K. Phelan1, C. Kubal1, J. Fridell1, R. Mangus1 1Department Of Surgery,Division Of Transplantation,Indianapolis, IN, USA
Introduction: Optimal portal flow is crucial to successful liver transplantation. Portal vein thrombosis (PVT), when present, is associated with increased risk of early mortality and graft failure [1]. At our center, an aggressive approach towards PVT was utilized to improve post-transplant outcomes. This study reports outcomes of liver transplantation in patients with pre-transplant PVT.
Methods: All records for liver transplants over a 15-year period at a single center were reviewed and data extracted. PVT was identified on pre-transplant imaging and was documented in patient charts. Cavernous transformation, main portal vein thrombus, and thrombus of either splenic vein or superior mesenteric vein extending into the confluence was considered as PVT. Patient and graft survival were considered as primary endpoints.
Surgical techniques: Depending on the extent of PVT, various surgical approaches were used. In the majority of cases, extensive portal thromboendovenectomy was performed intraoperatively. When optimal portal flow was not established, superior/ inferior mesenteric venous bypass was utilized. Patients with extensive porto-mesenteric thrombosis were listed for back up multivisceral transplant which was performed if intraoperative attempts at liver transplant failed [2]. Post-transplant anticoagulation was utilized routinely for 3 to 6 months when complete clearance of the PVT was not achieved intraoperatively. Efforts were made to not use expanded criteria donor (ECD) liver allografts when significant PVT was present.
Results: There were 246 patients (12%) with pre-transplant PVT. Of those, 191 (78%) were in the main portal vein. Cavernous transformation existed in 2% of all patients with PVT. Patient demographic and clinical factors associated with PVT were year of transplant, number of days on the waiting list, race, and a primary diagnosis of fatty liver disease. Transplants with PVT had comparable graft loss at 7- and 90-days (3% and 3%, p=0.78; 7% and 7%, p=0.83). Patient and graft survival at 1-year for PVT and no PVT were 89% and 88% (p=0.66) and 89% and 90% (p=0.93). Cox regression showed comparable long-term graft survival for transplants with PVT (66% versus 64% at 10-years; p=0.64).
Conclusion: With an aggressive approach towards PVT, excellent early and long term outcomes can be achieved after liver transplantation.
