgery should no longer be considered contraindications for OLT.

Section snippets

Portal Vein Thrombosis

Accurate epidemiological data on PVT are difficult to obtain. Autopsy studies have reported a 0.05% to 0.5% prevalence of these conditions in the general population, while the prevalence varies from 0.6% to 64.1% among liver cirrhotic patients, depending on the diagnostic method or criteria for patient selection.¹

PVT is a common condition of high clinical importance with an incidence varying from 2.1% to 26% in large review study.² Along with different ages, the etiology of PVT is quite

Recipients With Previous Surgery

Surgical operations in the upper abdomen may not only result in a distorted anatomy, but also lead to the formation of intra-abdominal adhesions and scar formation, making the OLT procedure technically more complex, especially in the presence of portal hypertension. A late transplantation, namely, a redo procedure 6 months after the first transplantation, can show the liver to be attached to the surrounding organs and structures due to adhesions and fibrous reaction. In all these cases,

Epidemiology

Between July 30, 1999, and November 14, 2007, we performed 289 deceased orthotopic liver transplantation and 77 living donor liver transplantation (LDLT) in 338 adult patients. The end of follow-up was November 14, 2007. During the study period, portal thrombosis was discovered by imaging studies and confirmed at the time of the surgery in 33 patients (9.01%, Group A).

In the same period, 34 recipients had undergone previous surgery (Group B). The control group consisted of 33 patients without

Results

Group A showed a mean age of 53.63 years (range 35 to 66 years) with a gender distribution of 20 men (60.6%) and 13 women (39.3%). Group B had a mean age of 56.91 years (range, 35 to 68 years), with a gender distribution of 24 men (70.5%) and 10 women (29.57%). Group C showed a mean age of 52.63 years (range, 19 to 65 years) with a gender distribution of 24 men (72.7%) and 9 women (27.3%; Table 1).

The indications for transplantation are shown in Table 2. To compare the groups of patients, we

Discussion

In our series the incidence of marginal recipients due to PVT was 9.01%, and due to previous surgery 9.28%. In regard to the surgical intervention itself, although the durations of the anhepatic phase and the transplant itself were slightly longer, the differences were not statistically significant compared with other patients transplanted in our hospital, in contrast to the data available in the literature.¹⁰

The transfusion requirements were also not different between the two groups except for

References (14)

J.T. Wang et al.
Portal vein thrombosis
Hepatobiliary Pancreat Dis Int
(2005)
A. Sobhonslidsuk et al.
Portal vein thrombosis: a concise review
AJG
(2002)
F.A. Gimeno et al.
Comparative analysis of the results of OLTx in patients with or witout portal vein thrombosis
Transplant Proc
(2005)
G. Manzanet et al.
Liver transplantation in patients with portal vein thrombosis
Liver Transpl
(2001)
R. Bertelli et al.
Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center
Transplant Proc
(2005)
R. Charco et al.
Portal vein thrombosis in liver transplantation
Transplant Proc
(2005)
A. Shaked et al.
Liver transplantation in patients with portal vein thrombosis and central portocaval shunts
Ann Surg
(1991)

There are more references available in the full text version of this article.

Cited by (19)

