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Majlesara A, Golriz M, Ramouz A, Khajeh E, Sabetkish N, Wielpütz MO, Rio Tinto H, Abbasi Dezfouli S, Loos M, Mehrabi A, Chang DH. Postoperative Management of Portal Vein Arterialization: An Interdisciplinary Institutional Approach. Cancers (Basel) 2024; 16:2459. [PMID: 39001521 PMCID: PMC11240632 DOI: 10.3390/cancers16132459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024] Open
Abstract
Portal vein arterialization (PVA) is a surgical procedure that plays a crucial role in hepatic vascular salvage when hepatic artery flow restoration remains elusive. Dedicated diagnostic vascular imaging and the timely management of PVA shunts are paramount to preventing complications, such as portal hypertension and thrombosis. Regrettably, a lack of standardized postoperative management protocols for PVA has increased morbidity and mortality rates post-procedure. In response to this challenge, we developed a PVA standard operating procedure (SOP) tailored to the needs of interventional radiologists. This SOP is designed to harmonize postoperative care, fostering scientific comparability across cases. This concise brief report aims to offer radiologists valuable insights into the PVA technique and considerations for post-PVA care and foster effective interdisciplinary collaboration.
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Affiliation(s)
- Ali Majlesara
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
| | - Nastaran Sabetkish
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
| | - Mark O. Wielpütz
- Department of Interventional Radiology, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Hugo Rio Tinto
- Radiology Department, Champalimaud Foundation, 1400-038 Lisbon, Portugal;
| | - Sepehr Abbasi Dezfouli
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany; (A.M.); (M.G.); (A.R.); (E.K.); (N.S.); (S.A.D.); (M.L.); (A.M.)
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
| | - De-Hua Chang
- Liver Cancer Center Heidelberg (LCCH), University of Heidelberg, 69120 Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Radiology, Lucerne Kantonsspital, Spitalstrasse, CH-6000 Lucerne, Switzerland
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Cortes-Mejia NA, Bejarano-Ramirez DF, Guerra-Londono JJ, Trivino-Alvarez DR, Tabares-Mesa R, Vera-Torres A. Portal vein arterialization in 25 liver transplant recipients: A Latin American single-center experience. World J Transplant 2024; 14:92528. [PMID: 38947972 PMCID: PMC11212596 DOI: 10.5500/wjt.v14.i2.92528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/19/2024] [Accepted: 04/28/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Portal vein arterialization (PVA) has been used in liver transplantation (LT) to maximize oxygen delivery when arterial circulation is compromised or has been used as an alternative reperfusion technique for complex portal vein thrombosis (PVT). The effect of PVA on portal perfusion and primary graft dysfunction (PGD) has not been assessed. AIM To examine the outcomes of patients who required PVA in correlation with their LT procedure. METHODS All patients receiving PVA and LT at the Fundacion Santa Fe de Bogota between 2011 and 2022 were analyzed. To account for the time-sensitive effects of graft perfusion, patients were classified into two groups: prereperfusion (pre-PVA), if the arterioportal anastomosis was performed before graft revascularization, and postreperfusion (post-PVA), if PVA was performed afterward. The pre-PVA rationale contemplated poor portal hemodynamics, severe vascular steal, or PVT. Post-PVA was considered if graft hypoperfusion became evident. Conservative interventions were attempted before PVA. RESULTS A total of 25 cases were identified: 15 before and 10 after graft reperfusion. Pre-PVA patients were more affected by diabetes, decompensated cirrhosis, impaired portal vein (PV) hemodynamics, and PVT. PGD was less common after pre-PVA (20.0% vs 60.0%) (P = 0.041). Those who developed PGD had a smaller increase in PV velocity (25.00 cm/s vs 73.42 cm/s) (P = 0.036) and flow (1.31 L/min vs 3.34 L/min) (P = 0.136) after arterialization. Nine patients required PVA closure (median time: 62 d). Pre-PVA and non-PGD cases had better survival rates than their counterparts (56.09 months vs 22.77 months and 54.15 months vs 31.91 months, respectively). CONCLUSION This is the largest report presenting PVA in LT. Results suggest that pre-PVA provides better graft perfusion than post-PVA. Graft hyperperfusion could play a protective role against PGD.
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Affiliation(s)
- Nicolas Andres Cortes-Mejia
- Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
- Transplant and Hepatobiliary Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
| | | | - Juan Jose Guerra-Londono
- Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | | | - Raquel Tabares-Mesa
- General Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
| | - Alonso Vera-Torres
- Transplant and Hepatobiliary Surgery Department, Fundacion Santa Fe de Bogota, Bogota 110111, Colombia
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Basso CD, Meniconi RL, Usai S, Guglielmo N, Colasanti M, Ferretti S, Sandri GBL, Ettorre GM. Portal vein arterialization following a radical left extended hepatectomy for Klatskin tumor: A case report. Ann Hepatobiliary Pancreat Surg 2021; 25:426-430. [PMID: 34402447 PMCID: PMC8382860 DOI: 10.14701/ahbps.2021.25.3.426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 12/01/2022] Open
Abstract
Portal vein arterialization (PVA) has been attracting attention for its role as a salvage inflow technique in various clinical applications. Initially performed in shunt surgery for portal hypertension, with the aim of preventing a decreased hepatic inflow, it is largely used in case of hepatic artery thrombosis in the transplantation domain or in the enlarged radical operations in case of hilar cancer invading the hepatic artery. A 62-year-old man underwent a left extended hepatectomy with hepatic bile duct resection and right Roux-en-Y hepaticojejunostomy for hilar cholangiocarcinoma. Computed tomography scan on postoperative day (POD) 5 revealed right hepatic artery pseudo-aneurysm, which was confirmed by an angiography. Stent placement was infeasible. Coiling of the pseudoaneurysm was associated with a risk of complete occlusion inducing critical liver failure. Since his general conditions were deteriorated, the patient underwent an emergency laparotomy. Hepatic artery reconstruction was impossible. Thus, a PVA was performed by anastomosing the ileocecal artery and vein. The intraoperative ultrasound showed satisfactory patency of the PVA with good portal flow in the absence of arterial flow. Doppler ultrasound on POD 15 showed that the cross-sectional area and blood flow of the portal vein were increased. The patient was discharged on POD 54 in good general condition. Hepatic artery disruption represents potentially lethal complications of hepatic, biliary, and pancreatic surgery. PVA may be a feasible therapeutic strategy to guarantee arterial inflow to the remnant liver. Although PVA is a salvage surgical procedure, increased portal flow should be controlled to avoid portal hypertension and liver fibrosis.
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Affiliation(s)
- Celeste Del Basso
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Roberto Luca Meniconi
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Sofia Usai
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Stefano Ferretti
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
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Durand F, Dokmak S, Roux O, Francoz C. Liver Transplantation in the Setting of Non-malignant Portal Vein Thrombosis. PORTAL VEIN THROMBOSIS 2021:131-156. [DOI: 10.1007/978-981-33-6538-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Roy A, Taneja S, Behera A, Kaman L, Kalra N, Chaluvashetty SB, Das A, Dahiya D, Duseja AK, Singh V. Intrahepatic Arterioportal Fistula: A Rare Cause of Portal Hypertension After Deceased Donor Liver Transplant. EXP CLIN TRANSPLANT 2020; 18:645-648. [PMID: 32778016 DOI: 10.6002/ect.2020.0119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 43-year-old male patient, who received a deceased donor liver transplant for background ethanol-related decompensated cirrhosis, presented 7 months after transplant with mild abdominal distension and pain. On evaluation, the patient had thrombocytopenia, high serum-ascites albumin gradient ascites, and deranged liver functions. The Doppler study of the splenoportal axis showed hepatofugal flow in the recipient's portal vein, normal hepatic veins, a normal liver, splenomegaly, mild ascites, and multiple periportal collaterals. A transjugular liver biopsy and a hepatic venous pressure gradient measurement were done, which suggested mild portal tract inflammation with portal tract fibrosis with prominent portal venous thickening and normal hepatic venous pressure gradient (4 mm). However, the patient had a progressive increase in ascites and a dramatic increase in serum bilirubin level. A triple-phase computed tomography was done that showed rapid contrast flow in both the portal and hepatic arterial phase, suggesting arterialization of the portal flow with possible suspicion of a communicating arterioportal fistula. The patient underwent digital subtraction angiography, which was followed by an embolization of the arterioportal fistula. After embolization, serum bilirubin gradually decreased and ascites resolved. A repeat Doppler of the portal venous system showed established hepatopetal flow with progressively rising portal flow velocities.
