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Portal Vein Inflow From Enlarged Coronary Vein in Liver Transplantation
Portal Vein Inflow From Enlarged Coronary Vein in Liver Transplantation Surgical Approach and Technical Tips: A Case Report M. Safwan, S. Nagai*, and M.S. Abouljoud Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI
ABSTRACT Portal vein thrombosis is common in patients with end-stage liver disease, with an incidence as high as 26% in liver transplant candidates. It is known to be associated with a high risk of morbidity and mortality posttransplantation, and its management can be challenging. The management options range from a simple thrombendvenectomy to multivisceral transplantation in cases with diffuse portomesenteric thrombosis. We report a case of liver transplantation in which we performed a rare reconstruction of the portal vein. Briefly, the patient had diffuse portomesenteric thrombosis, calcified aneurysmosis, and a large collateral coronary vein, to which we directly anastomosed the donor portal vein in an end-to-side fashion. This report describes a unique surgical approach for similar cases of severe portal vein thrombosis in liver transplant candidates.
P
CASE REPORT
shunts. The enlarged coronary vein originated at the confluence of the SMV and splenic vein and was widely patent and clear from any thrombus. Based on imaging studies, the coronary vein seemed to account for most mesenteric-portal venous drainage and was of adequate size and quality for portal venous inflow during transplantation. Intraoperatively, an enlarged and prominent coronary vein was found in the lesser sac along the lesser stomach curvature. The vein had a good thrill and was ballotable without evidence of thrombosis or phlebitis. Hepatectomy was performed, with no complications. As suspected, the portal vein had chronic occlusive thrombus with calcifications and no flow. A portal vein thrombendvenectomy was performed. Even with the thrombus removed down to the splenic confluence, adequate portal flow could not be established. In addition, the SMV was not suitable for a vein jump graft. Hence, a decision was made to use the enlarged collateral coronary vein as portal inflow. The coronary vein wall was very thin, risking easy tearing and difficulty with suturing. We therefore decided to incorporate the overlying
The patient was a 58-year-old man who presented with a history of end-stage liver disease due to chronic alcohol consumption and chronic hepatitis C infection. On evaluation, his imaging showed a chronic occlusion of the main portal vein and superior mesenteric vein (SMV), calcified aneurysmosis with marked portosystemic collaterals, and gastroesophageal and splenic varices, including an enlarged coronary vein (Fig 1); there were no obvious splenorenal
The first two authors contributed equally to this work. *Address correspondence to Shunji Nagai, MD, PhD, Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, 2799 W. Gland Blvd, CFP-2, Detroit, MI 48202. E-mail: [email protected]
ORTAL vein thrombosis is a common entity seen in patients with end-stage liver disease, with studies reporting incidences as high as 26% in liver transplant candidates [1]. Management options may range from a simple thrombendvenectomy to multivisceral transplantation in cases with diffuse portomesenteric thrombosis. We report a case of liver transplantation in which we performed a rare reconstruction of the portal vein. Briefly, the patient had diffuse portomesenteric thrombosis, calcified aneurysmosis, and a large collateral coronary vein, to which we directly anastomosed the donor portal vein in an end-to-side fashion. The present report demonstrates this unique surgical approach for similar cases of severe portal vein thrombosis in liver transplant candidates.
0041-1345/16 http://dx.doi.org/10.1016/j.transproceed.2016.05.001
3070
ª 2016 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 48, 3070e3072 (2016)
PORTAL VEIN INFLOW FROM ENLARGED CORONARY VEIN
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Fig 1. Preoperative (A) coronal and (B) transverse views of the abdomen showing chronic occlusion of the main portal vein (arrow) with marked portosystemic collaterals, including an enlarged coronary vein (arrow).
serosal tissue within the anastomotic suture line. The coronary vein was side-clamped with the adjacent peritoneum, and a 12-mm longitudinal venotomy was made. The donor portal vein had sufficient length and was appropriately trimmed. The anastomosis was performed with the use of running 6-0 polypropylene sutures in an end-to-side fashion (Fig 2). After unclamping, reperfusion was uneventful, the liver was very well perfused, and the portal vein flow measured at 4 L/min (Transonic Systems, Ithaca, NY, United States). On postoperative day 1, a liver Doppler ultrasound study was performed and revealed good portal flow (Fig 3A). The velocity was 30 to 40 cm/s at the main portal vein, which is comparable to other liver transplant patients with conventional portal vein reconstruction. The patient was started on aspirin on postoperative day 2 (per protocol). A computed tomography scan of the abdomen performed at 1 week showed patency of the portal vein supporting adequate flow from the enlarged coronary vein
Fig 2. Portal vein reconstruction to the enlarged coronary vein.
