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Objective To analyze three-dimensional imaging characteristics and advantages for severe portal vein stenosis after liver transplantation, and to evaluate clinical efficacy of portal vein stent implantation. Methods Clinical data of 10 patients who received portal vein stent implantation for severe portal vein stenosis after liver transplantation were retrospectively analyzed. Imaging characteristics of severe portal vein stenosis, and advantages of three-dimensional reconstruction imaging and interventional treatment efficacy for severe portal vein stenosis were analyzed. Results Among 10 patients, 3 cases were diagnosed with centripetal stenosis, tortuosity angulation-induced stenosis in 2 cases, compression-induced stenosis in 2 cases, long-segment stenosis and/or vascular occlusion in 3 cases. Three-dimensional reconstruction images possessed advantages in accurate identification of stenosis, identification of stenosis types and measurement of stenosis length. All patients were successfully implanted with portal vein stents. After stent implantation, the diameter of the minimum diameter of portal vein was increased [(6.2±0.9) mm vs. (2.6±1.7) mm, P<0.05], the flow velocity at anastomotic site was decreased [(57±19) cm/s vs. (128±27) cm/s, P<0.05], and the flow velocity at the portal vein adjacent to the liver was increased [(41±6) cm/s vs. (18±6) cm/s, P<0.05]. One patient suffered from intrahepatic hematoma caused by interventional puncture, which was mitigated after conservative observation and treatment. The remaining patients did not experience relevant complications. Conclusions Three-dimensional visualization technique may visually display the location, characteristics and severity of stenosis, which is beneficial for clinicians to make treatment decisions and assist interventional procedures. Timely implantation of portal vein stent may effectively reverse pathological process and improve portal vein blood flow.
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Objective To investigate the diagnosis and treatment strategy of the portal vein complications in children undergoing split liver transplantation. Methods The clinical data of 88 pediatric recipients who underwent split liver transplantation were retrospectively analyzed. Intraoperative anastomosis at the bifurcating site of the portal vein or donor iliac vein bypass anastomosis was performed depending on the internal diameter and development of the recipient's portal vein. A normalized portal venous blood stream monitoring was performed during the perioperative stage. After operation, heparin sodium was used to bridge warfarin for anticoagulation therapy. After portal vein stenosis or thrombosis was identified with enhanced CT or portography, managements including embolectomy, systemic anticoagulation, interventional thrombus removal, balloon dilatation and/or stenting were performed. Results Among the 88 recipients, a total of 10 children were diagnosed with portal vein complications, of which 4 cases were diagnosed with portal vein stenosis at 1 d, 2 months, 8 months, and 11 months after surgery, and 6 cases were diagnosed with portal vein thrombosis at intraoperative, 2 d, 3 d (n=2), 6 d, and 11 months after surgery, respectively. One patient with portal vein stenosis and one patient with portal vein thrombosis died perioperatively. The fatality related to portal vein complications was 2% (2/88). Of the remaining 8 patients, 1 underwent systemic anticoagulation, 2 underwent portal venous embolectomy, 1 underwent interventional balloon dilatation, and 4 underwent interventional balloon dilatation plus stenting. No portal venous related symptoms were detected during postoperative long term follow up, and the retested portal venous blood stream parameters were normal. Conclusions The normalized intra- and post-operative portal venous blood stream monitoring is a useful tool for the early detection of portal vein complications, the early utilization of useful managements such as intraoperative portal venous embolectomy, interventional balloon dilatation and stenting may effectively treat the portal vein complications, thus minimizing the portal vein complication related graft loss and recipient death.