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Affiliation(s)
- Akash Roy
- From the Division of General Surgery and Liver Transplantation, Hospital Oswaldo Cruz, Pernambuco University, Recife, Pernambuco, Brazil
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Tekin A, Beduschi T, Vianna R, Mangus RS. Multivisceral transplant as an option to transplant cirrhotic patients with severe portal vein thrombosis. Int J Surg 2020; 82S:115-121. [PMID: 32739540 DOI: 10.1016/j.ijsu.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/15/2022]
Abstract
Non-tumoral portal vein thrombosis (PVT) is a critical complication in the patient with advanced cirrhosis awaiting liver transplantation (LT). With the evolution of liver transplant (LT) technique, PVT has morphed from an absolute contraindication to a relative contraindication, depending on the grade of the thrombus. The Yerdel classification is one system of grading PVT severity. Patients with Yerdel class 1-3 PVT can undergo LT at centers with experience in complex portal vein (PV) dissection, thrombectomy, and reconstruction. Class 4 PVT, however, is even more complex and may require heroic techniques such as cavoportal hemitransposition, PV arterialization or multivisceral transplant (MVT). Some centers use a MVT back-up approach for patients with Yerdel class 4 PVT. In these patients, all organs with PV outflow are procured simultaneously as a cluster graft from a deceased donor (liver, pancreas, intestine±stomach). If physiologic PV inflow is established intraoperatively, the recipient undergoes LT. Otherwise the MVT graft is transplanted. MVT establishes physiologic PV flow, but transplantation of the intestine confers significant lifelong risks including rejection, graft-versus host disease and post-transplant lymphoma. Yerdel class 1-4 PVT patients undergoing successful LT have 5-year survival similar to non-PVT patients, while patients requiring full MVT experience somewhat higher mortality because of the complexity of the surgery and medical management.
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Teng F, Sun KY, Fu ZR. Tailored classification of portal vein thrombosis for liver transplantation: Focus on strategies for portal vein inflow reconstruction. World J Gastroenterol 2020; 26:2691-2701. [PMID: 32550747 PMCID: PMC7284174 DOI: 10.3748/wjg.v26.i21.2691] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed via low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.
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Affiliation(s)
- Fei Teng
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Ke-Yan Sun
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Zhi-Ren Fu
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
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Yamamoto R, Sugiura T, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Aramaki T, Uesaka K. Multidisciplinary treatment of left hepatic artery pseudoaneurysm after hepatobiliary resection for gallbladder cancer: a case report. Surg Case Rep 2019; 5:192. [PMID: 31820140 PMCID: PMC6901650 DOI: 10.1186/s40792-019-0757-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/29/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND When a postoperative hepatic artery pseudoaneurysm develops after massive hepatectomy, both an intervention for the pseudoaneurysm and patency of hepatic artery should be considered because occlusion of the residual hepatic artery results in critical liver failure. However, the treatment strategy for a pseudoaneurysm of the hepatic artery after hepatobiliary resection is not well established. CASE PRESENTATION A 65-year-old woman underwent right hepatectomy, extrahepatic duct resection, and portal vein resection, for gallbladder cancer. Although the patient had an uneventful postoperative course, computed tomography on postoperative day 6 showed a 6-mm pseudoaneurysm of the hepatic artery. Angiography revealed the pseudoaneurysm located on the bifurcation of the left hepatic artery to the segment 2 artery plus the segment 3 artery and 4 artery. Stent placement in the left hepatic artery was not feasible because the artery was too narrow, and coiling of the pseudoaneurysm was associated with a risk of occluding the left hepatic artery and inducing critical liver failure. Therefore, portal vein arterialization constructed by anastomosing the ileocecal artery and vein was performed prior to embolization of the pseudoaneurysm to maintain the oxygen level of the remnant liver, even if the left hepatic artery was accidentally occluded. The pseudoaneurysm was selectively embolized without occlusion of the left hepatic artery, and the postoperative laboratory data were within normal limits. Although uncontrollable ascites due to portal hypertension occurred, embolization of the ileocolic shunt rapidly resolved it. The patient was discharged on postoperative day 45. CONCLUSION Portal vein arterialization prior to embolization of the aneurysm may be a feasible therapeutic strategy for a pseudoaneurysm that develops after hepatectomy for hepatobiliary malignancy to guarantee arterial inflow to the remnant liver. Early embolization of arterioportal shunting after confirmation of arterial inflow to the liver should be performed to prevent morbidity induced by portal hypertension.
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Affiliation(s)
- Ryusei Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan.
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
| | - Takeshi Aramaki
- Division of Interventional Radiology, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan
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Au KP, Chok KSH, Sin SL, Fung JYY, Lo CM, Mok VWK. Partial portal vein arterialization using right gastroepiploic artery: A novel solution for portal hypoperfusion. Hepatobiliary Pancreat Dis Int 2018; 17:367-370. [PMID: 30029952 DOI: 10.1016/j.hbpd.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/12/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Kin Pan Au
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Kenneth Siu Ho Chok
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong, China.
| | - Sui Ling Sin
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - James Yan Yue Fung
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Chung Mau Lo
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong, China
| | - Vivian Way Kay Mok
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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刘 鹏, 向 俊, 郑 幸, 苏 敬, 董 鼎, 杨 丽, 吕 毅. [Implantation strategy of tissue-engineered liver based on decellularized spleen matrix in rats]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:698-703. [PMID: 29997092 PMCID: PMC6765707 DOI: 10.3969/j.issn.1673-4254.2018.06.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To explore the optimal implantation strategy of tissue-engineered liver (TEL) constructed based on decellularized spleen matrix (DSM) in rats. METHODS DSM was prepared by freeze-thawing and perfusion with sodium dodecyl sulfate (SDS) of the spleen of healthy SD rats. Primary rat hepatocytes isolated using modified Seglen 2-step perfusion method were implanted into the DSM to construct the TEL. The advantages and disadvantages were evaluated of 4 transplant strategies of the TEL, namely ectopic vascular anastomosis, liver cross-section suture transplantation, intrahepatic insertion and mesenteric transplantation. RESULTS The planting rate of hepatocytes in the DSM was (74.5∓7.7)%. HE staining and scanning electron microscopy showed satisfactory cell status, and immunofluorescence staining confirmed the normal expression of ALB and G6Pc in the cells. For TEL implantation, ectopic vascular anastomosis was difficult and resulted in a mortality rate of 33.3% perioperatively and massive thrombus formation in the matrix within 6 h. Hepatic cross-section suture failed to rapidly establish sufficient blood supply, and no viable graft was observed 3 days after the operation. With intrahepatic insertion method, the hepatocytes in the DSM could survive as long as 14 days. Mesenteric transplantation resulted in a hepatocyte survival rate of (38.3+7.1)% at 14 days after implantation. CONCLUSION TEL constructed based on DSM can perform liver-specific functions with a good cytological bioactivity. Mesenteric transplantation of the TEL, which is simple, safe and effective, is currently the optimal transplantation strategy.