(Fig 3B). Chronic thrombus in the splenic confluence was also seen, but it did not progress or compromise flow through the coronary vein anastomosis. Imaging studies repeated at 1 and 3 months revealed good flow through the portal vein with stable chronic thrombus without extension into the coronary vein anastomosis (Fig 3C).
DISCUSSION
Various reports have been published regarding liver transplantation in patients with portal vein thrombosis and their classification based on thrombosis extension. The Yerdel classification is the most widely used because it correlates thrombosis extension with intraoperative management [2]. In patients with diffuse portal vein thrombosis, as seen in grades III and IV (Table 1), complex vascular reconstruction techniques may be required. Portal vein anastomosis to an enlarged splanchnic tributary (coronary or choledochal vein) if available would be a preferred option compared with jump graft techniques. The shorter length of the portal vein to a coronary vein and the anatomical lie can potentially reduce the risks for torsion or kinking; technically, this approach would also be straightforward. This technique was initially described by Hiatt et al [3] and Lerut et al [4]. In their experience, virtually any large collateral (2 cm in diameter) may be sufficient to supply portal flow to the graft (usually a pericholedochal varix or a coronary vein). Although this technique was known to be one of the options in situations of severe portal vein thrombosis, details of the surgical techniques are not well documented in the literature inclusive of the thought process [5]. We suggest the following surgical tips when considering this technique: (1) before transplantation, develop a good understanding of portomesenteric flow and collateral patterns from preoperative imaging; (2) test the flow source before transplantation, to ensure that there is adequate inflow; (3) the length of donor portal vein is
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Fig 3. (A) Postoperative day 1 Doppler study showing good portal flow to the liver. Postoperative (B) day 7 and (C) day 60 computed tomography studies showing patency of flow through the portal vein from an enlarged coronary vein with resolving thrombus (arrows). Abbreviation: MPV, main portal vein.
Table 1. Classification of Portal Vein Thrombosis (Yerdel Classification [2]) Grade
I II III IV
Description
Partial thrombosis of MPV (<50% occlusion) Near-total to complete thrombosis of MPV (>50% occlusion) Complete thrombosis of MPV with extension into proximal SMV (distal SMV not involved) Complete thrombosis of MPV with extension into proximal and distal SMV Abbreviations: MPV, main portal vein; SMV, superior mesenteric vein.
usually long enough, whereas an interposition graft may be required in some cases; (4) care should be taken to account for the anatomical lie of the portal vein to avoid kinking and/or torsion; (5) attention to detail is critical when suturing these enlarged and ectatic variceal structures to the donor portal vein because they tear easily and may not handle sutures well; and (6) the portal vein flow must be measured to assure adequacy and assess need for additional maneuvers. This is the second such procedure we performed using similar techniques. In our experience, we did not attempt to extensively dissect and isolate the coronary vein wall but rather incorporated adjacent
serosal tissue to reinforce the anastomosis to prevent the wall from tearing. Long-term, full-dose aspirin therapy was planned for this patient because of the residual thrombus and the nonanatomic nature of the anastomosis.
REFERENCES [1] Ponziani FR, Zocco MA, Senzolo M, Pompili M, Gasbarrini A, Avolio AW. Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up. Transplant Rev (Orlando) 2014;28: 92e101. [2] Yerdel MA, Gunson B, Mirza D, Karayalcin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation 2000;69:1873e81. [3] Hiatt JR, Quinones-Baldrich WJ, Ramming KP, Lois JF, Busuttil RW. Bile duct varices. An alternative to portoportal anastomosis in liver transplantation. Transplantation 1986;42:85. [4] Lerut J, Tzakis AG, Bron K, Gordon RD, Iwatsuki S, Esquivel CO, et al. Complications of venous reconstruction in human orthotopic liver transplantation. Ann Surg 1987;205(4): 404e14. [5] Wang Z, Yang L. Gastric coronary vein to portal vein reconstruction in liver transplant: case report. Exp Clin Transplant 2014;12:562e4.