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Objective:To investigate the correlation between Doppler ultrasound parameters and pressure gradient of portal vein in pediatric liver transplant patients, and to analyze the diagnostic value of Doppler ultrasound for portal vein stenosis.Methods:This retrospective study involved the data from 92 pediatric liver transplant patients in Tianjin First Central Hospital from June 2014 to September 2021, who underwent pressure gradient measurement. The collected ultrasonic parameters included the diameter and flow velocity of the native portal vein, the portal vein anastomosis, and the donor portal vein. The anastomotic stenosis rate=(the native portal vein diameter–the portal vein anastomosis diameter)/the native portal vein diameter, the velocity ratio=the portal vein anastomosis velocity /the native portal vein velocity, the velocity difference=the portal vein anastomosis velocity–the native portal vein velocity. According to the diagnostic standard of portal vein stenosis, pressure gradient more than 5 mmHg was the portal vein stenosis group, and the pressure gradient less than 5 mmHg was the non-stenosis group. The correlation and differences between ultrasonic parameters and pressure gradient were analyzed. ROC curve was used to evaluate the diagnostic efficiency of each parameter.Results:Firstly, there was a positive correlation between pressure gradient and the portal vein anastomosis velocity, the velocity difference and the velocity ratio ( r=0.521, 0.531, 0.417; all P<0.001). And there was a negative correlation between pressure gradient and the anastomotic diameter ( r=-0.284, P=0.004). Secondly, the portal vein anastomotic velocity, velocity difference and velocity ratio in stenosis group were significantly higher than those in non-stenosis group [135.5(111.0, 169.0)cm/s vs 103.7(72.9, 118.7)cm/s, (112.2±40.3)cm/s vs (67.9±30.5)cm/s, 5.56(3.73, 7.26) vs 3.85(2.78, 4.70); all P≤0.001]; Furthermore, by ROC curve analysis, the cut-off value, the area under the ROC curve, Jordan index, accuracy, sensitivity and specificity of each parameter for the diagnosis of portal vein stenosis were: the anastomotic velocity 124.5 cm/s, 0.814, 0.592, 80.0%, 65.5% and 93.7%; velocity ratio 5.67, 0.760, 0.488, 73.0%, 48.8% and 100%; velocity difference 107.25 cm/s, 0.797, 0.511, 76.0%, 51.9% and 100%. Conclusions:The anastomosis velocity, velocity difference and velocity ratio of portal vein in pediatric liver transplant patients are correlated with the pressure gradient, and there is higher accuracy and specificity of each parameter for diagnosing portal vein stenosis, but the sensitivity is slightly lower.
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Objective To investigate the ultrasonographic features and its diagnostic value in portal vein stenosis (PVS) after pediatric liver transplantation. Methods Clinical data of 84 pediatric recipients undergoing liver transplantation who were followed up by routine ultrasound were retrospectively analyzed. According to ultrasound and digital subtraction angiography (DSA) results, all recipients were divided into the normal group (n=57) and PVS group (n=27). The incidence of PVS was assessed by ultrasound. The measurement parameters consisted of diameter of portal vein anastomosis, flow velocity of portal vein anastomosis, hepatic artery velocity, resistance index (RI) of hepatic artery and maximum diameter of the spleen, etc. The ultrasound parameters were statistically compared between the PVS and normal groups. The diagnostic value of ultrasound parameters for PVS after pediatric liver transplantation was evaluated. Results The diameter of portal vein anastomosis in the normal group was significantly larger than that in the PVS group[(0.44±0.08) cm vs. (0.27±0.10) cm], and the flow velocity of portal vein anastomosis in normal group was significantly lower than in the PVS group[(43±12) cm/s vs. (119±58) cm/s] (both P < 0.001). The hepatic artery velocity, RI of hepatic artery and maximum diameter of the spleen did not significantly differ between two groups (all P > 0.05). The diameter of portal vein anastomosis for the optimal diagnosis of PVS in pediatric liver transplantation, pediatric liver transplantation from organ donation after citizen's death and living-related donor pediatric liver transplantation was 0.35 cm, 0.35 cm and 0.33 cm, respectively. The corresponding area under curve (AUC) was 0.906, 0.916 and 0.906, the sensitivity was 0.947, 0.951 and 0.938, and the specificity was 0.852, 0.833 and 0.889, respectively. The flow velocity of portal vein anastomosis for the optimal diagnosis of PVS was 62.7 cm/s, 69.6 cm/s and 61.2 cm/s. The AUC was 0.990, 0.993 and 1.000, the sensitivity was 1.000, 1.000 and 1.000, and the specificity was 0.930, 0.951 and 1.000. Conclusions Ultrasound features of the pediatric recipients with PVS after liver transplantation include the smaller diameter of portal vein anastomosis and faster anastomotic flow velocity, which possess high diagnostic value.
