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Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis
Y. Fundora, AJ. Hessheimer, L. Del Prete, L. Maroni, J. Lanari, O. Barrios, M. Clarysse, M. Gastaca, M. Barrera Gómez, A. Bonadona, J. Janek, A. Boscà, JM. Álamo Martínez, G. Zozaya, D. López Garnica, P. Magistri, F. León, G. Magini, D. Patrono,...
Language English Country Netherlands
Document type Multicenter Study, Journal Article
- MeSH
- Ascites complications MeSH
- Esophageal and Gastric Varices * complications MeSH
- Gastrointestinal Hemorrhage MeSH
- End Stage Liver Disease * complications MeSH
- Middle Aged MeSH
- Humans MeSH
- Hypertension, Portal * complications surgery MeSH
- Severity of Illness Index MeSH
- Liver Transplantation * methods MeSH
- Portal Vein surgery MeSH
- Venous Thrombosis * etiology surgery MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
BACKGROUND & AIMS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS: Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.
Abdominal Transplant Surgery UZ Leuven KUL Leuven Belgium
Centrum Kardiovaskulární a Transplantační Chirurgie Brno Czechia
CIBERehd Instituto de Salud Carlos 3 Madrid Spain
Department of HPB and Liver Transplant Surgery St James's University Hospital Leeds UK
Department of Transplant Surgery F D Roosevelt Hospital Banská Bystrica Slovakia
European Liver and Intestine Transplant Association Board
General and Digestive Surgery Service Hospital Clínic Barcelona Spain
General and Digestive Surgery Service Hospital Universitario La Paz IdiPAZ Madrid Spain
Hepatobiliary Surgery and Transplant Unit Policlinico Sant'Orsola IRCCS University of Bologna Italy
Hôpitaux Universitaires de Genève Geneva Switzerland
Hospital Alemán Buenos Aires Argentina
Hospital Clínico Universitario de Zaragoza Zaragoza Spain
Hospital Regional Universitario de Málaga Málaga Spain
Hospital Universitario de Badajoz Universidad de Extremadura Badajoz Spain
Hospital Universitario Marqués de Valdecilla Santander Spain
Hospital Universitario Nuestra Señora de Candelaria Santa Cruz de Tenerife Spain
Hospital Universitario Ramón y Cajal Madrid Spain
Hospital Universitario Vall d'Hebrón Barcelona Spain
Hospital Universitario Virgen del Rocío Seville Spain
HPB and Liver Transplant Unit Clínica Universidad de Navarra
Institute of Health Research of Navarra Pamplona Spain
Medical University of Warsaw Warsaw Poland
Medipol University Hospital Center for Organ Transplantation Istanbul Turkey
Transplantation Center Department of General Surgery Cleveland Clinic Cleveland Ohio USA
University of Massachusetts Memorial Medical Center Worcester Massachusetts USA
University of Texas Houston Memorial Hermann TMC Houston Texas USA
References provided by Crossref.org
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- $a BACKGROUND & AIMS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS: An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS: A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS: Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS: Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.
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