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Treatment of hepatic venous stenosis by transfemoral venous balloon dilation following living donor liver transplantation: a case report
JNMU Journal of Nanjing Medical University，2009，23(6):430-432 Case Report
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Treatment of hepatic venous stenosis by transfemoral venous balloon dilation following living donor liver transplantation: a case report☆ Weiwei Jianga, Yangsui Liub, Lianbao Kongb*
Department of Neonatal Surgery, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing 210029, China. b Department of Liver Transplantation Center, the National Institute of Living Donor Liver Transplantation, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China Received 16 July 2009
a
Abstract Hepatic venous stenosis may be a cause of graft failure in living donor liver transplantation (LDLT). Balloon dilation and metallic frame approaches have been used successfully to treat hepatic venous stenosis. Here, we report the effect of transfemoral venous balloon dilation for treating a child with hepatic venous stenosis after LDLT.
Keywords: balloon dilation; living donor liver transplantation; hepatic venous stenosis
INTRODUCTION Living donor liver transplantation(LDLT) has recently become a popular option for managing the end stages of liver disease worldwide[1-7]. However, there are still some complications after liver transplantation[8-11]. Vascular complications, including stenosis, occlusion and thrombosis are one group of severe complications, among which hepatic venous stenosis is rare but more common in LDLT than in orthotopic liver transplantation[12-15]. In our center, hepatic venous stenosis after LDLT is rare, and the recipient reported in this study was the only one of 102 patients with this complication (<1% morbidity). Previously, balloon dilation and metallic frame approaches have been used successfully to treat hepatic venous stenosis. For the current recipient, transfemoral venous balloon dilations were performed successfully. This study was supported by a grant from Jiangsu Health Department of China (RC2007058). * Corresponding author. E-mail address: [email protected] ☆
CASE REPORT In May 2004, an 11-year-old girl was admitted to the Liver Transplantation Center, the First Affiliated Hospital of Nanjing Medical University to undergo LDLT. The indication for liver transplantation was Wilson’s disease with liver dysfunction [alanine a m i n o t r a n s f e r a s e (A L T) 123.4 U/L, a s p a r t a t e aminotransferase (AST) 164.2 U/L] and esophageal varicosis. After detailed explanation about the risks to the donor, as well as the risks and benefits to the recipient, her 40-year-old father volunteered to be a living donor. Surgery for LDLT was performed on 28 May 2004. There was no postoperative graft dysfunction and the patient recovered rapidly. However, 1 month later, some ascites was detected by color Doppler sonography. At 5 months post-operation, color Doppler sonography showed a mass of ascites and hepatic venous stenosis, with distension of the hepatic portal vein (~1.4 cm). At the same time, liver dysfunction (ALT 89.2 U/L, AST 180.4 U/L) was observed. Thus, balloon dilation surgery was performed on 27 October 2004.
431
W.Jiang et al. / Journal of Nanjing Medical University, 2009, 23(6): 430-432 Informed consent was obtained from the patient and her parents prior to treatment. The procedures were conducted under local anesthesia. A small incision was made in the left inguinal fold. The femoral vein was exposed and punctured with an 18-gauge needle (Hanako, Saitama, Japan). A 7-F sheath was used to traverse the inferior vena cava, with an 8-F interventional sheath introducer (Arrow International, Reading, PA, USA). In the inferior vena cava, venograms were obtained with contrast medium, and showed no stenosis. In the hepatic veins, venography demonstrated that the degree of stenosis was ~70%. A 0.034-inch angled hydrophilic guidewire (Terumo Medical Corporation, Japan) and a 6-F catheter (Medikit, Miyazaki, Japan) were then used to traverse the stenosis. Dilation was performed three times (~10 s each time), until the stenosis disappeared completely. Portal venography was performed again to evaluate the effectiveness of the procedure, and it was found that the hepatic venous stenosis had disappeared, and that blood flow was normal(Fig. 1). On completion of the procedures, the incision was sutured. Balloon dilation was performed three times until venograms indicated the complete disappearance of stenosis. Ascites disappeared and liver functions recovered to normal about 2 weeks after surgery. Thereafter, ascites and abnormal liver function were not detected in this patient. The changes in liver functions prior to and after balloon dilation are shown in Table 1.
A: Hepatic venogram showed hepatic venous stenosis, which was close to occlusion. B: Transfemoral venous balloon dilation was performed and hepatic venography clearly shows severe stenosis (arrow). C: The stenosis was dilated using the balloon catheter. D: Post-dilation venography showed no residual stenosis and the collateral vessels had disappeared.
