title: Hepatic venous outflow obstruction in living donor liver transplantation: balloon angioplasty or stent placement?
abstract: BACKGROUND
  The incidence of hepatic venous outflow obstruction (HVOO) has been reported to be 5%-13% when a partial graft is used for orthotopic liver transplantation (OLT). HVOO leads to graft congestion, portal hypertension, and finally cirrhosis, which jeopardizes both graft and recipient survivals. In this study, we sought to identify perioperative factors influencing HVOO and to investigate conditions that require stent placement.
  
  
  METHODS
  From February 1994 to December 2010, we performed 40 living donor liver transplantations (LDLT). HVOO occurred in 5 cases (12.5%), all of which were left lobe grafts. Because HVOO was not observed in patients with body weight (BW) <30 kg, we investigated the other 28 cases with BW >30 kg.
  
  
  RESULTS
  There was no difference from unaffected subjects except for cold ischemic time (CIT), which was significantly longer: 86.2 ± 10.4 minutes vs 46.0 ± 4.8 minutes (P = .001). Balloon angioplasty, which was selected as the initial treatment for all stricture patients, improved 2 patients after 1 and 5 treatments, respectively, but 3 subjects underwent repeated HVOO, finally being treated with self-expandable metallic stents at 9, 6, and 10 years after LDLT, respectively. All patients finally resolved their strictures.
  
  
  CONCLUSIONS
  HVOO reflects intimal hyperplasia and fibrosis at the anastomotic sites or compression and twisting of the anastomosis caused by graft regeneration. In addition, progression of chronic rejection and fibrosis are possibly responsible for late-onset HVOO. Longer CIT possibly reflects difficulties in the venoplasty before anastomosis. No bleeding or thrombosis complications were observed during dilatation among our cases. The selection of the stent size for each case and careful stent deployment are important to prevent complications. Stent placement should be considered in patients with chronic rejection who are refractory to several balloon angioplasties with early-onset or late-onset HVOO.
authors.affiliation: Department of Pediatric Surgery, Hirosaki University School of Medicine, Hirosaki, Japan. mumehara@cc.hirosaki-u.ac.jp
authors.forename: M
authors.initials: M
authors.lastname: Umehara
authors.forename: S
authors.initials: S
authors.lastname: Narumi
authors.forename: M
authors.initials: M
authors.lastname: Sugai
authors.forename: Y
authors.initials: Y
authors.lastname: Toyoki
authors.forename: K
authors.initials: K
authors.lastname: Ishido
authors.forename: D
authors.initials: D
authors.lastname: Kudo
authors.forename: N
authors.initials: N
authors.lastname: Kimura
authors.forename: T
authors.initials: T
authors.lastname: Kobayashi
authors.forename: K
authors.initials: K
authors.lastname: Hakamada
mesh_terms: D000328:Adult; D000800:Angioplasty, Balloon; D006502:Budd-Chiari Syndrome / Q000601:surgery*; D005260:Female; D006801:Humans; D016031:Liver Transplantation; D019520:Living Donors; D008297:Male; D015607:Stents