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Affiliation(s)
- 鹏 刘
- 西安交通大学第一附属医院肝胆外科，陕西 西安 710061Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University
- 陕西省肿瘤医院妇瘤外科，陕西 西安 710061Department of Gynecology Oncology Surgery, Shaanxi Provincial Cancer Hospital
| | - 俊西 向
- 西安交通大学第一附属医院肝胆外科，陕西 西安 710061Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University
- 精准外科与再生医学国家地方联合工程研究中心，陕西 西安 710061National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an 710061, China
| | - 幸龙 郑
- 精准外科与再生医学国家地方联合工程研究中心，陕西 西安 710061National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an 710061, China
| | - 敬博 苏
- 精准外科与再生医学国家地方联合工程研究中心，陕西 西安 710061National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an 710061, China
| | - 鼎辉 董
- 西安交通大学第一附属医院肝胆外科，陕西 西安 710061Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University
- 精准外科与再生医学国家地方联合工程研究中心，陕西 西安 710061National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an 710061, China
| | - 丽斐 杨
- 精准外科与再生医学国家地方联合工程研究中心，陕西 西安 710061National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an 710061, China
| | - 毅 吕
- 西安交通大学第一附属医院肝胆外科，陕西 西安 710061Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University
- 精准外科与再生医学国家地方联合工程研究中心，陕西 西安 710061National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, Xi'an 710061, China
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Cocca CJ, Weisse C, Berent AC, Rosen R. Minimally invasive treatment of mesenteric arterioportal fistulas in two dogs. J Am Vet Med Assoc 2017; 251:1306-1312. [DOI: 10.2460/javma.251.11.1306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Qiao JL, Sun J, Li J, Zhang JJ, Meng XK. Liver dual arterial blood supply maintains liver regeneration: Analysis of signaling pathways in rats. Mol Med Rep 2017; 17:979-987. [PMID: 29115531 PMCID: PMC5780179 DOI: 10.3892/mmr.2017.7961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 10/18/2017] [Indexed: 11/06/2022] Open
Abstract
Liver dual arterial blood supply (LDABS) could increase blood supply to the liver and maintain normal liver regeneration in patients with compromised portal vein. The current study attempted to examine the underlying molecular mechanisms. Male Sprague-Dawley rats randomly received partial hepatectomy (PH) alone or PH followed by LDABS. Liver regeneration was assessed by histological examination, liver function and liver regeneration rate (LRR). Whole-genome oligo microarray analysis was used to compare gene expression profile between rats receiving PH and rats receiving PH plus LDABS. Key genes identification was validated using a MAPK signaling polymerase chain reaction (PCR) array. The extent of liver regeneration in rats receiving PH plus LDABS was comparable to that in rats receiving PH alone. The differentially expressed genes were enriched in 12 signaling pathways in two groups. MAPK signaling pathway, NF-kappa B signaling pathway, and Toll-like receptor signaling pathway were involved in LDABS-mediated liver regeneration, with Retinoblastoma 1 (Rb1), Cyclin D1, Cyclin-dependent kinase 4, Mitogen-activated protein kinase 10 (Mapk10) and CAMP responsive element binding protein 1 genes in the initiation phase, Kirsten rat sarcoma viral oncogene homolog (Kras), tumor protein 53, MYC proto-oncogene, BHLH transcription factor, Cyclin E1 and Heat shock protein family B (small) member 1 genes in the proliferation phase, Kras, Rb1, Jun proto-oncogene, AP-1 transcription factor subunit, Cyclin D2 and Mapk10 genes in the termination phase were identified as key genes in LDABS-mediated liver regeneration using MAPK signaling PCR array analysis.
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Affiliation(s)
- Jian-Liang Qiao
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
| | - Juan Sun
- Department of Immunology, Inner Mongolia Medical University, Hohhot 010110, P.R. China
| | - Jun Li
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
| | - Jun-Jing Zhang
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
| | - Xing-Kai Meng
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
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Shrivastava A, Rampal JS, Nageshwar Reddy D. Giant Intrahepatic Portal Vein Aneurysm: Leave it or Treat it? J Clin Exp Hepatol 2017; 7:71-76. [PMID: 28348475 PMCID: PMC5357696 DOI: 10.1016/j.jceh.2016.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/28/2016] [Indexed: 12/12/2022] Open
Abstract
Portal vein aneurysm (PVA) is a rare vascular dilatation of the portal vein. It is a rare vascular anomaly representing less than 3% of all visceral aneurysms and is not well understood. Usually, PVA are incidental findings, are asymptomatic, and clinical symptoms are proportionally related to size. Patients present with nonspecific epigastric pain or gastrointestinal bleeding with underlying portal hypertension. PVA may be associated with various complications such as biliary tract compression, portal vein thrombosis/rupture, duodenal compression, gastrointestinal bleeding, and inferior vena cava obstruction. Differential diagnoses of portal vein aneurysms are solid, cystic, and hypervascular abdominal masses, and it is important that the radiologists be aware of their multi-modality appearance; hence, the aim of this article was to provide an overview of the available literature to better simplify various aspects of this rare entity and diagnostic appearance on different modality with available treatment options. In our case, a 55-year-old male patient came to the gastroenterology OPD for further management of pancreatitis with portal hypertension and biliary obstruction with plastic stents in CBD and PD for the same. In this article, we have reported a case of largest intrahepatic portal vein aneurysm and its management by endovascular technique. As per our knowledge, this is the largest intrahepatic portal vein aneurysm and first case where the endovascular technique was used for the treatment of the same.
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Affiliation(s)
- Amit Shrivastava
- McGill University, Montreal, Canada
- Address for correspondence: Amit Shrivastava, Post Doctoral Fellow, Abdominal Imaging and Non-vascular Intervention, McGill University, Montreal, Canada. Fax: +1 514 934 8263.Post Doctoral Fellow, Abdominal Imaging and Non-vascular Intervention, McGill UniversityMontrealCanada
| | - Jagdeesh S. Rampal
- Chief, Department of Intervention Radiology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D. Nageshwar Reddy
- Director, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Saad WEA, Davies MG, Rubens DJ, Sahler LG, Patel NC, Lee DE, Kitanosono T, Sasson T, Waldman DL. Endoluminal Management of Arterioportal Fistulae in Liver Transplant Recipients: A Single-Center Experience. Vasc Endovascular Surg 2016; 40:451-9. [PMID: 17202091 DOI: 10.1177/1538574406294072] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transcatheter embolization of arterioportal fistulae in liver transplant recipients is restricted to symptomatic arterioportal fistulae. Angiograms of liver transplant recipients from a single university medical center were retrospectively reviewed. Hemodynamically significant arterioportal fistulae were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Six arterioportal fistulae were found. Doppler ultrasound imaging detected 50% of all arterioportal fistulae and all 3 hemodynamically significant arterioportal fistulae. Three successful embolizations were performed. Follow-up (37 to 67 months) demonstrated patent hepatic arteries and no parenchymal ischemic changes with graft preservation. High-throughput arterioportal fistulae may require larger intrahepatic artery branch embolization. There is a window of opportunity for embolizing significant arterioportal fistulae before their progression to large symptomatic, high through-put arterioportal fistulae with their added risk of ischemic changes before and after embolization.
