Stenosis of the portal vein anastomosis occurred in three pediatric patients seven to 42 months after transplantation. Dominant symptoms were those of portal hypertension and hypersplenism. Diagnosis was made by angiography. Successful surgical reconstruction was possible in all three patients. © 1989, American Medical Association. All rights reserved

Esquivel, CO

Marino, IR

Scantlebury, VP

Starzl, TE

Zajko, AB

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..... ---~-K-KKK---Reprinted from the kr;;hive$ of Surgery Apn 1989. \b\nne 124 Brief Clinical Note Copyright 1989. Americafl Medical Association Successful Reconstruction of Late Portal Vein Stenosis After Hepatic Transplantation Velma P. Scantlebury, MD; Albert B. Zajko, MD; Carlos O. Esquivel, MD, PhD; Ignazio R. Marino, Ma;~omas E. Starzl;"llD;·Pftt> • Stenosis of the portal vein anastomosis occurred In three pediatric patients seven to 42 months after transplantation. Dominant symptoms were those of portal hypertension and hypersplenism. Diagnosis was made by angiography. Suc-cessful surgical reconstruction was possible In all three patients. (Arch Sur9 1989;124:503·505) Biliary tract complications and thrombosis of the hepatic artery are the most common technical problems ob-served following orthotopic liver transplantation (OLT). t.2 In contrast, portal vein (PV) complications are unusual; however, they are associated with high morbidity and mortality.3-<I Three pediatric patients presented 7, 10, and 42 months after OLT with PV stenoses that were success-fully treated by excision of the stenotic segment and reanastomosis. PATIENTS AND METHODS The condition of the PV; hepatic artery, and vena cava is determined routinely with ultrasonography in all liver transplant recipients. Between March 1980 and January 1986, three of 184 children who survived more than three months after transplan-tation had evidence of PV stenosis. The diagnosis was confirmed by selective angiograph)! In one patient (case 3), venous pressures were measured across the stenosis after transhepatic catheteri-zation of the pv. The following parameters were reviewed: age, indication for transplantation, time interval between OLT and diagnosis of PV stenosis, symptoms, physical and laboratory findings at the time of diagnosis, angiograms, the type of technique for secondary reconstruction, and clinical outcome. The technique for liver transplantation has been previously reported. 7 RESULTS The Table summarizes the profile of these three patients and their clinical features at the time PV stenosis was diagnosed. Two of the three patients were symptomatic. Accepted for publication July 16, 1988. From the Departments at Surgery (Drs Scantlebury, Eaquival, 1UriDo, and Starz\) and Radiology (Dr Zajko), University Health Center of Pitts· burgh, University of Pittsburgh, and the Veterans AdmiDistration Hedieal Center, Pittsburgh (Dr Stan!). Reprint requests to Department of Surgery, 3601 Fifth Ave. Falk C1iJIie • West, Pittsburgh. PA 16213 (Dr Scantlebury). Arch Surg-VoI124, Apri 1989 The other patient (case 2) had no overt symptoms, although she had mild hepatic dysfunction. On further evaluation, she was found to have splenomegaly and sonographic findings ofhepatofugal flow. Because of this, she underwent angiographic evaluation. The cause of hepatic dysfunction was from a stricture of the common bile duct. Anglographlc Findings All three patients underwent selective celiac and supe-rior mesenteric angiography. In each case, stenosis of the PV anastomosis was identified (Fig I, left). Two patients (cases 1 and 3) underwent further evalua-tion by transhepatic catheterization of the PV to determine if there was a significant pressure gradient across the anastomotic stenosis. Successful catheterization of the PV was possible in both cases. However, in only one patient could the catheter be advanced across the stenosis to measure a gradient (Fig 2). In the other patient, transhe-patic portal venography clearly demonstrated a marked stricture even though a gradient could not be measured (Fig 3). In two patients (cases 1 and 3), evidence of portal hypertension was found as manifested by gastroesophageal varices (Fig 2). In the third patient (case 2), no varices were seen despite the presence of a severe stenosis (Fig I, left). This last patient underwent follow-up angiography after operative revision of the PV anastomosis, document-ing a widely patent PV (Fig I, right). Operative Findings Operation was performed through the same subcostal incision that had been used for the transplantation. In one patient (case 3), the choledochojejunostomy was not taken down because mobilization of the Roux-en-Y allowed ade-quate exposure of the pv. In the other two cases, the eholedochojejunostomy was taken down to f'acilitate the exposure. Both of these patients (cases 1 and 2) had biliary strictures. Stenosis of the PV in all three patients was at the anastomoses. The gross pathologic findings were similar in each case. The veins were phlebosclerotic, with focal calcification and foreign-body reaction at the site of the -Portal Vein Stenosis-8canllebury et al 503 Summary of Profile and Clinical Features at Time of Diagnosis of Portal Vein Stenosis Indication Time From for Orthotopic Orthotopic LIver Clinical PhysIcal Laboratory Case No.lAge. y Liver Tranaplantatlon Transplantation, mo Symptom. Finding. Finding. 1/10 Familial cholestasis 7 Variceal Splenomegaly Pancytopenia hemorrhage and ascites 216 Biliary atresia 10 Asymptomatic Splenomegaly Leukopenia 3/6 Biliary hypoplasia 42 Fatigue Splenomegaly Thrombocytopenia and leukopenia Fig 1.