Trombose de veia porta no transplante hepático / Portal vein thrombosis in liver transplantation

INTRODUÇÃO: A trombose de veia porta foi considerada contraindicação ao transplante de fígado no passado em razão da elevada morbi-mortalidade. Diversos avanços permitiram melhora dos resultados. OBJETIVO: Revisão dos avanços e das estratégias cirúrgicas utilizadas para realização do transplante de fígado na vigência de trombose de veia porta. MÉTODO: Revisão da literatura nas bases de dados Medline, Scielo, Lilacs cruzando os descritores: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Foram estudados a epidemiologia, fatores de risco, classificação, diagnóstico, estratégias cirúrgicas e resultados. CONCLUSÃO: A trombose de veia porta deixou de ser contraindicação para o transplante hepático. O cirurgião dispõe atualmente de uma série de estratégias para realização do transplante, variando conforme o grau da trombose. Apesar de implicar em maior morbidade e taxas de re-trombose, os resultados do transplante na presença de trombose portal são semelhantes aos observados nas séries habituais.

BACKGROUND: Portal vein thrombosis was considered a contraindication for liver transplantation in the past because of the high morbidity and mortality rates. Many advances made the results better. AIM: Review the advances and surgical strategies for liver transplantation in presence of portal vein thrombosis. METHOD: Survey of publications in Medline, Scielo and Lilacs databases. Headings crossed: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Data analyzed were epidemiology, risk factors, classification, diagnosis, surgical strategies and outcomes. CONCLUSION: Portal vein thrombosis is not a contraindication for liver transplantation anymore. There are many strategies to perform the liver transplantation in this condition, depending on portal vein thrombosis grade. Regardless higher morbidity and re-trhombosis rates, the outcomes of liver transplantation in portal vein thrombosis are similar to series without portal vein thrombosis.

Clinical Outcome of Preoperative Portal Vein Thrombosis in Living Donor Liver Transplantation / 대한이식학회지

PURPOSE: Portal vein thrombosis (PVT), which once had been considered a relative contraindication for living donor liver transplantation (LDLT), is no longer contraindication of LDLT owing to technical achievement but could be remained as one of risk factor affecting patients. The aim of the present study was to improving outcomes of LDLT of patients with PVT by analyzing patients with PVT. METHODS: Between January 2000 and May 2006, 246 cases of LDLT in adult using right lobe were performed. The presence of PVT was preoperatively evaluated by CT and/or MR angiography. The patients were subdivided according to presence and characteristics of PVT; No PVT (n=196; 79.7%), Partial PVT (n=39; 15.9%) and Total PVT (n=11; 4.4%) and characteristics of each group were analyzed. RESULTS: Preoperatively, only the incidence of variceal bleeding was significantly higher in patients with PVT (P<05). Intraoperatively, larger amounts of transfused RBC were needed in PVT group and postoperatively, there were prolonged stay in ICU and higher incidence of hemorrhagic complications in PVT group. Portal inflow was reestablished by thrombectomy and end-to-end anastomosis without vessel graft in 97.4%(38/39) of partial PVT and in 54.5%(6/11) of total PVT. Cryopreserved veins were used as interposition (n=1) or jump (n=4) grafts and an autologous iliac vein was used as a jump graft (n=1). Of 5 cases of jump grafts, 2 cases were anastomosed to coronary vein, and 3 cases to superior mesenteric vein. The patency rate using vessel grafts was 83.3%(5/6) and overall patency rate including thrombectomy cases was 98.0%(39/40). CONCLUSION: Regardless of operative methods and materials, higher patency rate of portal vein could be achieved so that operation of patients with PVT could be undertaken safely without increased mortality.

A Case of Liver Transplantation using a Jump Graft in a Patient with Portal Vein Thrombosis and Postoperative Chylous Ascites

Venous anomalies, including portal vein thrombosis (PVT) and prior portosystemic shunts, are not uncommon in orthotopic liver transplantation (OLT) and require vascular reconstruction. PVT has been considered as a contraindication to OLT because of surgical complexity and increased postoperative morbidity and mortailty rates. Postoperative chylous ascites occur following disruption of abdominal lymphatics after retroperitoneal dissection. Chyloperitoeum after OLT is very rare. We report a case of piggyback OLT in a cirrhotic patient with portal vein thrombosis. A thromboendarterectomy was attempted first, and a venous jump graft was required between the donor portal vein and the infrapancreatic superior mesenteric vein. An aortic conduit was used for the hepatic arterial reconstruction. Retroperitoneal dissection was inevitable. Chylous ascites developed after the operation and were managed successfully with a low-at diet. In conclusion, we suggest that the presence of PVT is not a contraindication for OLT. Chylous ascites are rare after OLT, and the treatment of choice is a conservative one based on diet control.