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Affiliation(s)
- Wael E A Saad
- Department of Imaging Sciences, Section of Vascular/Interventional Radiology, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Fernández-Rodríguez OM, Ríos A, Palenciano C, Ramírez P, Navarro JL, Martínez-Alarcón L, Martínez C, Fuente T, Pons JA, Navarro JA, Majado M, Martínez P, Parrilla P. A hemodynamic, metabolic and histopathological study of a heterotopic auxiliary swine liver graft with portal vein arterialization. Cir Esp 2015; 94:77-85. [PMID: 26615737 DOI: 10.1016/j.ciresp.2015.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/18/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Auxiliary heterotopic liver transplantation with portal vein arterialization (AHLT-PVA) is a model that has been hardly studied, despite its therapeutic potential. METHODS Hemodynamic and biochemical characterization was carried out during graft implantation, in a pig-to-pig model (n=15 AHLT-PVA). Furthermore a histopathological study was performed to establish microscopic alterations due to PVA. RESULTS Reperfusion of the arterialized graft produced an increase in heart rate (HR) vs. baseline (P=.004) and vs. inferior vena cava clamping phase (P=.004); and a decrease in systemic vascular resistance vs. cava clamping phase (P=.021). At the end of implantation, cardiac output remained elevated (P=.001), likewise HR remained increased vs. baseline phase (P=.002). Mean arterial pressure decreased with cava clamping, but was not affected by the reperfusion of the graft, nor the skin closure. The histopathological study at 3, 10, and 21 days post-PVA revealed that functional liver structure was maintained although it is common to find foci of perilobular necrosis on day 3 (P=.049), and perilobular connective tissue proliferation at day 10 (P=.007), vs. native liver. CONCLUSIONS The described arterialized liver graft model minimizes the number of vascular anastomoses vs. previously described models. It is hemodynamically and metabolically well tolerated and the double arterial vascularization of the graft does not cause significant changes in liver histology.
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Affiliation(s)
- Olga M Fernández-Rodríguez
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Antonio Ríos
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Cirugía, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España.
| | - Carlos Palenciano
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Anestesia, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Pablo Ramírez
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Cirugía, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - José Luis Navarro
- Departamento de Medicina Nuclear, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Laura Martínez-Alarcón
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Carlos Martínez
- Departamento de Patología, Facultad de Veterinaria, Universidad de Murcia, España
| | - Teodomiro Fuente
- Departamento de Medicina Nuclear, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - José Antonio Pons
- Departamento de Medicina Interna, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - José Antonio Navarro
- Departamento de Patología, Facultad de Veterinaria, Universidad de Murcia, España
| | - Maruja Majado
- Departamento de Hematología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Pedro Martínez
- Departamento de Hematología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Pascual Parrilla
- Departamento de Cirugía, Cirugía Experimental, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; Departamento de Cirugía, Unidad de Trasplante Hepático, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
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Abstract
Portal vein aneurysm is an unusual vascular dilatation of the portal vein, which was first described by Barzilai and Kleckner in 1956 and since then less than 200 cases have been reported. The aim of this article is to provide an overview of the international literature to better clarify various aspects of this rare nosological entity and provide clear evidence-based summary, when available, of the clinical and surgical management. A systematic literature search of the Pubmed database was performed for all articles related to portal vein aneurysm. All articles published from 1956 to 2014 were examined for a total of 96 reports, including 190 patients. Portal vein aneurysm is defined as a portal vein diameter exceeding 1.9 cm in cirrhotic patients and 1.5 cm in normal livers. It can be congenital or acquired and portal hypertension represents the main cause of the acquired version. Surgical indication is considered in case of rupture, thrombosis or symptomatic aneurysms. Aneurysmectomy and aneurysmorrhaphy are considered in patients with normal liver, while shunt procedures or liver transplantation are the treatment of choice in case of portal hypertension. Being such a rare vascular entity its management should be reserved to high-volume tertiary hepato-biliary centres.
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17
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McKenna GJ. Making the extraordinary, ordinary: renoportal bypass for complete portal vein thrombosis. Liver Transpl 2015; 21:275-6. [PMID: 25678340 DOI: 10.1002/lt.24091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 01/18/2015] [Indexed: 01/17/2023]
Affiliation(s)
- Greg J McKenna
- Department of Surgery, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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18
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Qiao J, Han C, Zhang J, Wang Z, Meng X. A new rat model of auxiliary partial heterotopic liver transplantation with liver dual arterial blood supply. Exp Ther Med 2015; 9:367-371. [PMID: 25574199 PMCID: PMC4280989 DOI: 10.3892/etm.2014.2110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 10/16/2014] [Indexed: 01/23/2023] Open
Abstract
Auxiliary partial heterotopic liver transplantation (APHLT) with portal vein arterialization is a valuable procedure to be considered in the treatment of patients with acute liver failure and metabolic liver diseases. The aim of this study was to develop a new rat model of APHLT with liver dual arterial blood supply (LDABS). A total of 20 rats were used. The donor liver was resected, and the celiac trunk was reserved. Left and medial hepatic lobes accounting for 70% of the liver mass were removed en bloc and the suprahepatic caval vein was ligated simultaneously. Thus, 30% of the donor liver was obtained as the graft. Sleeve anastomosis of the graft portal vein and splenic artery were performed after narrowing the portal vein lumen through suturing. The right kidney of the recipient was removed, and sleeve anastomosis was performed between the celiac trunk of the graft and the right renal artery of the recipient. In addition, end-to-end anastomosis was performed between the infrahepatic caval vein of the graft and the right renal vein of the recipient. Following the reperfusion of the graft, the blood flow of the arterialized portal vein was controlled within the physiological range through suturing and narrowing under monitoring with an ultrasonic flowmeter. The bile duct of the graft was implanted into the duodenum of the recipient through an internal stent catheter. A 70% section of the native liver (left and medial hepatic lobes) was resected using bloodless hepatectomy. The mean operative duration was 154.5±16.4 min, and the warm and cold ischemia times of the graft were 8.1±1.1 min and 64.5±6.6 min, respectively. The blood flow of the arterialized portal vein to the graft was 1.8±0.3 ml/min/g liver weight. The success rate of model establishment (waking with post-surgical survival of >24 h) was 70% (7/10). Following successful model establishment, all rats survived 7 days post-surgery (100%; 7/7). The graft was found to be soft in texture and bright red in color following exploratory laparotomy. In conclusion, a new rat model of APHLT with LDABS without stent for vascular reconstruction was developed. This is a feasible and reliable rat model for liver transplantation study.
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Affiliation(s)
- Jianliang Qiao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China ; Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Chunlei Han
- Turku PET Centre, Turku University Hospital and University of Turku, Turku 20521, Finland
| | - Junjing Zhang
- Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Zhiyong Wang
- Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Xingkai Meng
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China ; Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
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19
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Zhang K, Jiang Y, Lv LZ, Cai QC, Yang F, Hu HZ, Zhang XJ. Portal vein arterialization technique for liver transplantation patients. World J Gastroenterol 2014; 20:12359-12362. [PMID: 25232274 PMCID: PMC4161825 DOI: 10.3748/wjg.v20.i34.12359] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 04/02/2014] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
Liver transplantations were performed on two patients with hepatic failure caused by liver cirrhosis. Hard obsolete thrombi and portal venous sclerosis were observed in the major portal veins of both patients. The arteria colica media of one recipient and the portal vein of the donor were anastomosed end-to-end. The hepatic artery of the first donor was anastomosed end-to end with the gastroduodenal artery of the first recipient; meanwhile, the portal vein of the second donor was simultaneously anastomosed end- to-end with the common hepatic artery of the second recipient. The blood flow of the portal vein, the perfusion of the donor liver and liver function were satisfactory after surgery. Portal vein arterialization might be an effective treatment for patients whose portal vein reconstruction was difficult.
