Koneru, B

Mieles, LA

Starzl, TE

Stieber, A

Tzakis, AG

Yanaga, K

English

PubMed

Name not available

Portal vein thromboembolism of liver allografts from splenectomized donors

D-Scholarship@Pitt

; I f t f f , February 1989 BRIEF COMMUNICA nONS 399 42 patients received cyclosporine. Our current one-year graft survival in all recipients of LRD allografts is 95%, cyc1osporine being used in all except HLA-identical recipients. Twenty-one patients (50%) currently have functioning allo-grafts 1-14 ye posttransplantation (mean: 5 years). Allograft failure occurred eight patients within one year following transplantation. In 0 of these patients, arterial occlusion resulted in graft loss a 1 and 3 days, respectively. In the remaining six patients, rej . n was responsible for graft loss. In three of these six patients, im osuppreasion was less than optimum because of concurrent se . A fourth patient was noncompliant with her immunosup ssive medications. Chronic rejection led to graft loss at 20 mo s in one patient and at 6, 7, and 14 years posttransplantation . respectively. In summary, no adverse affect upon patient s . al was noted due to the presence of MRA. MRA, however, adv Iy affected graft survival in two cases. One allograft was lost the early postoperative period due to infarction following rep . of a completely transected superior polar vessel. It mus stressed that this complication has not occurred sin 976, and therefore, as more experience was gained, inju to these small vessels has been avoided. In the second pa . nt, ligation of a superior polar vessel with resultant hype sion may have contributed to allograft loss 20 months fo wing transplanta-tion. The presence of MRA and the a tional time required for arterial reconstruction contribu to postoperative ATN in only one patient, who required enous patch angioplasty prior to arterial reconstruction. I our recent experience, renovas-cular hypertension seeon to RAS occurred in 39 of 547 renal allograft recipien 7.1 %) (2). In the present series, RAS was present in 5% patients. In all cases RAS occurred proximal to the . al reconstruction. The most freque urologic complication in the present series was distal ureteral fistula (in three patients). Interference with blood flow to the ureter may have occurred during dissection of the inferior polar artery. The presence of multiple renal arteries has previously been recognized as contributing to the formation of ureteral fistulae (3). Concurrent rejection in one patient may also have further affected blood flow to the ureter. No allografts were lost secondary to urologic complications. In conclusion, the present study demons tes that the use of donors with MRA is associated wit creased risk to the allograft. Nonetheless, satisfactol'Y. tient and graft survival was achieved. Exclusion of don based upon the presence of MRA would deny a large n r of patients the advantages of an LRD renal allo in our series, and place further supply of cadaveric renal allografts. I Ad correspondence to: Allan M. Roza, M.D., Division of Transplanta ~ Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Aven , Milwaukee, Wisconsin 53226. 1. Starzl TE. Experience in nal tran8plantation. Philadelphia: Saun-ders 1964. 2. Grossman RA. Dafoe DC, Sc meld RB. et al. Perc:utaneoua transluminal angioplasty treatment of renal transplant artery stenosis. Transplantation 1982: 34, 6. 3. Hricko GM, Birtch A, Bennett AH, Wilson RE. Factors responsible for urinary fistula in the renal transplant recipient. Ann Surg 1973; 178: 609. Received 11 April 1988. Accepted 7 July 1988 PORTAL VEIN THROMBOEMBOLISM OF LIVER ALWGRAFrS FROM SPLENECTOMIZED DONORS! Since first reported by Delatour (1) in 1895, thrombosis of the splenoportal venous system has been known as a serious complication of splenectomy. This complication primarily af-fects patients with congestive splenomegaly and myeloprolif-erative disorders (2, 3), and is supposedly rare after splenec-tomy for trauma or incidental injury during laparotomy (4, 5). We describe two patienta who underwent splenectomy for trauma, in whom thromboembolism of the portal vein was identifIed later in the livers harvested for liver transplantation. Case 1. A 13-year-old boy was involved in a traffic