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Objective To summarize the experiences of diagnosing and treating portal vein stenosis (PVS) after pediatric liver transplantation from China donation after citizen 's death (CDCD) grafts .Methods Retrospective analysis was performed for 30 cases of pediatric CDCD liver transplantation recipients with PVS .The screening ,diagnosis ,treatment and prognosis of PVS were analyzed .Results Among 218 pediatric liver transplantation recipients with CDCD grafts ,PVS was diagnosed in 30 cases with an incidence rate of 13 .8％ (30/218) .The initial diagnosis of PVS ranged from 5 days to 27 months post-operation with a median age of 2 .9 months .Ultrasonography indicated that stenotic rate of anastomotic site diameter was (41 .28 ± 12 .93)％ and blood flow velocity ratio (358 .77 ± 117 .82)％ .Intervention examination showed average pressure gradient was (9 .06 ± 5 .34) mmHg between both sides of stenosis . All cases underwent percutaneous intrahepatic balloon dilatation .The recipients were followed up for a median follow-up time of 23(3-63) months .For three cases of restenosis ,percutaneous intrahepatic balloon dilatation was repeated .Two cases underwent stent implantation due to ineffective balloon dilation .After treatment ,the stenotic rate of anastomotic site diameter was (34 .69 ± 8 .82) and blood flow velocity ratio (61 .18 ± 63 .11)％ on ultrasound while the average pressure gradient was (1 .03 ± 0 .85) mmHg .Conclusions PVS is a common vascular complication after pediatric CDCD liver transplantation .Portal vein balloon dilation is both safe and efficacious .However ,some cases require repeated balloon dilation and stent implantation serves as the last option for intractable PVS .Color ultrasound is both convenient and effective for making a primary diagnosis and evaluating outcomes .
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Objective To summarize the experience of clinical diagnosis and treatment of portal vein stenosis after liver transplantation. Methods Clinical data of 18 patients presenting with portal vein stenosis after undergoing liver transplantation were retrospectively analyzed. The incidence, treatment and prognosis of portal vein stenosis were summarized. Results Seventeen patients had a medical history of liver cirrhosis before liver transplantation, 7 cases with a medical history of portal vein thrombosis and 8 cases with a medical history of devascularization or shunt with splenectomy. Three cases received the pediatric liver grafts. Eighteen patients suffered from portal vein stenosis from postoperative 23 d to 24 months with a median time of 2.2 months, which was detected by color Doppler ultrasound (CDU) and diagnosed by CT angiography (CTA) of the portal vein or interventional therapy. After the diagnosis was confirmed,all cases received anticoagulant treatment by warfarin. Five patients with portal hypertension underwent balloon dilatation,and one of them received endovascular stent implantation simultaneously. The remaining 13 patients received conservative therapy. After corresponding treatment, 9 cases were mitigated, 7 patients remained unchanged and 2 cases were aggravated. Conclusions For the recipients with a medical history of liver cirrhosis before liver transplantation, portal vein stenosis should be monitored by conventional CDU and diagnosed by CTA or interventional therapy after transplantation. Patients without clinical symptoms can receive conservative treatment. Those complicated with portal hypertension can undergo interventional therapy. Favorable clinical prognosis is obtained in most cases.