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20
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Bhangui P, Salloum C, Lim C, Andreani P, Ariche A, Adam R, Castaing D, Kerba T, Azoulay D. Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience. HPB (Oxford) 2014; 16:723-38. [PMID: 24329988 PMCID: PMC4113254 DOI: 10.1111/hpb.12200] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 10/27/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Portal vein arterialization (PVA) has been used as a salvage inflow technique when hepatic artery (HA) reconstruction is deemed impossible in liver transplantation (LT) or hepatopancreatobiliary (HPB) surgery. Outcomes and the management of possible complications have not been well described. METHODS The present study analysed outcomes in 16 patients who underwent PVA during the period from February 2005 to January 2011 for HA thrombosis post-LT (n = 7) or after liver resection (n = 1), during curative resection for locally advanced HPB cancers (requiring HA interruption) (n = 7) and for HA resection without reconstruction (n = 1). In addition, a literature review was conducted. RESULTS Nine patients were women. The median age of the patients was 58 years (range: 30-72 years). Recovery of intrahepatic arterial signals and PVA shunt patency were documented using Doppler ultrasound until the last follow-up (or until shunt thrombosis in some cases). Of five postoperative deaths, two occurred as a result of haemorrhagic shock, one as a result of liver ischaemia and one as a result of sepsis. The fifth patient died at home of unknown cause. Three patients (19%) had major bleeding related to portal hypertension (PHT). Of these, two underwent re-exploration and one underwent successful shunt embolization to control the bleeding. Four patients (25%) had early shunt thrombosis, two of whom underwent a second PVA. After a median follow-up of 13 months (range: 1-60 months), 10 patients (63%) remained alive with normal liver function and one submitted to retransplantation. CONCLUSIONS Portal vein arterialization results in acceptable rates of survival in relation to spontaneous outcomes in patients with completely de-arterialized livers. The management of complications (especially PHT) after the procedure is challenging. Portal vein arterialization may represent a salvage option or a bridge to liver retransplantation and thus may make curative resection in locally advanced HPB cancers with vascular involvement feasible.
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Affiliation(s)
- Prashant Bhangui
- Department of Surgery, Medanta Institute of Liver Transplantation and Regenerative MedicineDelhi, India
| | - Chady Salloum
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Chetana Lim
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Paola Andreani
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Arie Ariche
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - René Adam
- Department of Hepato-Biliary Surgery and Liver Transplantation, Paul Brousse Hospital, AP-HPVillejuif, France
| | - Denis Castaing
- Department of Hepato-Biliary Surgery and Liver Transplantation, Paul Brousse Hospital, AP-HPVillejuif, France
| | - Tech Kerba
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
| | - Daniel Azoulay
- Department of Hepato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP)Créteil, France
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21
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Francoz C, Valla D, Durand F. Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 2012; 57:203-12. [PMID: 22446690 DOI: 10.1016/j.jhep.2011.12.034] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 12/08/2011] [Accepted: 12/22/2011] [Indexed: 12/13/2022]
Abstract
Portal vein thrombosis is not uncommon in candidates for transplantation. Partial thrombosis is more common than complete thrombosis. Despite careful screening at evaluation, a number of patients are still found with previously unrecognized thrombosis per-operatively. The objective is to recanalize the portal vein or, if recanalization is not achievable, to prevent the extension of the thrombus so that a splanchnic vein can be used as the inflow vessel to restore physiological blood flow to the allograft. Anticoagulation during waiting time and transjugular intrahepatic portosystemic shunt (TIPS) are two options to achieve these goals. TIPS may achieve recanalization in patients with complete portal vein thrombosis. However, a marked impairment in liver function, which is a characteristic feature of most candidates for transplantation, may be a contraindication for TIPS. Importantly, the MELD score is artificially increased by the administration of vitamin K antagonists due to prolonged INR. When patency of the portal vein and/or superior mesenteric vein is not achieved, only non-anatomical techniques (renoportal anastomosis or cavoportal hemitransposition) can be performed. These techniques, which do not fully reverse portal hypertension, are associated with higher morbidity and mortality risks. Multivisceral transplantation including the liver and small bowel needs to be evaluated. In the absence of prothrombotic states that may persist after transplantation, there is no evidence that pre-transplant portal vein thrombosis justifies long term anticoagulation post-transplantation, provided portal flow has been restored through conventional end-to-end portal anastomosis.
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Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care, Hopital Beaujon, Clichy, INSERM U773 CRB3, University of Paris VII Denis Diderot, Paris, France
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22
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Caval inflow to the graft for liver transplantation in patients with diffuse portal vein thrombosis: a 12-year experience. Ann Surg 2012; 254:1008-16. [PMID: 21869678 DOI: 10.1097/sla.0b013e31822d7894] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyze the short- and long-term results of cavoportal anastomosis (CPA) and renoportal anastomosis (RPA) in 20 consecutive liver transplantation (LT) candidates with diffuse portal vein thrombosis (PVT). SUMMARY BACKGROUND DATA Caval inflow to the graft (CIG) by CPA or RPA has been the most commonly used salvage technique to overcome the absolute contraindication for LT in case of diffuse PVT. METHODS From 1996 to 2009, 3 patients (15%) underwent CPA and 17 patients (85%) had an RPA during LT. In addition to routine follow-up, patients were specifically evaluated for signs of portal hypertension (PHT) and for patency of the anastomoses. The follow-up ranged from 3 months to 12 years (median of 4.5 years). RESULTS : Caval inflow to the graft was feasible in all attempted cases. In the short term (<6 months), 35% of patients had residual PHT-related complications (massive ascites and variceal bleeding). These resolved spontaneously or with endoscopic management. Three deaths occurred; none was related to PHT or shunt thrombosis. In the long term (>6 months), 1 death occurred because of recurrent variceal bleeding after RPA thrombosis. At last follow-up, all living patients [n = 13 (65%)] had normal liver function, no signs of PHT and patent anastomoses. There were no retransplantations. Graft and patient survival at 1, 3, and 5 years were 83%, 75%, and 60%, respectively. CONCLUSIONS Caval inflow to the graft is an efficacious salvage technique with satisfactory long-term results, considering the spontaneous outcome in patients denied LT because of diffuse PVT. Adequate preoperative management of PHT and its associated complications is vital in obtaining good results. In the long term, residual PHT resolves and the liver function returns to normal.
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23
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Saad W, Lippert A, Davies M, Arslan B, Kumer S, Waldman D, Turba U, Schmitt T, Matsumoto A, Angle J. Prevalence, presentation, and endovascular management of hemodynamically or clinically significant arterio-portal fistulae in living and cadaveric donor liver transplant recipients. Clin Transplant 2011; 26:532-8. [PMID: 22151012 DOI: 10.1111/j.1399-0012.2011.01547.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the prevalence (cadaveric vs. living donor transplants), clinical features, and the effectiveness of endovascular management of significant arterio-portal fistulae (APF) in liver transplant recipients. METHODS A retrospective audit of liver transplant recipients in two institutions was performed (1996-2009). Significant APF were included and were defined as symptomatic and/or hemodynamically significant (causing graft dysfunction and/or having abnormal Doppler findings in the portal vein). Patients with significant APF were evaluated for presenting symptoms, imaging features, size/branch order portal vein involvement, and effectiveness of the endovascular management (coil embolization). RESULTS Four significant APF were found in 1992 (0.2%) liver transplants. Two were symptomatic and two were asymptomatic but were hemodynamically significant with liver function test abnormalities. All four APF were found in cadaveric donor graft recipients (0.23%, N = 4/1753) and none in 239 living donor graft recipients. However, there was no statistical difference between cadaveric and living donor graft recipients (p = 1.0, odds ratio = 1.23). Coil embolization was technically and clinically successful in all 4 without complications and causing normalization of the abnormal Doppler findings. CONCLUSION Significant APF are a rare diagnosis (0.2% of transplants). Coil embolization is a safe and effective treatment option for APF in transplants.
