Endovascular Recanalization of a Thrombosed Portocaval Hemitransposition Graft in a Liver Transplant Recipient

Abstract

Portal vein thrombosis was historically considered a contraindication for liver transplantation. However, recent technical advancements have enabled surgeons to manage this complication through various innovative approaches. One such technique is portocaval hemitransposition, particularly applicable in cases of extensive porto-splanchnic thrombosis. This procedure involves utilizing the recipient's inferior vena cava to perfuse the portal vein of the liver graft. We report a case of acute thrombosis of a portocaval hemitransposition graft that was successfully managed with catheter-directed thrombolysis, angioplasty, and stent placement.

 

MissingLinkText

Keywords

portocaval hemitransposition - portal vein thrombosis - liver transplantation

Introduction

Portal vein thrombosis has long been regarded as a significant challenge in liver transplantation, historically considered a relative or absolute contraindication due to technical difficulties and the risk of poor graft perfusion. However, with advancements in surgical and endovascular techniques, innovative strategies have emerged to overcome these challenges. One such approach is portocaval hemitransposition, a technique particularly valuable in patients with extensive porto-splanchnic thrombosis, wherein the recipient's inferior vena cava (IVC) is utilized to provide portal inflow to the liver graft. Despite its effectiveness, complications such as graft thrombosis may still arise, necessitating prompt and effective intervention.

 

MissingLinkText

Case Report

A 32-year-old male with liver cirrhosis (Model for End-Stage Liver Disease score: 24), secondary to advanced alveolar echinococcosis complicated by Budd–Chiari syndrome and extensive portomesenteric venous thrombosis, underwent right split-liver transplantation. Intraoperatively, the native portal vein was fibrosed, and no suitable mesenteric or variceal vessels were large enough for anastomosis. Consequently, portocaval hemitransposition was performed, involving an end-to-end anastomosis of the suprahepatic donor and recipient inferior vena cavae (IVCs), and an end-to-end anastomosis of the infrahepatic donor portal vein to the recipient's IVC ([Fig. 1]). The IVC was looped distal to the left renal vein and proximal to the right renal vein, and a cryopreserved vascular portal vein graft was used as an extension from the distal portion of the divided IVC.

Fig. 1 Diagrammatic representation of the portocaval hemitransposition graft.

On postoperative day 10, the patient developed mildly elevated liver enzymes and increased ascitic output. Doppler ultrasound revealed complete thrombosis of the portocaval hemitransposition graft, extending up to the IVC anastomosis along the right lateral wall. This was confirmed by computed tomography ([Fig. 2A, B]).

Fig. 2 (A) Axial CT of the abdomen (portovenous phase); (B) coronal image showing nonopacification of the portal vein (arrow). CT, computed tomography.

Endovascular recanalization was attempted via a right femoral venous approach. Angiography demonstrated near-complete thrombotic occlusion of the hemitransposition graft, with only a thin streak of contrast visible within the portal vein graft ([Fig. 3A]). Balloon dilatation and thrombus maceration were performed using a 10 mm × 40 mm balloon catheter (35LP Low Profile; Cook Medical), followed by mechanical thrombectomy with the AngioJet Thrombectomy System ([Fig. 3B]). A loading dose of alteplase (0.1 mg/kg; total dose: 5 mg) was administered, followed by catheter-directed continuous thrombolysis at 0.25 mg/h for 12 hours. Partial recanalization was achieved. Subsequently, portal vein stenting was performed using a 10 mm × 100 mm self-expanding bare metal stent (Luminex; Bard Peripheral Vascular). Final angiography demonstrated complete graft recanalization with satisfactory intrahepatic portal flow ([Fig. 3C]).

Fig. 3 (A) Fluoroscopic angiographic image showing a thin streak of contrast along the thrombosed graft (small arrow) and the IVC end of the graft (large arrow). (B) Balloon dilatation of the thrombosed graft (arrow). (C) Digital subtraction angiography showing a patent stent (small arrow) and opacification of intrahepatic portal vein branches with opacified infrahepatic IVC (large arrow). IVC, inferior vena cava.

Anticoagulation therapy with apixaban (Eliquis) 5 mg twice daily was initiated. The patient's clinical condition improved, with stabilization of liver enzymes and resolution of ascites over the following week. He remains on follow-up for the next 3 months, with Doppler imaging showing adequate portal flow.

 

MissingLinkText

Discussion

Although portal vein thrombosis was previously considered a contraindication for liver transplantation, several techniques have since been developed to address this challenge. These include portal vein thrombectomy (with or without venous interposition grafting), rearterialization of the portal vein, renoportal anastomosis, and multivisceral transplantation—each with its own technical limitations and risks.[1]

Cavoportal hemitransposition[2] is regarded as a salvage procedure in cases of diffuse portal and splanchnic vein thrombosis when conventional techniques are unfeasible. This technique uses the recipient's IVC to perfuse the graft's portal vein. However, it is associated with complications such as persistent portal hypertension, variceal bleeding, and an increased risk of delayed thrombosis involving the portal vein, IVC, or lower extremities.[3]

Posttransplant portal vein thrombosis is typically managed with anticoagulation. In refractory cases, percutaneous thrombolysis—with or without stent placement—is considered, often via transhepatic, transsplenic, or transjugular access. The etiology of postoperative graft thrombosis is usually due to an underlying hypercoagulable state (the hypercoagulable workup was negative in our case), outflow obstruction (hepatic venous outflow was normal), or a low-flow state (likely in this case). Here, the hemitransposition graft was accessed via the femoral vein, offering a minimally invasive alternative for managing cavoportal anastomotic complications that might otherwise require complex surgical revision or retransplantation.[4]

 

MissingLinkText

Conclusion

Portocaval hemitransposition offers a viable option for selected patients with extensive portomesenteric thrombosis—those for whom liver transplantation was once considered unfeasible, and in whom other options for portal revascularization have failed. Due to its unique anatomy, postoperative graft thrombosis can be effectively assessed and treated via a femoral venous approach, thereby avoiding more invasive transhepatic or transjugular methods.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

None declared.

• References

• 1 Selvaggi G, Weppler D, Nishida S. et al. Ten-year experience in porto-caval hemitransposition for liver transplantation in the presence of portal vein thrombosis. Am J Transplant 2007; 7 (02) 454-460
• 2 Olausson M, Norrby J, Mjornstedt L, Liden H, Friman S. Liver transplantation using cavoportal hemitransposition—a life-saving procedure in the presence of extensive portal vein thrombosis. Transplant Proc 2001; 33: 1329-1330
• 3 Gerunda GE, Merenda R, Neri D. et al. Cavoportal hemitransposition: a successful way to overcome the problem of total portosplenomesenteric thrombosis in liver transplantation. Liver Transpl 2002; 8 (01) 72-75
• 4 Haider HH, Froud T, Moon J. et al. Successful percutaneous pulse spray thrombolysis of extensive acute portocaval hemitransposition thrombosis. Transpl Int 2006; 19 (11) 941-944

Publication History

Article published online:
29 July 2025