ABSTRACT Portal vein thrombosis is common in patients with end-stage liver disease, with an incidence as high as 26% in liver transplant candidates. It is known to be associated with a high risk of morbidity and mortality posttransplantation, and its management can be challenging. The management options range from a simple thrombendvenectomy to multivisceral transplantation in cases with diffuse portomesenteric thrombosis. We report a case of liver transplantation in which we performed a rare reconstruction of the portal vein. Briefly, the patient had diffuse portomesenteric thrombosis, calcified aneurysmosis, and a large collateral coronary vein, to which we directly anastomosed the donor portal vein in an end-to-side fashion. This report describes a unique surgical approach for similar cases of severe portal vein thrombosis in liver transplant candidates.
P
CASE REPORT
shunts. The enlarged coronary vein originated at the confluence of the SMV and splenic vein and was widely patent and clear from any thrombus. Based on imaging studies, the coronary vein seemed to account for most mesenteric-portal venous drainage and was of adequate size and quality for portal venous inflow during transplantation. Intraoperatively, an enlarged and prominent coronary vein was found in the lesser sac along the lesser stomach curvature. The vein had a good thrill and was ballotable without evidence of thrombosis or phlebitis. Hepatectomy was performed, with no complications. As suspected, the portal vein had chronic occlusive thrombus with calcifications and no flow. A portal vein thrombendvenectomy was performed. Even with the thrombus removed down to the splenic confluence, adequate portal flow could not be established. In addition, the SMV was not suitable for a vein jump graft. Hence, a decision was made to use the enlarged collateral coronary vein as portal inflow. The coronary vein wall was very thin, risking easy tearing and difficulty with suturing. We therefore decided to incorporate the overlying
The patient was a 58-year-old man who presented with a history of end-stage liver disease due to chronic alcohol consumption and chronic hepatitis C infection. On evaluation, his imaging showed a chronic occlusion of the main portal vein and superior mesenteric vein (SMV), calcified aneurysmosis with marked portosystemic collaterals, and gastroesophageal and splenic varices, including an enlarged coronary vein (Fig 1); there were no obvious splenorenal
The first two authors contributed equally to this work. *Address correspondence to Shunji Nagai, MD, PhD, Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, 2799 W. Gland Blvd, CFP-2, Detroit, MI 48202. E-mail: [email protected]
ORTAL vein thrombosis is a common entity seen in patients with end-stage liver disease, with studies reporting incidences as high as 26% in liver transplant candidates [1]. Management options may range from a simple thrombendvenectomy to multivisceral transplantation in cases with diffuse portomesenteric thrombosis. We report a case of liver transplantation in which we performed a rare reconstruction of the portal vein. Briefly, the patient had diffuse portomesenteric thrombosis, calcified aneurysmosis, and a large collateral coronary vein, to which we directly anastomosed the donor portal vein in an end-to-side fashion. The present report demonstrates this unique surgical approach for similar cases of severe portal vein thrombosis in liver transplant candidates.
0041-1345/16 http://dx.doi.org/10.1016/j.transproceed.2016.05.001
3070
ª 2016 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 48, 3070e3072 (2016)
PORTAL VEIN INFLOW FROM ENLARGED CORONARY VEIN
3071
Fig 1. Preoperative (A) coronal and (B) transverse views of the abdomen showing chronic occlusion of the main portal vein (arrow) with marked portosystemic collaterals, including an enlarged coronary vein (arrow).
serosal tissue within the anastomotic suture line. The coronary vein was side-clamped with the adjacent peritoneum, and a 12-mm longitudinal venotomy was made. The donor portal vein had sufficient length and was appropriately trimmed. The anastomosis was performed with the use of running 6-0 polypropylene sutures in an end-to-side fashion (Fig 2). After unclamping, reperfusion was uneventful, the liver was very well perfused, and the portal vein flow measured at 4 L/min (Transonic Systems, Ithaca, NY, United States). On postoperative day 1, a liver Doppler ultrasound study was performed and revealed good portal flow (Fig 3A). The velocity was 30 to 40 cm/s at the main portal vein, which is comparable to other liver transplant patients with conventional portal vein reconstruction. The patient was started on aspirin on postoperative day 2 (per protocol). A computed tomography scan of the abdomen performed at 1 week showed patency of the portal vein supporting adequate flow from the enlarged coronary vein
Fig 2. Portal vein reconstruction to the enlarged coronary vein.
