Early Portal Vein Thrombosis after Living Donor Liver Transplant: Interventional Radiology May be the Answer

Background: Incidence of PVT is close to 4% in adult LDLT due to technical difficulties in PV reconstructions, mainly related to a shorter vessel pedicle and limited vessel graft. Most cases of PVT occur early (1 month from transplant) and the clinical presentation is severe acute liver insufficiency or graft failure. When it occurs late (more than 4 weeks) recurrence of portal hypertension is a dominant feature. Without treatment PVT is associated with poor survival. Therapeutic options for PVT range from systemic anticoagulation to interventional radiological (IR) treatment, to surgical revision to retransplantation. The IR options presented in the literature include thrombolysis, portal vein angioplasty, stent placement and shunt occlusion if present. The IR approach may be via percutaneous transhepatic (PT), via transjugular intrahepatic portosystemic shunt (TIPS) creation or transplenic approach. Method(s): A total of 430 liver transplants were done at our institution between February 2017 and December 2018. Five cases of early PVT were referred to us for IR treatment. The diagnosis was initially made on colour Doppler ultrasound and findings confirmed on contrast CT. Portal vein access was taken by ultrasound guided direct percutaneous trans-hepatic approach in all but 1 case where percutaneous trans-splenic approach was taken. Urokinase (1 to 5 lac units) were used for thrombolysis, in 2 cases overnight urokinase infusion was used at 50,000 units/h. Balloon dilatation was done with a 6 mm diameter balloon. Portal flow steal by a large shunt was present in 2 cases which were closed by coils and covered stent respectively. Result(s): With IR treatment spontaneous portal vein flow was re-established in all but 1 patient [Table 2]. Long term follow up is available in 2 patients (7 and 9 months respectively) and they are doing well and shows excellent portal flow. The patient in whom spontaneous portal flow could not be established (s. no 3) was taken for surgical re-exploration after his liver enzymes increased remarkably next day. The surgical re-exploration revealed HAT in addition to PVT. There were areas of liver necrosis on gross inspection. Hepatic artery flow was re-establised after thrombectomy. However only sluggish portal flow could be re-established. This patient expired 2 days later due to multi-organ failure. One patient (s. no. 1) had undergone surgical re-exploration for concomitant HAT and PVT one day before IR treatment. Another patient (s. no. 5) had surgical re-exploration for HAT on POD 1 and had HAT recurrence on POD 6. Hepatic artery thrombolysis was done successfully. However this patient had intracranial bleed on POD 8 likely due to thrombolysis and died of liver insufficiency and progressive neurological deterioration on POD 38. Conclusion(s): Evidence-based evaluation outcomes of surgical and IR techniques to manage PVT is made difficult by its low incidence, which has heretofore prevented the publication of prospective comparative trials and limited the publication of large, retrospective series. However, IR therapies promise to avoid the risks of re-do operations in select post-surgical patients, besides providing a fair idea of anatomic causes such as venous redundancy, kinking, stenosis, anastomotic size mismatch and presence of shunts. IR management may be safe in early PVT and can often identify the anatomical cause of the PVT and corrective measures can be taken which might lead to long term improved results. However more studies with larger sample size are required to establish the safety and outcome of this approach. Our experience suggests that IR treatment is feasible and safe in early PVT in LDLT patients with good outcomes in cases where concomitant HAT is not present.

Publication History

Article published online:
11 May 2021