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Affiliation(s)
- Wael Saad
- Division of Vascular Interventional Radiology, University of Rochester Medical Center, Rochester, NY, USA
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24
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Rotellar F, Cienfuegos JA, Bueno A, Martí P, Valentí V, Zozaya G, Pardo F. Portal revascularization in the setting of cavernous transformation through a paracholedocal vein: a case report. Transplant Proc 2011; 42:3079-80. [PMID: 20970613 DOI: 10.1016/j.transproceed.2010.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Diffuse thrombosis of the entire portal system (PVT) and cavernomatous transformation of the portal vein (CTPV) represents a demanding challenge in liver transplantation. We present the case of a patient with nodular regenerative hyperplasia and recurrent episodes of type B hepatic encephalopathy concomitant with PVT as well as CTPV, successfully treated with orthotopic liver transplantation. The portal inflow to the graft was carried out through the confluence of 2 thin paracholedochal varicose veins, obtaining good early graft function and recovery of the encephalopatic episodes. This alternative should be kept in mind as an option to assure hepatopetal splanchnic flow in those cases of diffuse thrombosis and cavernomatous transformation of portal vein.
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Affiliation(s)
- F Rotellar
- Department of General Surgery, University Clinic of Navarra, University of Navarra, Pamplona, Spain
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Maggi U, Camagni S, Reggiani P, Lauro R, Sposito C, Melada E, Rossi G. Portal vein arterialization for hepatic artery thrombosis in liver transplantation: a case report, Doppler-ultrasound aspects, and review of the literature. Transplant Proc 2010; 42:1369-74. [PMID: 20534305 DOI: 10.1016/j.transproceed.2010.03.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Portal vein arterialization (PVA) is a salvage procedure for insufficient hepatic arterial or portal vascularization. It plays a role in auxiliary and orthotopic liver transplantation (OLT). In OLT, current indications for PVA include hepatic artery thrombosis (HAT), pre-OLT or post-OLT extended splanchnic vein thrombosis, intraoperative low portal flow, and anatomic variations like the absence of portal and mesenteric veins. Out of the transplantation domain, PVA is used both in extensive surgery for malignancies of the liver, biliary tract, and pancreas and in the treatment of fulminant hepatic failure (FHF) due to intoxications. We describe a case of acute post-OLT HAT successfully treated with PVA as a short bridge to retransplantation. By Doppler ultrasound of clinical PVA we detected an increased intrahepatic portal flow velocity, with disappearance of the arterial spikes, a finding that needs further investigation. PVA represents a rare surgical procedure. In fact, it has been used most of all in urgent conditions or in case of abrupt vascular complications during surgery. According to the literature, PVA emerges as a salvage procedure for poor arterial or portal hepatic flow, both in OLT and in general abdominal surgery. The outcome of this procedure is unpredictable. The aim of the shunt is to gain time, awaiting the onset of collateral arterial vessels or the performance of definitive surgery. Its early thrombosis may be a catastrophic event, due to acute liver ischemia. In contrast, a late occlusion is often well tolerated. Strict surveillance is always useful because sometimes it is mandatory to embolize the arterioportal fistula to treat or to prevent the onset of portal hypertension.
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Affiliation(s)
- U Maggi
- Unitá Operativa Chirurgia Generale e Trapianti di Fegato, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano, Italy.
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Bonnet S, Sauvanet A, Bruno O, Sommacale D, Francoz C, Dondero F, Durand F, Belghiti J. Long-term survival after portal vein arterialization for portal vein thrombosis in orthotopic liver transplantation. ACTA ACUST UNITED AC 2009; 34:23-8. [PMID: 19643558 DOI: 10.1016/j.gcb.2009.05.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 04/27/2009] [Accepted: 05/17/2009] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis is a relatively common finding during liver transplantation. The management of portal vein thrombosis during liver transplantation is technically demanding and ensures adequate portal flow to the liver graft. Eversion thromboendovenectomy and bypass using a patent splanchnic vein and cavoportal hemitransposition are the most often used procedures to treat portal vein thrombosis. There have been anecdotal reports of portal vein arterialization. We report a case of portal vein arterialization during orthotopic liver transplantation for decompensated cirrhosis. When thromboendovenectomy failed to restore sufficient portal flow and completion of arterial anastomosis between the recipient hepatic artery and the donor celiac trunk, a calibrated end-to-side anastomosis between the donor splenic artery and the donor portal vein was performed. With a 6-year follow-up, there are no symptoms related to portal hypertension, liver function is normal. However, an aneurismal dilatation of the portal branches has progressively developed. Calibrated portal vein arterialization is a possible option for portal vein thrombosis in liver transplantation, allowing long-term patient and graft survival.
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Affiliation(s)
- S Bonnet
- Pôle des maladies de l'appareil digestif, service de chirurgie hépato-biliaire et pancréatique, hôpital Beaujon, AP-HP, université Paris-VII, 100, boulevard du Général-Leclerc, 92110 Clichy, France
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Young AL, Prasad KR, Adair R, Abu Hilal M, Guthrie JA, Lodge JPA. Portal vein arterialization as a salvage procedure during left hepatic trisectionectomy for hilar cholangiocarcinoma. J Am Coll Surg 2008; 207:e1-6. [PMID: 18954768 DOI: 10.1016/j.jamcollsurg.2008.07.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 07/29/2008] [Indexed: 02/08/2023]
Affiliation(s)
- Alastair L Young
- HPB and Transplant Unit, St James's University Hospital, Leeds, UK
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Miyazaki K, Takatsuki M, Eguchi S, Hidaka M, Tokai H, Hamasaki K, Tajima Y, Kanematsu T. Living donor liver transplantation for hepatitis C virus cirrhosis with a huge portal vein aneurysm. Liver Transpl 2008; 14:1221-2. [PMID: 18668657 DOI: 10.1002/lt.21463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kensuke Miyazaki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
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31
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Schleimer K, Stippel D, Kasper HU, Allwissner R, Yavuzyasar S, Hölscher A, Beckurts K. Competition Between Native Liver and Graft in Auxiliary Liver Transplantation in a Rat Model. Transplant Proc 2008; 40:967-70. [DOI: 10.1016/j.transproceed.2008.03.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Saad WEA. Management of nonocclusive hepatic artery complications after liver transplantation. Tech Vasc Interv Radiol 2008; 10:221-32. [PMID: 18086427 DOI: 10.1053/j.tvir.2007.09.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Nonocclusive arterial disease represents less than 5% of posttransplant arterial complications. Nonocclusive arterial complications are classified into (1) nonocclusive diminished flow in the hepatic artery, (2) arteriovenous fistulae, (3) pseudoaneurysms, and (4) arterial rupture. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. Transcatheter embolization is the main mode of minimal invasive management of these uncommon complications. Other minimal invasive methods have been described such as stent placement or direct percutaneous embolization/thrombosis. The article discusses the presentation, etiology, types, treatment indications, and various modes of minimal invasive therapy used to manage these complications.
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Affiliation(s)
- Wael E A Saad
- Vascular Interventional Radiology Section, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY 14618, USA.