Fig.1 Hepatic venography revealed obstruction of the hepatic vein before and after balloon dilation
Table 1 Liver functions prior to and after balloon dilation
ALT (U/L) AST (U/L) Total bilirubin (μmol/L) Direct bilirubin (μmol/L) Total protein (g/L) Albumin (g/L)
3 days prior 89.2 180.4 60.2 30.5 57.3 40.3
1 day after 115.1 190.4 58.2 28.0 60.1 42.2
7 days after 67.7 112.4 33.6 22.9 57.9 40.8
14 days after 35.4 30.7 21.3 12.7 61.6 41.5
DISCUSSION Hepatic venous stenosis may be a cause of liver graft failure, and recognition of this complication as soon as possible can be helpful for the patient. Patients with hepatic venous stenosis usually have massive ascites, and protein supplements and maximal diuretic therapy are not effective[12,13]. Computed tomography (CT) and color Doppler sonography will help to diagnose hepatic venous stenosis. Surgical reconstruction of the hepatic stenotic vein is the treatment of choice for these patients, but repeated surgery might be difficult because of the severe adhesion that surrounds the liver graft[16]. Balloon dilation and stent placement have been described in portal venous stenoses after liver transplantation[15,17,18]. As for the present patient, we demonstrated that balloon dilation was a safe and effective procedure for treating primary hepatic venous stenosis after LDLT. However, balloon dilation or metal stenting, which should be a better treatment choice, is still controversial because hepatic vein stenosis might recur after balloon dilation[19] and the risk of intravascular thrombosis is increased after metal stent placement[14]. In our case, ascites was relieved after balloon dilation, and no thrombosis or other complications were observed. There was no recurrence during the following 4 years. This case suggests that balloon dilation can be the initial treatment of choice for hepatic vein stenosis following LDLT. However, if elastic or recurrent stenoses are detected, metallic stents may be a better choice[20]. Our case also suggests that transfemoral venous balloon dilation is an effective and safe procedure for hepatic venous stenosis after LDLT in children. References [1] Li GQ, Zhang F, Li XC, Sun BC, Cheng F, Ge WG, et al. Safety evaluation of donors for living-donor liver transplantation in Chinese mainland: a single-center report. World J Gastroenterol 2007; 13: 4379-84. [2] Wang XH, Zhang F, Li XC, Li GQ, Cheng F, Sun BC, et al. Surgical methods in living donor liver transplantation: with report of 50 cases. Zhonghua Wai Ke Za Zhi(in Chinese) 2006; 44: 1448-52.
432 [3]
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[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
W.Jiang et al. / Journal of Nanjing Medical University, 2009, 23(6): 430-432
Wang XH, Yan LN, Zhang F, Li XC, Zhu JY, Peng ZH, et al. Early experiences on living donor liver transplantation in China: multicenter report. Chin Med J 2006; 119: 1003-9. Jiang WW, Kong LB, Li GQ, Wang XH. Expression of iNOS in early injury in a rat model of small-for-size liver transplantation. Hepatobiliary Pancreat Dis Int 2009; 8: 146-51. Wang XH, Zhang F, Li XC, Cheng F, Li GQ, Sun BC, et al. Living related liver transplantation for Wilson’s disease: clinical study of 32 cases. Zhonghua Yi Xue Za Zhi(in Chinese) 2006; 86:3290-3. Kong LB, Wang XH, Zhang F, Li XC, Jiang WW. The application of ultrasonic dissector (CUSA) in hepatectomy and partial liver transplantation. Acta Univ Med Nanjing(in Chinese) 2008; 28: 1155-7. Sugawara Y, Makuuchi M, Takayama T, Imamura H, Kaneko J, Ohkubo T. Safe donor hepatectomy for living related liver transplantation. Liver Transpl 2002; 8: 58-62. Kong LB, Wang XH, Zhang F. Diagnosis and treatment of biliary sludge, cast and stone following liver transplantation. JNMU 2006; 20: 253-5. Sun B, Zhao C, Xia Y, Li G, Cheng F, Li J, et al. Late onset of severe graft-versus-host disease following liver transplantation. Transpl Immunol 2006; 16: 250-3. Shi XC, Peng ZH. Biliary complications in orthotopic liver transplantation: mechanism, diagnosis and treatment. JNMU 2009; 23 : 87-92. Jiang XZ, Yan LN, Li B, Zhao JC, Wang WT, Li FG, et al. Arterial complications after living-related liver transplantation: single-center experience from West China. Transplant Proc 2008; 40: 1525-8. Sze DY, Semba CP, Razavi MK, Kee ST, Dake MD. Endovascular treatment of hepatic venous outflow obstruction after piggyback technique liver transplantation. Transplantation 1999; 68: 446-9.