(Fig 3B). Chronic thrombus in the splenic confluence was also seen, but it did not progress or compromise flow through the coronary vein anastomosis. Imaging studies repeated at 1 and 3 months revealed good flow through the portal vein with stable chronic thrombus without extension into the coronary vein anastomosis (Fig 3C).
DISCUSSION
Various reports have been published regarding liver transplantation in patients with portal vein thrombosis and their classification based on thrombosis extension. The Yerdel classification is the most widely used because it correlates thrombosis extension with intraoperative management [2]. In patients with diffuse portal vein thrombosis, as seen in grades III and IV (Table 1), complex vascular reconstruction techniques may be required. Portal vein anastomosis to an enlarged splanchnic tributary (coronary or choledochal vein) if available would be a preferred option compared with jump graft techniques. The shorter length of the portal vein to a coronary vein and the anatomical lie can potentially reduce the risks for torsion or kinking; technically, this approach would also be straightforward. This technique was initially described by Hiatt et al [3] and Lerut et al [4]. In their experience, virtually any large collateral (2 cm in diameter) may be sufficient to supply portal flow to the graft (usually a pericholedochal varix or a coronary vein). Although this technique was known to be one of the options in situations of severe portal vein thrombosis, details of the surgical techniques are not well documented in the literature inclusive of the thought process [5]. We suggest the following surgical tips when considering this technique: (1) before transplantation, develop a good understanding of portomesenteric flow and collateral patterns from preoperative imaging; (2) test the flow source before transplantation, to ensure that there is adequate inflow; (3) the length of donor portal vein is
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SAFWAN, NAGAI, AND ABOULJOUD
Fig 3. (A) Postoperative day 1 Doppler study showing good portal flow to the liver. Postoperative (B) day 7 and (C) day 60 computed tomography studies showing patency of flow through the portal vein from an enlarged coronary vein with resolving thrombus (arrows). Abbreviation: MPV, main portal vein.
Table 1. Classification of Portal Vein Thrombosis (Yerdel Classification [2]) Grade
I II III IV
Description
Partial thrombosis of MPV (<50% occlusion) Near-total to complete thrombosis of MPV (>50% occlusion) Complete thrombosis of MPV with extension into proximal SMV (distal SMV not involved) Complete thrombosis of MPV with extension into proximal and distal SMV Abbreviations: MPV, main portal vein; SMV, superior mesenteric vein.
usually long enough, whereas an interposition graft may be required in some cases; (4) care should be taken to account for the anatomical lie of the portal vein to avoid kinking and/or torsion; (5) attention to detail is critical when suturing these enlarged and ectatic variceal structures to the donor portal vein because they tear easily and may not handle sutures well; and (6) the portal vein flow must be measured to assure adequacy and assess need for additional maneuvers. This is the second such procedure we performed using similar techniques. In our experience, we did not attempt to extensively dissect and isolate the coronary vein wall but rather incorporated adjacent
serosal tissue to reinforce the anastomosis to prevent the wall from tearing. Long-term, full-dose aspirin therapy was planned for this patient because of the residual thrombus and the nonanatomic nature of the anastomosis.
REFERENCES [1] Ponziani FR, Zocco MA, Senzolo M, Pompili M, Gasbarrini A, Avolio AW. Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up. Transplant Rev (Orlando) 2014;28: 92e101. [2] Yerdel MA, Gunson B, Mirza D, Karayalcin K, Olliff S, Buckels J, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation 2000;69:1873e81. [3] Hiatt JR, Quinones-Baldrich WJ, Ramming KP, Lois JF, Busuttil RW. Bile duct varices. An alternative to portoportal anastomosis in liver transplantation. Transplantation 1986;42:85. [4] Lerut J, Tzakis AG, Bron K, Gordon RD, Iwatsuki S, Esquivel CO, et al. Complications of venous reconstruction in human orthotopic liver transplantation. Ann Surg 1987;205(4): 404e14. [5] Wang Z, Yang L. Gastric coronary vein to portal vein reconstruction in liver transplant: case report. Exp Clin Transplant 2014;12:562e4.