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Schleimer K, Stippel DL, Kasper HU, Prenzel K, Gaudig C, Tawadros S, Hoelscher AH, Beckurts KTE. Portal vein arterialization increases hepatocellular apoptosis and inhibits liver regeneration. J Surg Res 2008; 149:250-8. [PMID: 18599086 DOI: 10.1016/j.jss.2008.01.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 01/22/2008] [Accepted: 01/24/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND Portal vein arterialization is performed in particular situations to guarantee sufficient blood flow in the portal vein. In addition, some authors have postulated a proliferation-promoting influence of portal vein arterialization on the liver tissue. However, portal vein arterialization is an unphysiological procedure: It increases portal blood flow and blood pressure as well as oxygenation of the liver tissue. On the other hand, it reduces the influx of hepatotrophic factors from the portal venous blood. The aim of these experiments was to investigate apoptosis and proliferation of hepatocytes during various conditions of the portal perfusion. MATERIALS AND METHODS After 70% liver resection in Lewis rats, the following four experimental groups were formed differing in portal perfusion: (I) hyperperfused, nonarterialized; (II) flow-regulated, nonarterialized; (III) hyperperfused, arterialized; (IV) flow-regulated, arterialized. A warm ischemia of 30 min was kept in all groups. RESULTS Portal vein arterialization of 70% reduced rat livers significantly reduced liver regeneration as shown by a significant reduction in liver weight, body weight, and liver function after 6 wk, in contrast to the group with 70% liver mass reduction and portal venous inflow of the portal vein. Furthermore, we found a significantly elevated number of apoptotic hepatocytes after portal vein arterialization. These results were independent from blood flow regulation of the arterialized portal vein, which caused no improvement of the results. CONCLUSIONS Portal vein arterialization should be performed only temporarily and is clinically not recommended as a permanent option, because of the increased hepatocellular apoptosis and the very distinctive, negative long-term effects on liver weight.
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Affiliation(s)
- Karina Schleimer
- Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany.
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Paskonis M, Jurgaitis J, Mehrabi A, Kashfi A, Fonouni H, Strupas K, Büchler MW, Kraus TW. Surgical strategies for liver transplantation in the case of portal vein thrombosis--current role of cavoportal hemitransposition and renoportal anastomosis. Clin Transplant 2007; 20:551-62. [PMID: 16968480 DOI: 10.1111/j.1399-0012.2006.00560.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Portal vein thrombosis (PVT), a common complication of end stage liver disease, is no longer considered a definite contraindication for liver transplantation (LTx). The clinical decision to perform an LTx in the case of PVT depends on the degree of PVT and the experience of the surgeon. Eversion thromboendovenectomy was suggested by most authors as the surgical technique of choice for PVT grade 1, 2, and 3. If PVT obstructs more extended parts of the porto-mesenteric venous circulation, surgical options would include different types of venous jump graft reconstructions or arterialization of the portal vein. Combined liver and small bowel transplantation is another possible alternative. Cavoportal hemitransposition (CPHT) and renoportal anastomosis (RPA) were recently particularly advocated as creative surgical strategies in case of diffuse PVT. In this work, we focus on CPHT and RPA surgical techniques during LTx, which attempts to secure the portal flow to the liver graft in case of pre-existent diffuse PVT. We provide a review of all reported clinical experience at international clinical centers using these techniques. According to our meta-analysis a total of 15 studies were published on this topic between 1996 and 2005. In summary, a total of 56 orthotopic LTx have been performed in 53 patients (28 men, 25 women) combined with either CPHT or RPA, for the purpose of providing the donor graft with adequate inflow. Mean age was 44 yr including two patients who were infants, with the youngest recipient being two yr old. Main indications for LTx were liver cirrhosis caused by viral hepatitis, alcoholic cirrhosis and cryptogenic cirrhosis. CPHT was performed in 46 cases, and RPA in 10 cases. Thirty-five of 53 patients (66%) had surgery previous to LTx. Of these, 13 patients (37%) [corrected] presented with a history of other previous surgical procedures for decompression of portal hypertension or treatment of associated complications (portocaval shunts, splenectomy, etc). Ascites, renal dysfunction, lower extremity and torso edema and variceal bleeding were dominant post-operative complications after CPHT or RPA noted in 22 cases (41.5%), 18 cases (34%), 17 cases (32%) and 13 cases (24.5%) respectively. Patients' follow-up ranged from two to 48 months. Thirty nine of 53 patients [corrected] (74%) survived [corrected] and 14 patients died (26%) [corrected] during the course of observation. Based on the literature, we conclude that the ideal technique to overcome PVT during LTx is still controversial. Short-term follow-up results of both methods are promising, however, long-term results are unknown at present. Furthermore, clinical follow-up and basic experimental work is required to evaluate the influence of systemic venous inflow to the liver graft with respect to long-term liver function and liver regeneration.
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Affiliation(s)
- Marius Paskonis
- Department of Abdominal Surgery, Vilnius University Hospital 'Santariskiu klinikos', University of Vilnius, Vilnius, Lithuania
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Ringers J, Baranski AG, Dubbeld J, Sarton E, Veenendaal RA, Schaapherder AFM, van der Linden E, Terpstra OT, van Hoek B. A novel technique for auxiliary partial liver transplantation with reno-portal anastomosis and avoidance of the hepatoduodenal ligament. Am J Transplant 2006; 6:2802-8. [PMID: 17049066 DOI: 10.1111/j.1600-6143.2006.01538.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Auxiliary liver transplantation (ALT) is a treatment for acute liver failure when regeneration of the native liver is possible or for metabolic disorders. In selected cases ALT and orthotopic liver transplantation (OLT) have similar survival when ALT is performed in the orthotopic position (auxiliary partial orthotopic liver transplantation, APOLT). Drawback of ALT with portal vein to portal vein anastomosis is the frequent occurrence of thrombosis, compromising both graft and native liver, and the necessity of a significant resection. To avoid division of portal flow we performed ALT with an end-to-end anastomosis between the graft portal vein and the left renal vein of the recipient (reno-portal ALT, REPALT). The hepatic artery was anastomosed to the aorta using an iliac arterial graft conduit. The bile duct was anastomosed to the stomach. In the two cases presented here excellent immediate graft function occurred with rapid regeneration of the graft and without early vascular complications.
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Affiliation(s)
- J Ringers
- Department of Transplant Surgery, Leiden Univ ersity Medical Center, Leiden, The Netherlands
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36
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Nardo B, Caraceni P, Puviani L, Pertosa AM, Domenicali M, Pariali M, Angiolini G, Chieco P, Trevisani F, Bernardi M, Cavallari A. Successful Treatment of CCl4-Induced Acute Liver Failure With Portal Vein Arterialization in the Rat. J Surg Res 2006; 135:394-401. [PMID: 16780880 DOI: 10.1016/j.jss.2006.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 03/22/2006] [Accepted: 03/24/2006] [Indexed: 01/22/2023]
Abstract
BACKGROUND Optimization of the conditions for regeneration is a major goal in the management of patients with acute liver failure (ALF). Previous observations suggested that hyperoxygenation of the liver may improve its regenerative capacity. Thus, this study aimed to determine whether an additional supply of oxygenated blood achieved by portal vein arterialization (PVA) is protective in rat ALF caused by toxin administration or hepatectomy. METHODS Sprague-Dawley rats were subjected or not to PVA after CCl(4) intoxication or extended hepatectomy. PVA was performed by interposing a stent between the left renal artery and splenic vein after left nephrectomy and splenectomy. Liver injury was evaluated by the serum ALT level and necrotic cell count. Hepatocyte regeneration was assessed by calculating the mitotic index and bromodeoxyuridine (BrdU) staining. The 10-day survival was assessed in separate experimental groups. RESULTS The pO(2) in portal blood increased significantly following PVA. In the CCl(4)-induced ALF, serum ALT levels and necrosis were significantly reduced in arterialized than non-arterialized rats. PVA greatly promotes liver regeneration in both models. Finally, PVA significantly improved survival compared to controls (CCl(4): 100 versus 40%; 90% hepatectomy: 90 versus 30%). Interestingly, in the CCl(4)-induced ALF, survival was 100% even when the shunt was closed after 48 h. CONCLUSION These data indicate that the additional supply of arterial oxygenated blood through PVA promotes a rapid regeneration leading to the resolution of toxic-induced massive liver necrosis and a faster restoration of liver mass after partial hepatectomy in rats. Thus, PVA may represent a novel tool for optimizing hepatocyte regeneration.
