Portal vein (PV) thrombosis remains a challenging issue during liver transplantation, even with the acquisition of innovative surgical techniques and years of experience. Frequently, eversion thromboendovenectomy is initially performed, and depending on the extent of the thrombosis and intraoperative findings, further revascularization options include venous jump grafts, portocaval hemitransposition, renoportal anastomosis, and PV arterialization. Reports on these surgical approaches are limited, although the outcomes have been acceptable. We report a case of PV arterialization using an accessory right hepatic artery as an adjunct during an orthotopic liver transplant with 4 years of follow-up.
Portal vein thrombosis remains to be a challenging issue during liver transplantation even with the acquisition of innovative surgical techniques and years of experience. Most frequently, an initial eversion thromboendovenectomy is performed and depending on the extent of thrombosis and intraoperative findings, further revascularization options include venous jump grafts, portocaval hemitransposition, renoportal anastomosis or portal vein arterialization. Reports on these surgical approaches are limited although with acceptable outcomes. We present a 64-year-old patient with hepatitis C cirrhosis who underwent orthotopic liver transplantation with portal vein arterialization using an accessory right hepatic artery. Liver graft function has remained stable four years after transplant with notable aneurysmal dilatation of the portal vein. Liver Transpl 19:773–775, 2013. © 2013 AASLD.
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common bile duct
common hepatic artery
inferior vena cava
superior mesenteric artery
A 64-year-old male underwent orthotopic liver transplantation via the piggyback technique for decompensated cirrhosis secondary to hepatitis C in 2009. His significant past surgical history included a right hemicolectomy for colon cancer. Preoperative computed tomography showed complete portomesenteric vein thrombosis that extended to the confluence of the superior mesenteric and splenic veins. An end-to-end anastomosis was created for the PV reconstruction despite a marginal flow after eversion thromboendovenectomy and between the donor's celiac artery and the recipient's common hepatic artery (CHA) for the arterial reconstruction. PV arterialization was an option because there was an easily accessible accessory right hepatic artery originating from the superior mesenteric artery (SMA), which was then end-to-side anastomosed to the recipient's PV to augment the blood flow (Fig. 1). Intraoperative Doppler ultrasound revealed good waveforms with a cold ischemia time of 6.5 hours. Duct-to-duct biliary reconstruction was performed with internal stent placement.
The postoperative course was unremarkable, and the patient was discharged after 9 days. Liver enzyme levels were fluctuating up to 3 months after transplantation, but this was eventually resolved. The patient underwent endoscopic retrograde cholangiopancreatography with stenting a month after his surgery for a biliary stricture, and a liver biopsy sample at this time revealed evidence of recurrent hepatitis C. Surveillance Doppler ultrasonography consistently showed elevated velocities, increased pulsatility, and turbulent flow in the PV. Two years after transplantation, a follow-up computed tomography scan revealed aneurysmal dilatation of the PV (4.5 × 4.1 × 7.2 cm) and its intrahepatic branches (Fig. 2).
At the last follow-up (4 years after liver transplantation), the patient was doing well with good graft function and normal liver function tests. He also completed treatment for recurrent hepatitis C with an excellent response.
PV thrombosis used to be an absolute contraindication for liver transplantation. However, years of experience have led surgeons to acquire a number of surgical approaches to address the difficult issue of finding a pathological PV. Developed techniques include thromboendovenectomy, bypass, portocaval hemitransposition, renoportal anastomosis, combined liver–small bowel transplantation, and PV arterialization. Eversion thromboendovenectomy is almost always the initial maneuver for any degree of PV thrombosis; it has a reported success rate of 96% and a low risk for rethrombosis. Bypass using venous conduits, which also has a low rate of thrombosis, can be an option if there are divertible veins. However, it requires complex and extensive dissection, which is associated with high morbidity rates. Extra-anatomical reconstruction with portocaval hemitransposition and renoportal anastomosis are more challenging techniques with survival rates ranging from 60% to 74%.[3, 4] Common complications are ascites, portal thrombosis, renal dysfunction, and variceal bleeding. In addition to the overall morbid condition of our patient, marked inflammation and adhesions due to extensive vascular thrombosis and previous colon surgery precluded such complex procedures. We felt that PV arterialization was technically easier because of the presence of an accessory right hepatic artery. Some surgeons have also proposed combined liver-intestine transplantation, and there are limited reports of improved overall survival rates.
PV arterialization is a simple and effective method of augmenting portal inflow. It may involve the use of a donor iliac artery graft as a jump graft from the aorta or a donor splenic artery anastomosed to the PV. A disadvantage, however, is that it leaves the portal hypertension unchanged, and overarterialization of the liver can eventually lead to fibrosis. Bonnet et al. presented a patient who survived 6 years after PV arterialization, and they reported biliary leakage and cholangitis with a liver abscess as complications. Recent abdominal computed tomography also revealed aneurysmal dilatation of the PV and its intrahepatic branches. In addition, they presented 13 case reports of PV arterialization with various complications (most notably right-sided heart failure and portal hypertension). Their study also suggested that limiting the arterial inflow to the portal system through the creation of a surgical stenosis might contribute to long-term survival and prevent so-called overarterialization of the liver. In support of this concept, Ott et al. reported unfavorable outcomes for 2 patients who underwent PV arterialization with donor iliac artery grafts, and they attributed these outcomes to the lack of an artificial stenosis, which led to overarterialization.
To our knowledge, this is the first report of PV arterialization with an accessory right hepatic artery for augmenting portal inflow. The presence of this variant made the procedure simpler and easier. It provided the liver with sufficient blood flow, which was admixed with the limited hepatotrophic factors draining from the splanchnic bed. Although we did not create a surgical stenosis of the accessory right hepatic artery, it seems that the patient did not have evidence of right-sided heart failure, a biliary stricture, or stenosis as of the last follow-up. Reports of outcomes with this technique are limited. Moreover, proponents of surgically creating an arterial stenosis have provided various recommendations about what an ideal blood flow is. In this case, there were persistently increased velocities as high as 3.9 L/minute along the PV. However, the clinical significance of surgically creating an arterial stenosis or not as well as aneurysmal dilatation of the PV remains to be seen.
In conclusion, PV arterialization is a viable option for patients with extensive portomesenteric thrombosis, especially when portal revascularization has failed. Although our experience is limited to only a few cases, this procedure can be performed safely with acceptable long-term outcomes.