accident on July 1, 1987, and suffered from multiple trauma. The patient underwent splenectomy, in addition to other procedures. Be-cause of irreversible head injury, the patient became a multiple organ donor, and the heart, Over and left kidney, were procured. The laboratory data before the organ donation were: SGOT 100 lUlL, SGPT 46 lUlL, total bilirubin 1.7 mg/dl, prothrom-bin time 13.7 sec, partial thromboplastin time 24.S sec, leuko-I Tbia work was BUppOrted by Reeean:h Grants from the Veterans Administration and Project Grant No. AM 29961 from the National Institute of Health, Bethesda, Maryland. cyte count 1OKRu1~/mmPI hematocrit level 42.4%. The platelet count was not measured. At the time of organ procurement, the liver appeared grossly normal and soft on palpation, and the intestine showed no evidence of venous congestion or edema. A small amount of serosanguinous fluid was seen in the peri-toneal cavity. In view of the extensive retroperitoneal hema-toma. a rapid flush technique (6) was used: Briefly, the portal cannula was inserted into the portal vein through the inferior mesenteric vein; following croea-clamp of the supraceliac aorta, the intraabdominal organs were flushed with cold solution from the portal as weD as terminal aortic cannulae. The allograft hepatectomy was uneventful with immediate blanching and fast cooling of the liver. The liver was then transplanted into a recipient with Laennec'. cirrhoeia. When the donor portal vein was transected prior to ita anastomosis with the recipient portal vein, a fresh clot was found at the cut margin. The clot, which was cylindrical and measured 6.2X0.4xO.2 cm, was removed and a Fogarty catheter was passed into the allograft portal vein, which showed DO evidence of residual thromboemboli. Following the portal vein anastomosis, the liver allograft was revascularized, and excellent reperfusion was observed. The TRANSPLANTATION VoL 47. NO.2 liver allograft functioned well and the recipient's postoperative recovery was uneventful except for an episode of rejection. An ultrasonograph performed on the eleventh postoperative day showed no evidence of portal vein thrombi. The recipient was discharged 48 days postoperatively with good allograft function. Case 2. A 19-year-old male patient was involved in a motor-cycle accident on December 27,1987, in which he suffered from closed-head injury and blunt abdominal trauma. The patient underwent splenectomy for lacerated spleen. Because of ine-versible brain damage, he became a multiple organ donor. The laboratory data prior to the organ donation were: SOOT 73 IU / L, SGPT 46 IU fL, total bilirubin 0.7 mg/dl, prothrombin time 12.8 sec, partial thromboplastin time 26.9 sec, leukocyte count 15.8xIQ3/mm3 , hematocrit level 33.9%, and platelet count 146xIQ3 /mm3• The liver and intestines appeared normal during organ recovery. The pancreas felt firm, but a biopsy of the pancreas showed no evidence of pancreatitis. No ascites was present. The portal cannula was inserted through the splenic vein after caudad mobilization of the pancreas. At the time of cannulation of the splenic vein, no clot was encountered. The supraceliac abdominal aorta was cross-clamped, and the in-traabdominal organs were flushed with cold solution from the portal and terminal aortic cannulae. The liver blanched and cooled down fast, and hepatectomy was performed without difficulty. When the graft was brought back and a redundant portion of the donor portal vein was excised immediately before portal vein anastomosis, a semiorganized clot measuring 2.0XO.8xO.8 cm was found lying loose in the donor portal vein. The clot was removed and the portal vein anastomosis was completed. The allograft perfused and functioned well. A Dop-pler ultrasonograph performed on the eighth postoperative day showed patent portal vein without any evidence of portal vein thromboemboli. The recipient was discharged 28 days postop-eratively with good graft function. Both donors were victims of multiple trauma in traffic acci-denta, for whom splenectomy was performed for blunt abdom-inal trauma. At the time of multiple organ donation, the liver and intestines showed no evidence of pathology, and liver allografts were harvested without technical difficulty. The