--case 2. Left. Portal vein anastomotic stenosis (arrow) demonstrated on venous phase of superior mesenteric arteriogram. Poststenotie dilatation of portal vein is evident. Right. Widely patent portal vein anastomosis (arrow) demonstrated on venous phase of superior mesenteric arteriogram performed six days after portal vein revision. Decrease in previously seen poststenotic dilatation is shown. Fig 2.--case 3. Portal vein anastomotic stenosis (arrow) demon-strated on trans hepatic portogram. Prominent gastric varices are seen. Pressure in splenic vein was 29 mm Hg. and pressure in intrahepatic portal vein was 12 mm Hg. 504 Arch Surg-\\:)I 124. April 1989 anastomoses. In one patient (case 1), a recent clot was found in the donor side of the PV that extended into the hilum. Histologic examination of this specimen showed mural thrombosis with recanalization. Thrombectomy was performed. In each case the anastomosis was excised by removing a ring of vein measuring 1 to 2 cm long after obtaining proximal and distal vascular control. In all three cases the length of the vein was adequate for allowing reapproxima-tion of the two ends without tension. The anastomoses were performed end-to-end with 7-0 polypropylene suture. Systemic heparinization was not used. All patients recov-ered suceessfully and were discharged in excellent condi-tion. The spleen in all three patients was noted to have decreased in size at the time of last follow-up. COMMENT Portal vein thrombosis after OLT occurs more frequently in pediatric patients. Symptoms of portal hypertension are the primary manifestations. Lerut et all reported seven cases of PV thrombosis following OLT, with an overall incidence of 1.8%. Five of the seven patients developed variceal hemorrhage. Previous portosystemic shunt and partial or complete thrombosis of the portal system requiring thrombectomy Portal Vein Stenosis-8cantJebury et al Fig 3.-Case 1. Marked stenosis of portal vein anastomosis demonstrated on transhepatic portogram (arrow). Catheter could not be advanced across stenosis to measure pressure gradient. at the time of transplantation are thought to be contrib-uting factors to the development of postoperative PV complications. However, not all patients demonstrate an obvious cause. Of the seven cases reported by Lerut, only three had contributing factors. One patient had a porta-caval shunt, one had a thrombosed pv, and one had hypoplasia of the pv. None of the three patients described herein had any contributing cause for the development of PV stenosis following transplantation. However, dense scarring in the portal area may have contributed; two of the three recipients also had a stricture at the site of bile duct anastomosis. The best possibility is that technical errors were made at the time of the original transplanta-tion. The fact that secondary repair was possible without vein grafts might suggest that the cuffs were originally made too long, which consequently caused kinking or distortion. In all three cases, the diagnosis was suspected by physical examination and confirmed by angiograph)t Evi-dence of a recent clot in the portal vein extending into the hilum of the liver was found in one patient (case 1). This clot was not demonstrated by angiographic studies per-formed three and eight days before revision and may have been contributed to by the instrumentation. Pathologic findings of focal calcification, thickening, and fibrosis in the area of the anastomotic suture line were common to all cases. The status of the extrahepatic PV should be evaluated in patients after transplantation with recurring symptoms of portal hypertension, hypersplenism, or both. Ultraso-nography can be performed for screening, but definitive diagnosis requires angiography. Successful surgical correc-tion of PV anastomotic stenosis can be achieved with little morbidity. The possibility of balloon dilatation of the strictures after transhepatic PV catheterization was not seriously considered for these patients, but this may be a viable nonoperative option for the future. This study was supported in part by research grants from the veterans Administration, Pittsburgh, and grant AM 29961 from the Nationallnsti-tutes of Health, Bethesda, Md. References 1. Tzakis AG, Gordon RD, Shaw BW Jr, et al: Clinieal presentation of hepatic artery thromboaia after liver transplantation in the cycl08porine era. 7'ramplantati01l 1985;4:667-671. 2. lwatauki S, Shaw BW Jr, Starz) TE: Biliary tract complications in liver transplantation under cycloaporine steroid theraplt 7'rauplallt Proc 1983;15:1288-1291. 3. Lerut J, Tzakis AG, Bron K, et aJ: Complications or venoU8 reconstruc-tion in human orthotopic liver transplantation. A .. S"rrI 1987;205:404-414. 4. Wozney P, Zajko AB, Bron D, et al: VuruIar eomplications after Arch Surg-VoI124, April 1989 Uver transplantation: A five-year experience. AIR 1986;147:657-663. 5. Cardella JF, Castaneda-Zuniga WR, Hunter D, et aJ: AngiOll"8phic and interventional radiologic considerations in liver transplantation. AIR 1986;147:143-153. 6. Zajko AB, Bron D: HepatopetaJ collateraJa after portal vein throm-boaia following liver transplantation. Cardiovtuc IIIt#Irvent Rotliol 1986;9:46-48. 7. Starz) TE, lwatsuki S, Eaquiwl Co, et aJ: Refinementa in the Im'IicaJ technique orUver transplantation. Semin Liver IMI986;5:349-3S6. Portal Vein Sten08is-Scantlebury et aI 505 Printed and Published in the United Slales of America 

Successful Reconstruction of Late Portal Vein Stenosis After Hepatic Transplantation

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Successful reconstruction of late portal vein stenosis after hepatic transplantation

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Successful Reconstruction of Late Portal Vein Stenosis After Hepatic Transplantation

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