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Article

PubMed

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Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

Journal of hepatology. 2023 Apr ; 78 (4) : 794-804. [epub] 20230121

J Hepatol
ISSN 1600-0641 | 0168-8278
Source

Language English Country Netherlands Media print-electronic

Document type Multicenter Study, Journal Article

Persistent link https://www.medvik.cz/link/pmid36690281

PubMed 36690281
DOI 10.1016/j.jhep.2023.01.007
PII: S0168-8278(23)00018-1
Knihovny.cz E-resources

Keywords
cavoportal anastomosis, cavoportal hemitransposition, liver transplantation, multivisceral transplantation, portal hypertension, portal vein thrombosis, renoportal anastomosis,
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; Liver Transplantation and Hepatology Laboratory Hepatology HPB Surgery and Transplant Unit Health Research Institute Hospital La Fe La Fe University Hospital Valencia Spain

Department of Hepato Biliary and Pancreatic Surgery and Liver Transplantation Hospital Universitari de Bellvitge Barcelona Spain

Department of HPB and Liver Transplant Surgery St James's University Hospital Leeds UK

Department of Surgery and Transplantation Hospital Clínico Universitario Virgen de la Arrixaca Murcian Institue of Biosanitary Research Murcia Spain

Department of Surgery Oncology and Gastroenterology Hepatobiliary and Liver Transplantation Unit Padua University Hospital Padua Italy

Department of Surgery Oncology and Gastroenterology Hepatobiliary and Liver Transplantation Unit Padua University Hospital Padua Italy; European Liver and Intestine Transplant Association Board

Department of Transplant Surgery F D Roosevelt Hospital Banská Bystrica Slovakia

Division of HPB and Transplant Surgery Department of Surgery Erasmus MC Transplant Institute University Medical Center Rotterdam Rotterdam the Netherlands; European Liver and Intestine Transplant Association Board

General and Digestive Surgery Service Hospital Clínic Barcelona Spain

General and Digestive Surgery Service Hospital Clínic Barcelona Spain; General and Digestive Surgery Service Hospital Universitario La Paz IdiPAZ Madrid Spain; CIBERehd Instituto de Salud Carlos 3 Madrid Spain