[13] Parrilla P, Sanchez-Bueno F, Figueras J, Jaurrieta E, Mir J, Margarit C,et al. Analysis of the complications of the piggy-back technique in 1112 liver transplants. Transplant Proc 1999; 31: 2388-9. [14] Totsuka E, Hakamada K, Narumi S, Toyoki Y, Umehara Y, Okawa H, et al. Hepatic vein anastomotic stricture after living donor liver transplantation. Transplant Proc 2004; 36: 2252-4. [15] Kubo T, Shibata T, Itoh K, Maetani Y, Isoda H, Hiraoka M, et al. Outcome of percutaneous transhepatic venoplasty for hepatic venous outflow obstruction after living donor liver transplantation. Radiology 2006; 239: 28590. [16] Akamatsu N, Sugawara Y, Kaneko J, Kishi Y, Niiya T, Kokudo N, et al. Surgical repair for late-onset hepatic venous outflow block after living-donor liver transplantation. Transplantation 2004; 77:1768-70. [17] Hotta R, Hoshino K, Nakatsuka S, Nakao S, Okamura J, Yamada Y, et al. Transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation in children. Pediatr Surg Int 2007; 23: 939-45. [18] Wang SL, Sze DY, Busque S, Razavi MK, Kee ST, Frisoli JK, et al. Treatment of hepatic venous outflow obstruction after piggyback liver transplantation. Radiology 2005; 236:352-9. [19] Tannuri U, Mello ES, Carnevale FC, Santos MM, Gibelli NE, Ayoub AA, et al. Hepatic venous reconstruction in pediatric living-related donor liver transplantationexperience of a single center. Pediatr Transplant 2005; 9:293-8. [20] Cherukuri R, Haskal ZJ, Naji A, Shaked A. Percutaneous thrombolysis and stent placement for the treatment of portal vein thrombosis after liver transplantation: longterm follow-up. Transplantation 1998; 65:1124-6.
www.elsevier.com/locate/jnmu
Treatment of hepatic venous stenosis by transfemoral venous balloon dilation following living donor liver transplantation: a case report☆ Weiwei Jianga, Yangsui Liub, Lianbao Kongb*
Department of Neonatal Surgery, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing 210029, China. b Department of Liver Transplantation Center, the National Institute of Living Donor Liver Transplantation, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China Received 16 July 2009
a
Abstract Hepatic venous stenosis may be a cause of graft failure in living donor liver transplantation (LDLT). Balloon dilation and metallic frame approaches have been used successfully to treat hepatic venous stenosis. Here, we report the effect of transfemoral venous balloon dilation for treating a child with hepatic venous stenosis after LDLT.
Keywords: balloon dilation; living donor liver transplantation; hepatic venous stenosis
INTRODUCTION Living donor liver transplantation(LDLT) has recently become a popular option for managing the end stages of liver disease worldwide[1-7]. However, there are still some complications after liver transplantation[8-11]. Vascular complications, including stenosis, occlusion and thrombosis are one group of severe complications, among which hepatic venous stenosis is rare but more common in LDLT than in orthotopic liver transplantation[12-15]. In our center, hepatic venous stenosis after LDLT is rare, and the recipient reported in this study was the only one of 102 patients with this complication (<1% morbidity). Previously, balloon dilation and metallic frame approaches have been used successfully to treat hepatic venous stenosis. For the current recipient, transfemoral venous balloon dilations were performed successfully. This study was supported by a grant from Jiangsu Health Department of China (RC2007058). * Corresponding author. E-mail address: [email protected] ☆
CASE REPORT In May 2004, an 11-year-old girl was admitted to the Liver Transplantation Center, the First Affiliated Hospital of Nanjing Medical University to undergo LDLT. The indication for liver transplantation was Wilson’s disease with liver dysfunction [alanine a m i n o t r a n s f e r a s e (A L T) 123.4 U/L, a s p a r t a t e aminotransferase (AST) 164.2 U/L] and esophageal varicosis. After detailed explanation about the risks to the donor, as well as the risks and benefits to the recipient, her 40-year-old father volunteered to be a living donor. Surgery for LDLT was performed on 28 May 2004. There was no postoperative graft dysfunction and the patient recovered rapidly. However, 1 month later, some ascites was detected by color Doppler sonography. At 5 months post-operation, color Doppler sonography showed a mass of ascites and hepatic venous stenosis, with distension of the hepatic portal vein (~1.4 cm). At the same time, liver dysfunction (ALT 89.2 U/L, AST 180.4 U/L) was observed. Thus, balloon dilation surgery was performed on 27 October 2004.
