title: Development of extensive inferior vena cava thrombosis due to the ligation of a large mesenteric-caval shunt during liver transplantation: A case report.
abstract: BACKGROUND
  Inferior vena cava (IVC) thrombosis can be a life-threatening complication after liver transplantation (LT). Although this complication is usually related to technical problems associated with vascular anastomosis, we report a case of IVC thrombosis which developed from a ligated large mesenteric-caval shunt.
  
  
  METHODS
  A 35-year-old man underwent LT from a brain-dead donor for primary sclerosing cholangitis. Enhanced computed tomography (CT) before LT showed a huge collateral vessel of the inferior mesenteric vein (IMV) draining into the infra-renal IVC directly. To obtain sufficient portal vein (PV) flow, the dilated IMV collateral was ligated. A routine Doppler ultrasound study on post-operative day 1 showed thrombus inside the infra-hepatic IVC. Enhanced CT showed that this thrombus originated from a ligated collateral vessel of the IMV and extended into the IVC. He was hemodynamically stable and liver function was consistently stable. The size of IVC thrombus slowly reduced and he is currently in good condition without any symptoms.
  
  
  CONCLUSIONS
  To obtain adequate PV flow, ligation of a major PSS at the time of LT has been suggested. However, where it should be occluded has not been discussed. We should occlude a mesenteric-caval shunt not only at the upper side, but at the IVC side, based on findings from the current case.
  
  
  CONCLUSIONS
  To obtain appropriate PV flow toward a liver graft, occlusion of portosystemic shunts during LT is recommended. However, the position of ligation should be carefully considered to avoid extension of thrombus to major vessels.
authors.affiliation: Departments of Transplantation Surgery, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan. Electronic address: kamei@med.nagoya-u.ac.jp.
authors.forename: Hideya
authors.initials: H
authors.lastname: Kamei
authors.affiliation: Departments of Transplantation Surgery, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan. Electronic address: onishiy@med.nagoya-u.ac.jp.
authors.forename: Yasuharu
authors.initials: Y
authors.lastname: Onishi
authors.affiliation: Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan. Electronic address: masaishi@med.nagoya-u.ac.jp.
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Ishigami
authors.affiliation: Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan. Electronic address: y-ishizu@med.nagoya-u.ac.jp.
authors.forename: Yoji
authors.initials: Y
authors.lastname: Ishizu
authors.affiliation: Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan. Electronic address: kojiro@med.nagoya-u.ac.jp.
authors.forename: Kojiro
authors.initials: K
authors.lastname: Suzuki
authors.affiliation: Departments of Transplantation Surgery, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, 466-8550 Japan. Electronic address: oguchan@med.nagoya-u.ac.jp.
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Ogura
keywords: IVC thrombosis; Liver transplantation; Portal hypertension; Portosystemic shunt