Section 6. Management of extensive nontumorous portal vein thrombosis in adult living donor liver transplantation.
BACKGROUND
Patent portal vein (PV) and adequate portal inflow is essential for successful living donor liver transplantation (LDLT). In extensive portal vein thrombosis (PVT) patients, however, complete PV thrombectomy is not feasible particularly at intrapancreatic portion, and subsequently portal flow steal through preexisting sizable collaterals or rethrombosis can occur. To overcome those problems, we introduced interruption of sizable collaterals and intraoperative cine-portogram (IOP), which is useful for diagnosis and treatment of residual PVT and sizable collaterals.


METHODS
Fourteen percent of adult LDLT (188/1399) had PVT from February 2008 to December 2012 and were subdivided into Yerdel's grades 1, 2, 3, and 4 based on preoperative imaging and operative findings. Considering the severity of PVT and presence of sizable collaterals, the managements were as follows: thrombectomy alone, additional PV plasty, PV stenting, interposition graft, or additional interruption of collaterals.


RESULTS
The Yerdel's grade of PVT patients were 1 (42%), 2 (54%), 3 (3%), and 4 (1%). One hundred one (77%) patients underwent interruption of sizable collaterals. The most common management for PVT was thrombectomy alone in grades 1 and 2, thrombectomy plus PV stenting and/or ballooning in grade 3, and interposition graft in grade 4. In LDLT for PVT patients, 1-year mortality was 9%, and PV-related complication occurred in 5%. The severity of PVT made no difference in the outcome.


CONCLUSIONS
Multi-disciplinary approaches including surgical correction of PVT, IOP, and interruption of sizable collaterals resulted in excellent outcome, and it was not affected by the severity of PVT.
1 Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea. 2 Address correspondence to: Sung-Gyu Lee, M.D., F.A.C.S., Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea.
Deok-Bog
DB
Moon
Sung-Gyu
SG
Lee
Chul-Soo
CS
Ahn
Shin
S
Hwang
Ki-Hun
KH
Kim
Tae-Yong
TY
Ha
Gi-Won
GW
Song
Dong-Hwan
DH
Jung
Gil-Chun
GC
Park
Jung-Man
JM
Namkoong
Hyung-Woo
HW
Park
Yo-Han
YH
Park
Cheon-Soo
CS
Park
Kyu-Bo
KB
Sung
Gi-Young
GY
Ko
Dong-Il
DI
Gwon
D000293:Adolescent; D000328:Adult; D000368:Aged; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002932:Cineangiography; D003097:Collateral Circulation; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D008102:Liver Circulation; D016031:Liver Transplantation / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D010690:Phlebography / Q000379:methods; D011169:Portal Vein / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D012086:Reoperation; D012720:Severity of Illness Index; D015607:Stents; D017131:Thrombectomy / Q000009:adverse effects / Q000401:mortality; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D014654:Vascular Patency; D020246:Venous Thrombosis / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D055815:Young Adult