The Impact of Previous Abdominal Surgery in a High-Acuity Liver Transplant Population
2021, Journal of Surgical Research
Citation Excerpt :
Multivariate analysis of prognostic factors for patient survival identified recipient pre-LT ICU admission as the only negative predictive factor among PAS, UAS, high-impact UAS, and PAS ≤90 (Table S8). PAS is considered a risk factor for substandard liver transplant results.6,9,11,12 Accordingly, it is integrated into the SRTR risk adjustment model as a variable associated with inferior post-LT outcomes.13
It is not uncommon for liver transplant (LT) recipients to have had previous abdominal surgery (PAS) preceding transplant. The impact of PAS on morbidity and mortality in LT patients remains unclear. In this study, we investigated the correlation between PAS and LT outcomes in a high-acuity patient population.
This is a single-center retrospective review of 936 adult primary LT recipients between 2012 and 2018. Patients were divided based on PAS history. PAS was subdivided into upper abdominal surgery (UAS) and lower abdominal surgery (LAS). UAS was separated into high-impact UAS and low-impact UAS. Finally, we studied patients with PAS ≤90 d versus PAS >90 d.
Extensive adhesiolysis was the only significant perioperative factor between the PAS group (n = 367) and the non-PAS group (n = 569) (P < 0.001). Red blood cell (RBC) transfusion (20U versus 17U, P = 0.044) and abdominal packing (24.2% versus 13.3%, P = 0.008) were significantly higher in the UAS group (n = 186) versus the LAS group (n = 181). Patients with high-impact UAS required greater RBC (P = 0.021) and fresh frozen plasma transfusion (P = 0.005), and arterial conduits (P = 0.016) during LT. Compared with recipients with PAS >90 d (n = 338), recipients with PAS ≤90 d (n = 29) had significantly higher RBC transfusion (P = 0.046), fresh frozen plasma transfusion (P = 0.022), and abdominal packing (P = 0.025). No differences in patient and graft survival was observed.
These findings suggest that, with appropriate care in the perioperative setting, PAS is not a contraindication to successful LT. Careful consideration is warranted when risk stratifying patients with multiple comorbidities who had PAS, especially those with UAS or PAS ≤90 d.
Portal vein surgical treatment on non-tumoral portal vein thrombosis in liver transplantation: Systematic review and meta-analysis
2021, Clinics
Citation Excerpt :
Data from three studies (13,24,26) evaluated 111 patients with PVT and 559 without PVT. The mean difference was 0.24 packs [0.03-0.46], p=0.03 (Figure 2D). Data from five studies (10,13,21,26,29) evaluated 269 patients with PVT and 2937 without PVT. The mean difference was 0.07 days [-0.06-0.19], (p=0.30) (Figure 3A). Data from five studies (10,13,21,26,29) evaluated 246 patients with PVT and 2,555 without PVT. The mean difference was 0.07 days [-0.06-0.20], (p=0.34) (Figure 3B).
Non-tumoral portal vein thrombosis (PVT) is associated with higher morbidity and mortality in liver transplantation (LT). In this study, we aimed to evaluate the impact of PVT in LT outcomes and analyze the types of surgical techniques used for dealing with PVT during LT.
A systematic review was conducted in Cochrane, MEDLINE, and EMBASE databases, selecting articles from January 1990 to December 2019. The MESH-terms used were (“Portal Vein”[Mesh] AND “Thrombosis”[Mesh] NOT “Neoplasms”[Mesh]) AND (“Liver Transplantation”[Mesh]). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendation was used, and meta-analysis was performed with Review Manager Version 5.3 software.
A total of 1,638 articles were initially found: 488 in PubMed, 289 in Cochrane Library, and 861 in EMBASE, from which 27 were eventually selected for the meta-analysis. Surgery time of LT in patients with PVT was longer than in patients without LT (p<0.0001). Intraoperative red blood cell (p<0.00001), fresh frozen plasma (p=0.01), and platelets (p=0.03) transfusions during LT were higher in patients with PVT. One-year (odds ratio [OR] 1.17; p=0.002) and 5-year (OR 1.12; p=0.01) patient survival after LT was worse in the PVT group. Total occlusive PVT presented higher mortality (OR 3.70; p=0.00009) and rethrombosis rates (OR 3.47 [1.18-10.21]; p=0.02). PVT Yerdel III/IV classification exhibited worse 1-year [2.04 (1.21-3.42); p=0.007] and 5-year [0.98 (0.59-1.62); p=0.93] patient survival. Thrombectomy with primary anastomosis was associated with better outcomes.
LT in patients with non-tumoral PVT demands more surgical time, needs more intraoperative transfusion, and presents worse 1- and 5-year patient survival. Total occlusive PVT and Yerdel III/IV PVT classification were associated with higher mortality. (PROSPERO, registration number: CRD42020132915).
Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation
2019, Journal of Hepatology
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry
2016, Clinics and Research in Hepatology and Gastroenterology
Citation Excerpt :
According to the severity and range of PVT, removing thrombus, portal vein intima denudation, vascular bypass, and inferior vena caval portal hemitransposition can be chosen for reconstruction of the portal vein during LT [13–18]. Although the majority of articles have reported that there is a similar prognosis between patients with and without PVT [7,19], a number of articles also indicate that there is a significantly increased incidence of postoperative complications in patients with PVT, particularly in patients with diffuse PVT [4,10,12]. At present, LT for patients with diffuse PVT remains a formidable technical challenge [20].
Portal vein thrombosis (PVT) is a common complication in patients with liver cirrhosis. During liver transplantation (LT), PVT may complicate the procedure and lead to a poor prognosis. The aim of this study is to evaluate patients enrolled in the China Liver Transplant Registry, to understand the influence of PVT to the LT recipients.
We collected data from patients who underwent LT and were entered into the China Liver Transplant Registry. All data of medical records and follow-up were retrospectively reviewed. The preoperative condition, duration of surgery, intraoperative blood loss, postoperative early and late PVT, and survival rates were compared between patients with PVT and those without PVT. Multivariate Cox analysis and survival analysis were used to determine the influence of PVT.