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Objective To observe the value of endovascular treatment of portal vein stenosis (PVS) after pediatric liver transplantation for biliary artesia.Methods The data of 14 children with PVS after liver transplantation for biliary atresia were retrospectively evaluated.All children were confirmed by portal vein angiography,and were treated with 1-2 times of percutaneous transluminal angioplasty with or without percutaneous transluminal stent angioplasty.The effect of endovascular interventional therapy in 14 children was analyzed.Results A total of 14 children received 23 times of endovascular interventional therapy.The technical success rate of the first treatment was 82.61％ (19/23).Ten children were treated with balloon dilatation,and stent angioplasty was performed in 4 children after balloon dilatation.These stents were not narrowed after implantation.There were no complications related to treatment in 14 cases.Conclusion Endovascular treatment for PVS after liver transplantation for biliary atresia is safe and effective.
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Objective To evaluate the medium and long-term therapeutic results of percutaneous transhepatic angioplasty for portal vein stenosis (PSV) following pediatric liver transplantation.Methods From Jan.2008 to Dec.2012,5 cases with PVS after pediatric liver transplantation received percutaneous transhepatic angioplasty.There were 3 male and 2 female cases ranging from 7 months to 8 year-old with the median age of 2 years and 10 months.The protopathy included 1 Carolis disease and 4 congenital biliary atresia.The therapeutic results were monitored by clinical follow-up and imaging examination.The clinical data,imaging examination and therapeutic results were analyzed.Results All interventions were performed successfully,and the treatment efficacy was 100％.One patient was diagnosed with earl-onset PVS at 0.5 month after liver transplantation.Four patients were diagnosed with late-onset PVS at 3-30 months after liver transplantation.The prestenotic portal venous average diameter was (2.3 ± 0.6) mm (1.2-3.0 mm),the degrees of stenosis were 70％-95％.The poststenotic portal venous average diameter was (9 ± 1) mm (8-10 mm) (t =32.560,P ＜ 0.05).The prestenotic portal venous average pressure gradient was (11.0 ± 3.2) mmHg (8-16 mmHg),and the poststenotic portal venous pressure gradient was(2.2 ± 1.5) mmHg(0-4.0 mmHg) (t =8.242,P ＜ 0.05).Postoperative follow-up was 10-66 months,the portal veins of all cases were patent,and patency rate was 100％.Conclusions Percutaneous transhepatic stent angioplasty is an effective and safe method for treatment of PVS following liver transplantation.Its medium and long-term patency rates are high.
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We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.
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Aged , Female , Humans , Middle Aged , Anemia , Constriction, Pathologic , Dilatation , Gastrointestinal Hemorrhage , Hemorrhage , Melena , Pancreaticoduodenectomy , Portal Vein , Portography , Stents , Varicose VeinsABSTRACT
PURPOSE: To overcome donor shortage, reduced-size liver transplantation, split-liver transplantation and partial liver transplantation from living donors for children are frequently used all over the world. Despite the difficulties of adequate volume reduction and the age difference between the donor and the recipent, all these techniques also share the problem of size mismatch between the vessels of the adult liver and those of the pediatric recipient. Portal vein reconstruction in a crucial factor for a successful transplantation because it allows blood flow to the liver graft, which ends the ischemic period for the graft, as well as the anhepatic period for the recipient. METHODS: In Group I (n=10, no growth factor), a partial liver of Sprague-Dawley(SD) rat was transplanted heterotopically, via microsurgical technique, to a SD rat with performing end-to-end portal vein anastomosis without applying growth factor to the suture of the portal vein. In Group II (n=10, 50-60% growth factor), a partial liver of a SD rat was transplanted heterotopically to a SD rat, via microsurgical technique, with applying growth factor to 50-60% of the diameter of the portal vein. In Group III (n=10, 80-100% growth factor), the portal vein was anastomosed, via microsurgical technique, with using growth factor to 80-100% of the diameter of the portal vein. RESULTS: In Group II, only one case has portal vein stenosis on the postoperative 14th day following portal vein anastomosis with growth factor. In Group I, 3 cases showed portal vein stenosis on the postoperative 7th day, and 5 cases showed portal vein thrombosis on the postoperative 14th day. In Group III, 6 cases died due to bleeding after declamping of the portal vein anastomosis with using 80-100% growth factor on the diameter and 1 case has portal vein thrombosis on the postoperative 14th day. CONCLUSION: Several surgical factors might have an important role in preventing vascular stenosis and thrombosis, and especially when transplanting a technical-variant liver graft like a reduced-size or split liver graft. To overcome the small caliber of the portal vein and the difference in caliber between the donor and recipient vessels, the growth-factor suture technique having 50-60% of one diameter might be helpful because it allows for expansion along the suture line and it also prevents a purse-string effect.