431
W.Jiang et al. / Journal of Nanjing Medical University, 2009, 23(6): 430-432 Informed consent was obtained from the patient and her parents prior to treatment. The procedures were conducted under local anesthesia. A small incision was made in the left inguinal fold. The femoral vein was exposed and punctured with an 18-gauge needle (Hanako, Saitama, Japan). A 7-F sheath was used to traverse the inferior vena cava, with an 8-F interventional sheath introducer (Arrow International, Reading, PA, USA). In the inferior vena cava, venograms were obtained with contrast medium, and showed no stenosis. In the hepatic veins, venography demonstrated that the degree of stenosis was ~70%. A 0.034-inch angled hydrophilic guidewire (Terumo Medical Corporation, Japan) and a 6-F catheter (Medikit, Miyazaki, Japan) were then used to traverse the stenosis. Dilation was performed three times (~10 s each time), until the stenosis disappeared completely. Portal venography was performed again to evaluate the effectiveness of the procedure, and it was found that the hepatic venous stenosis had disappeared, and that blood flow was normal(Fig. 1). On completion of the procedures, the incision was sutured. Balloon dilation was performed three times until venograms indicated the complete disappearance of stenosis. Ascites disappeared and liver functions recovered to normal about 2 weeks after surgery. Thereafter, ascites and abnormal liver function were not detected in this patient. The changes in liver functions prior to and after balloon dilation are shown in Table 1.
A: Hepatic venogram showed hepatic venous stenosis, which was close to occlusion. B: Transfemoral venous balloon dilation was performed and hepatic venography clearly shows severe stenosis (arrow). C: The stenosis was dilated using the balloon catheter. D: Post-dilation venography showed no residual stenosis and the collateral vessels had disappeared.
Fig.1 Hepatic venography revealed obstruction of the hepatic vein before and after balloon dilation
Table 1 Liver functions prior to and after balloon dilation
ALT (U/L) AST (U/L) Total bilirubin (μmol/L) Direct bilirubin (μmol/L) Total protein (g/L) Albumin (g/L)
3 days prior 89.2 180.4 60.2 30.5 57.3 40.3
1 day after 115.1 190.4 58.2 28.0 60.1 42.2
7 days after 67.7 112.4 33.6 22.9 57.9 40.8
14 days after 35.4 30.7 21.3 12.7 61.6 41.5
DISCUSSION Hepatic venous stenosis may be a cause of liver graft failure, and recognition of this complication as soon as possible can be helpful for the patient. Patients with hepatic venous stenosis usually have massive ascites, and protein supplements and maximal diuretic therapy are not effective[12,13]. Computed tomography (CT) and color Doppler sonography will help to diagnose hepatic venous stenosis. Surgical reconstruction of the hepatic stenotic vein is the treatment of choice for these patients, but repeated surgery might be difficult because of the severe adhesion that surrounds the liver graft[16]. Balloon dilation and stent placement have been described in portal venous stenoses after liver transplantation[15,17,18]. As for the present patient, we demonstrated that balloon dilation was a safe and effective procedure for treating primary hepatic venous stenosis after LDLT. However, balloon dilation or metal stenting, which should be a better treatment choice, is still controversial because hepatic vein stenosis might recur after balloon dilation[19] and the risk of intravascular thrombosis is increased after metal stent placement[14]. In our case, ascites was relieved after balloon dilation, and no thrombosis or other complications were observed. There was no recurrence during the following 4 years. This case suggests that balloon dilation can be the initial treatment of choice for hepatic vein stenosis following LDLT. However, if elastic or recurrent stenoses are detected, metallic stents may be a better choice[20]. Our case also suggests that transfemoral venous balloon dilation is an effective and safe procedure for hepatic venous stenosis after LDLT in children. References [1] Li GQ, Zhang F, Li XC, Sun BC, Cheng F, Ge WG, et al. Safety evaluation of donors for living-donor liver transplantation in Chinese mainland: a single-center report. World J Gastroenterol 2007; 13: 4379-84. [2] Wang XH, Zhang F, Li XC, Li GQ, Cheng F, Sun BC, et al. Surgical methods in living donor liver transplantation: with report of 50 cases. Zhonghua Wai Ke Za Zhi(in Chinese) 2006; 44: 1448-52.