A total of 20,524 cases were recruited into the study. In all, 1810 (8.82%) patients were diagnosed with preoperative PVT of various severities. All patients were followed up for an average of 30.25 ± 33.25 months (up to a maximum of 171.68 months). Patients with PVT had a significantly longer operating time, more intraoperative blood loss and a higher rate of post-LT PVT (P < 0.001). Multivariate Cox analysis showed that PVT did not reduce the recipients’ survival rate (HR = 0.89, 95% CI: 0.774–1.024, P = 0.103). There was no significant difference in cumulative survival rate (P = 0.059) between patients without PVT, and patients with PVT.
PVT increases the difficulty of LT, but doesn’t reduce the survival rate. Therefore, PVT is not an absolute contraindication for LT in experienced transplantation centers.
Portal vein thrombosis in cirrhosis
2014, Journal of Clinical and Experimental Hepatology
Portal vein thrombosis (PVT) is being increasingly recognized in patients with advanced cirrhosis and in those undergoing liver transplantation. Reduced flow in the portal vein is probably responsible for clotting in the spleno-porto-mesenteric venous system. There is also increasing evidence that hypercoagulability occurs in advanced liver disease and contributes to the risk of PVT. Ultrasound based studies have reported a prevalence of PVT in 10–25% of cirrhotic patients without hepatocellular carcinoma. Partial thrombosis of the portal vein is more common and may not have pathophysiological consequences. However, there is high risk of progression of partial PVT to complete PVT that may cause exacerbation of portal hypertension and progression of liver insufficiency. It is thus, essential to accurately diagnose and stage PVT in patients waiting for transplantation and consider anticoagulation therapy. Therapy with low molecular weight heparin and vitamin K antagonists has been shown to achieve complete and partial recanalization in 33–45% and 15–35% of cases respectively. There are however, no guidelines to help determine the dose and therapeutic efficacy of anticoagulation in patients with cirrhosis. Anticoagulation therapy related bleeding is the most feared complication but it appears that the risk of variceal bleeding is more likely to be dependent on portal pressure rather than solely related to coagulation status. TIPS has also been reported to restore patency of the portal vein. Patients with complete PVT currently do not form an absolute contraindication for liver transplantation. Thrombectomy or thromboendovenectomy is possible in more than 75% of patients followed by anatomical end-to-end portal anastomosis. When patency of the portal vein and/or superior mesenteric vein is not achieved, only non-anatomical techniques (reno-portal anastomosis or cavo-portal hemitransposition) can be performed. These techniques, which do not fully reverse portal hypertension, are associated with higher morbidity and mortality risks in the short term.
Portal vein thrombosis and liver transplantation: Implications for waiting list period, surgical approach, early and late follow-up
2014, Transplantation Reviews
Citation Excerpt :
PVT recurrence is not an uncommon event in the large part of series, ranging from 36% [10] of pioneering experiences to 2–3% of some recent ones [18,26,36]. Re-thrombosis occurs especially in the early post-operative period (Table 2) [1,2,7,10,11,14–18,21–24,26,28–32,37,38,42]. The reported in-hospital post-LT mortality is heterogeneous; one study reports a worse outcome for patients with PVT respect to those without [42] and in another series [33] patients with complete PVT had a higher in-hospital mortality than those with partial PVT. Nevertheless, two recent large studies [27,29] did not find significant differences between patients with or without PVT.
Portal vein thrombosis (PVT) is a well-known and relatively common complication of liver cirrhosis. In the past, PVT was considered as a contraindication for liver transplantation (LT). To characterize prevalence, risk factors, perioperative management and outcome of PVT in the setting of LT, the English literature published between 1991 and 2011 was reviewed.
Of 6807 articles, 280 were selected, and 39 experiences were analyzed in detail (methodology, type and duration of treatments, peri-operative management, strategy to avoid recurrence, strengths and weaknesses, Oxford evidence level, citations). 3/39 studies were prospective; 9/39 were based on prospectively recorded databases; no studies of 1, 2a, 3a level of evidence were present; 5/39 were recognized as level 2b, 23/39 as level 3b, and 8/39 as level 4.
High complication rate has been reported with consequent effect on graft and patient survival. Overall, PVT presents today good results similar to those obtained in patients without PVT undergoing LT even if they require a higher transfusion number and a longer ICU/hospital stay.
Reported cases were retrospectively stratified according to Yerdel classification. Grade 1–2 patients (76%) do well with eversion thromboendovenectomy, resection of damaged vein and porto-portal anastomosis. Results of patients with grade 3–4 (24%) are inferior, however data on outcome in this subsets are fragmented and do not allow a reliable analysis. Moreover, results obtained in grade 3–4 cases are better in transplant centers with large specific experience. The small number of reports suggests caution.
The role of anticoagulant treatment is still debated. Although in cirrhotics with PVT LT remains a demanding procedure, PVT should not be considered a contraindication anymore.

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Liver anesthesiaThe Recipient With Portal Thrombosis and/or Previous Surgery

Abstract

Introduction

Materials and methods

Results

Conclusions

Section snippets

Portal Vein Thrombosis

Recipients With Previous Surgery

Epidemiology

Results

Discussion

Hepatobiliary Pancreat Dis Int

AJG

Transplant Proc

Liver Transpl

Transplant Proc

Transplant Proc

Liver transplantation in patients with portal vein thrombosis and central portocaval shunts

Ann Surg

Liver anesthesia
The Recipient With Portal Thrombosis and/or Previous Surgery