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Adult , Animals , Child , Humans , Rats , Constriction, Pathologic , Hemorrhage , Liver , Liver Transplantation , Living Donors , Portal Vein , Suture Techniques , Sutures , Thrombosis , Tissue Donors , TransplantsABSTRACT
OBJECTIVE: We wanted to valuate the mid-term therapeutic results of percutaneous transhepatic balloon angioplasty for portal vein stenosis after liver transplantation. MATERIALS AND METHODS: From May 1996 to Feb 2005, 420 patients underwent liver transplantation. Percutaneous transhepatic angioplasty of the portal vein was attempted in six patients. The patients presented with the clinical signs and symptoms of portal venous hypertension or they were identified by surveillance doppler ultrasonography. The preangioplasty and postangioplasty pressure gradients were recorded. The therapeutic results were monitored by the follow up of the clinical symptoms, the laboratory values, CT and ultrasonography. RESULTS: The overall technical success rate was 100%. The clinical success rate was 83% (5/6). A total of eight sessions of balloon angioplasty were performed in six patients. The mean pressure gradient decreased from 14.5 mmHg to 2.8 mmHg before and after treatment, respectively. The follow up periods ranged from three months to 64 months (mean period; 32 months). Portal venous patency was maintained in all six patients until the final follow up. Combined hepatic venous stenosis was seen in one patient who was treated with stent placement. One patient showed puncture tract bleeding, and this patient was treated with coil embolization of the right portal puncture tract via the left transhepatic portal venous approach. CONCLUSION: Percutaneous transhepatic balloon angioplasty is an effective treatment for the portal vein stenosis that occurs after liver transplantation, and our results showed good mid-term patency with using this technique.
Subject(s)
Middle Aged , Male , Infant , Humans , Female , Child , Adult , Vascular Patency , Ultrasonography, Doppler , Treatment Outcome , Tomography, X-Ray Computed , Postoperative Complications , Portal Vein/pathology , Liver Transplantation , Follow-Up Studies , Constriction, Pathologic , Angioplasty, BalloonABSTRACT
PURPOSE: We wanted to evaluate the MR imaging findings of portal biliopathy. MATERIALS AND METHODS: We retrospectively reviewed the MR imaging of twelve patients having biliary abnormalities and portal cavernoma. Two radiologists working in consensus analyzed the presence of extrahepatic portal vein obstruction, cavernous transformation, portosystemic collaterals and bile ducts abnormalities that included irregular contour, stricture, ductal dilatation, wall thickening and enhancement of the ductal wall. RESULTS: Extrahepatic portal vein obstruction was replaced by cavernous transformations in all patients. The cavernous transformations depicted on the MR scans were paracholedochal veins in 12 patients and epicholedochal veins in 6 patients. Three different types of biliary abnormalities were present: 1) the pseudocholangiocarcinoma type (3 patients) that resembled extrahepatic cholangiocarcinoma, 2) the varicoid type (6 patients) that was mainly distinguished by the multiple smooth extrinsic impressions along the common bile duct and 3) the mixed type (3 patients). The highly specific findings for the pseudocholangiocarcinoma type disease were thickening and delayed enhancement of the biliary ductal wall. CONCLUSION: The MR findings of portal biliopathy include cavernous transformation of the portal vein and morphological alterations of the biliary tracts such as irregular contour, biliary stricture with proximal ductal dilatation and thickening of the ductal wall with delayed enhancement. Recognition of these MR findings should facilitate the accurate diagnosis of portal biliopathy and prevent the misinterpretation or inappropriate management of this disease as malignancy or sclerosing chloangitis.