432 [3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
W.Jiang et al. / Journal of Nanjing Medical University, 2009, 23(6): 430-432
Wang XH, Yan LN, Zhang F, Li XC, Zhu JY, Peng ZH, et al. Early experiences on living donor liver transplantation in China: multicenter report. Chin Med J 2006; 119: 1003-9. Jiang WW, Kong LB, Li GQ, Wang XH. Expression of iNOS in early injury in a rat model of small-for-size liver transplantation. Hepatobiliary Pancreat Dis Int 2009; 8: 146-51. Wang XH, Zhang F, Li XC, Cheng F, Li GQ, Sun BC, et al. Living related liver transplantation for Wilson’s disease: clinical study of 32 cases. Zhonghua Yi Xue Za Zhi(in Chinese) 2006; 86:3290-3. Kong LB, Wang XH, Zhang F, Li XC, Jiang WW. The application of ultrasonic dissector (CUSA) in hepatectomy and partial liver transplantation. Acta Univ Med Nanjing(in Chinese) 2008; 28: 1155-7. Sugawara Y, Makuuchi M, Takayama T, Imamura H, Kaneko J, Ohkubo T. Safe donor hepatectomy for living related liver transplantation. Liver Transpl 2002; 8: 58-62. Kong LB, Wang XH, Zhang F. Diagnosis and treatment of biliary sludge, cast and stone following liver transplantation. JNMU 2006; 20: 253-5. Sun B, Zhao C, Xia Y, Li G, Cheng F, Li J, et al. Late onset of severe graft-versus-host disease following liver transplantation. Transpl Immunol 2006; 16: 250-3. Shi XC, Peng ZH. Biliary complications in orthotopic liver transplantation: mechanism, diagnosis and treatment. JNMU 2009; 23 : 87-92. Jiang XZ, Yan LN, Li B, Zhao JC, Wang WT, Li FG, et al. Arterial complications after living-related liver transplantation: single-center experience from West China. Transplant Proc 2008; 40: 1525-8. Sze DY, Semba CP, Razavi MK, Kee ST, Dake MD. Endovascular treatment of hepatic venous outflow obstruction after piggyback technique liver transplantation. Transplantation 1999; 68: 446-9.
[13] Parrilla P, Sanchez-Bueno F, Figueras J, Jaurrieta E, Mir J, Margarit C,et al. Analysis of the complications of the piggy-back technique in 1112 liver transplants. Transplant Proc 1999; 31: 2388-9. [14] Totsuka E, Hakamada K, Narumi S, Toyoki Y, Umehara Y, Okawa H, et al. Hepatic vein anastomotic stricture after living donor liver transplantation. Transplant Proc 2004; 36: 2252-4. [15] Kubo T, Shibata T, Itoh K, Maetani Y, Isoda H, Hiraoka M, et al. Outcome of percutaneous transhepatic venoplasty for hepatic venous outflow obstruction after living donor liver transplantation. Radiology 2006; 239: 28590. [16] Akamatsu N, Sugawara Y, Kaneko J, Kishi Y, Niiya T, Kokudo N, et al. Surgical repair for late-onset hepatic venous outflow block after living-donor liver transplantation. Transplantation 2004; 77:1768-70. [17] Hotta R, Hoshino K, Nakatsuka S, Nakao S, Okamura J, Yamada Y, et al. Transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation in children. Pediatr Surg Int 2007; 23: 939-45. [18] Wang SL, Sze DY, Busque S, Razavi MK, Kee ST, Frisoli JK, et al. Treatment of hepatic venous outflow obstruction after piggyback liver transplantation. Radiology 2005; 236:352-9. [19] Tannuri U, Mello ES, Carnevale FC, Santos MM, Gibelli NE, Ayoub AA, et al. Hepatic venous reconstruction in pediatric living-related donor liver transplantationexperience of a single center. Pediatr Transplant 2005; 9:293-8. [20] Cherukuri R, Haskal ZJ, Naji A, Shaked A. Percutaneous thrombolysis and stent placement for the treatment of portal vein thrombosis after liver transplantation: longterm follow-up. Transplantation 1998; 65:1124-6.