in-tervale between splenectomy and multiple organ donation was 1 and 4 days, respectively. Fresh or semi-organized clota were identified lying loose in the portal vein of the liver allografts immediately before the portal vein anastomosis in the recipi-enta. It is unlikely that the donors had portal or superior mesen-teric vein thrombosis before multiple organ donation, since the liver and intestines looked grossly normal, no bloody ascites or melena was observed, and posttransplant liver functions in the recipienta of the livers were excellent without ischemic damage. Also, formation of a thrombus in the portal or superior mes-enteric vein during liver harvesting in case 1 is unlikely, since the portal cannula was inserted immediately before cross-clamping of the aorta, without interfering with the superior mesenteric venous flow, and since 3 mi/kg of heparin was administered immediately after the portal cannulation. Salter et al. (4) reported splenic vein thrombosis after sple-nectomy in 3 out of 7 patienta (42.9%) on autopsy, and Broe et al. (3) described 2 patienta in whom postmortem examination ~ the extension of thrombus from the splenic vein remnant to the portal vein. Since the splenic vein after the splenectomy becomes a cul-de-sac with very low flow, it is not surprising for a thrombus to form in this remnant structure (3). Allograft hepatectomy is associated with significant ma-nipulation of the splenoportal venous system. The size of the cylindrical thromboemboli in the allograft portal vein, 6.2xOAxO.2 cm in case 1 and 2.0xO.8xO.8 cm in case 2, seems to correlate with the size of the residual splenic vein in case 1, and the size of the splenic vein remnant proximal to the distal splenic ligature placed for cannulation of the portal cannula through the splenic vein in case 2. Although not confirmatory, it is suggested that the thromboemboli in our donors were formed in the residual splenic vein, and dislodged into the portal vein during liver allograft harvesting. Although portal vein thrombosis has been rare after liver transplantation in our experience (7), it can occur, and when it does, there is usually no good explanation for a thrombosis that apparently began in the liver allograft and extended doWD-ward Emboli already present in the graft at the time of organ procurement could be responsible. When liver allografts are harvested from splenectomized donors, manipulation of the remnant splenic vein or the pan-creas should be minimized. and the portal vein of the graft should be examined immediately after allograft hepatectomy in the donor hospital, in order to avoid a disastrous portal vein thrombosis in the recipient. KATSUHIKO YANAGA ANDREI STIEBER BABURAO KONERU LUIS A. MIELES ANDREAS G. TZAKIS THOMAS E. STARZL 2 Department of Surgery University Health Center of Pittsburgh University of Pittsburgh Pittsburgh, Pennsylvania 15213 S Address reprint requesta to Thomas E. Starzl, M.D., Ph.D., De-partment of Surgery. University of Pittsburgh School of Medicine, Falk Clinic. West, 3601 Fifth Avenue, Pittsburgh, Pennsy:,ania 15213. REFERENCES 1. Delatour HB. Thrombosis of mesenteric vein as a cause of death after splenectomy. Ann Surg 1895; 21: 24. 2. Davis HH, Sharpe JC. Splenic vein thrombosis following splenec-tomy. Surg Gynecol Obstet 1981; 67: 678. 3. Broe PJ, Conley CL. Cameron JL. Thrombosis of the portal vein following splenectomy for myeloid metaplasia. Surg Gyneco\ Obstet 1981; 152: 488. . o4. Salter PP. Sherlock EC. Splenectomy, thrombocytosis and venous thrombosis. Am Sure 1957; 23: 5-49. 5. Boxer MA, Braun J, Ellman L. thromboembolic risk of poataple-nectomy thrombocytosis. Arch Surg 1978; 113: 808. 6. Sta.rzl TE, Miller C, BJOZniek B, Makowka L. An improved tech-nique for multiple organ harveeting. Surg Gynecol Obstat 1987; 166: 3-43. 7. Lerut J, Tzakia AG. Bron K, et al. Complications of venous reconstruction in human orthotopic liver transplantation. Ann SUJ'I1987; 205: 40'. Received 7 June 1988. Accepted 30 June 1988. 

Portal vein thromboembolism of liver allografts from splenectomized donors.

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Portal vein thromboembolism of liver allografts from splenectomized donors.

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