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Affiliation(s)
- Bruno Nardo
- Department of Surgery, Intensive Care and Transplantation, University of Bologna, Bologna, Italy.
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Schleimer K, Stippel DL, Kasper HU, Tawadros S, Suer C, Schomäcker K, Hölscher A, Beckurts KTE. Auxiliary liver transplantation with flow-regulated portal vein arterialization offers a successful therapeutic option in acute hepatic failure--investigations in heterotopic auxiliary rat liver transplantation. Transpl Int 2006; 19:581-8. [PMID: 16764637 DOI: 10.1111/j.1432-2277.2006.00291.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA) was proposed in acute hepatic failure (AHF). However, clinical results of PVA are controversial because of lacking standardized flow-regulation. In rats, we examined HALT with flow-regulated PVA in AHF. Group A: HALT with flow-regulated PVA and 85% resection of the native liver to induce AHF [acute experiments (n = 8), killing after 7 days (n = 8) and after 6 weeks (n = 11)]. Group B: 85% liver-resection (n = 10). The average blood-flow in the arterialized portal vein in HALT achieved normal values (1.7 +/- 0.4 ml/min/g liver-weight). After reperfusion, the diameters of the sinusoids (6.4 +/- 0.6 microm), the postsinusoidal venules (31.1 +/- 3.3 microm) and the intersinusoidal distance (17.9+/-0.7 microm) also achieved normal values. The functional sinusoidal density amounted to 335 +/- 48/cm. The 6-week survival was nine of 11 with excellent liver function (Quick's value: 110% +/- 7.8%). The hepatobiliary radioisotope scanning with (99mTc) ethyl hepatic iminodiacetic acid (EHIDA) showed no significant differences between the native livers and grafts. The hepatocellular morphology was regular, apart from low-grade necroses in two grafts. The grafts' sinusoidal endothelial cells did not show any morphological changes. In group B, however, all rats died from AHF within 6 days. HALT with flow-regulated PVA achieved good results regarding microcirculation, morphology and function and can reliably bridge AHF.
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Affiliation(s)
- Karina Schleimer
- Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany.
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Schleimer K, Stippel DL, Kasper HU, Tawadros S, Allwissner R, Gaudig C, Greiner T, Hölscher AH, Beckurts KTE. Portal hyperperfusion causes disturbance of microcirculation and increased rate of hepatocellular apoptosis: investigations in heterotopic rat liver transplantation with portal vein arterialization. Transplant Proc 2006; 38:725-9. [PMID: 16647456 DOI: 10.1016/j.transproceed.2006.01.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Clinical results of portal vein arterialization (PVA) in liver transplantation are controversial. One reason for this is the lack of a standardized flow regulation. Our experiments in rats compared PVA with blood-flow regulation to PVA with hyperperfusion in heterotopic auxiliary liver transplantation (HALT). In group I (n = 19), the graft's portal vein was completely arterialized via the right renal artery in-stent technique, using a 0.3-mm stent, leading to a physiological average portal blood flow. In group II (n = 19), a 0.5-mm stent was used. In group II, the average portal blood flow after reperfusion was significantly elevated (group II: 6.4 +/- 1.5; group I: 1.7 +/- 0.4 mL/min/g of liver weight; P < .001). The sinusoidal diameter after reperfusion was significantly greater in group II (9.8 +/- 0.5 microm) than in group I (5.5 +/- 0.2 microm; P < .001). Red blood cell velocity in the dilated sinusoids was significantly lower in group II (171 +/- 18 microm/s) than in group I (252 +/- 13 microm/s). Stasis of erythrocytes occurred; consequently, the functional sinusoidal density was significantly reduced in group II (38 +/- 7%) compared with group I (50 +/- 3%; P < .01). Two hours after reperfusion of the portal vein, the number of apoptotic hepatocytes was significantly higher in group II than in group I (I: 0 +/- 0 vs II: 7 +/- 9 M30-positive hepatocytes/10 high-power fields). The 6-week survival rate was 9 of 11 in both groups. In group II, 6 of 9 grafts showed massive hepatocellular necroses after 6 weeks, whereas in group I, only 1 of 9 presented a slight hepatocellular necrosis. Finally, our results demonstrate negative effects of portal hyperperfusion in transplanted livers, which are correctable by adequate flow regulation.
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Affiliation(s)
- K Schleimer
- Department of Visceral, University of Cologne, Cologne, Germany.
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Fernández OM, Ríos A, Sánchez A, Palenciano CG, Martínez L, Conesa C, Montoya M, Pons JA, Ramírez P, Parrilla P. Pathology findings in a model of auxiliary liver transplantation with portal vein arterialization in pigs. Transplant Proc 2006; 37:3939-42. [PMID: 16386591 DOI: 10.1016/j.transproceed.2005.10.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine the histological findings and temporal evolution that occur in auxiliary liver grafts as a consequence of arterialization of the portal vein (PVA). MATERIALS AND METHODS We evaluated 10 auxiliary heterotopic liver transplants with arterialization of the PVA. The histological study was performed using an optical microscope to process liver samples with staining using hematoxylin and eosin. A biopsy of native liver tissue was used as a control. RESULTS Two animals were excluded from the study, one due to ischemic necrosis of the graft and one that died 4 hours after transplant. All of the remaining eight animals underwent a histological study at 1 day, 7 days, and 14 days. The most significant histological findings were: (1) dilation of portal areas and sinusoids, which were detected at 24 hours and persisted; (2) thickening of the interlobular septum, which was observed after day 7 and progressively increased to day 14; (3) bile duct hyperplasia detected at the seventh day. CONCLUSIONS The consistent, early findings in a pig liver with PVA included vascular dilation of the portal area and the sinusoids, with bile duct hyperplasia extending progressively and the thickening of interlobular connective tissue septa with a generalized perilobular connective tissue reaction, which did not seem to alter the internal structure of the lobule, which showed histologically normal hepatocytes. The fibrous reaction may be the first stage in chronic hepatopathy. Further long-term studies are required in this model.
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Affiliation(s)
- O M Fernández
- Unit of Experimental Surgery, Department of Surgery, Arrixaca University Hospital, El Palmar, Murcia, Spain.
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40
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Adani GL, Baccarani U, Risaliti A, Sainz-Barriga M, Lorenzin D, Bresadola F. Right lobe living related graft loss due to intrahepatic multiple arterio-portal fistulas. Transplant Proc 2005; 36:2733-5. [PMID: 15621135 DOI: 10.1016/j.transproceed.2004.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report a case of a 38-year-old Caucasian female with ileal carcinoid and bilobar hepatic metastases. After resection of the primary tumor, octreotide therapy was prescribed. Carcinoid histology was positive for chromogranin A and sinaptophsine and negative for MIB1. At 1-year, a follow-up computed tomography scan, Octreoscan, and PET scan were negative for extrahepatic involvement. The patient underwent right lobe living related liver transplantation donated by her sister. Acute hepatic artery thrombosis was successfully revascularized 24 hours after transplantation. Extrahepatic biliary ischemia was treated by a bilio-digestive anastomosis. Eight months later, ascites and clinical and serologic signs of liver failure developed; a liver biopsy revealed fibrosis. Spiral computed tomography scan and hepatic angiography showed multiple intrahepatic arterio-portal fistulas resulting in arterialization and inversion of the portal flow in the absence of graft outflow obstruction.
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Affiliation(s)
- G L Adani
- Department of Surgery and Transplantation Unit, University Hospital, 33100 Udine, Italy
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41
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Nivatvongs S, Sirijindakul B, Nontasoot B. Portal vein arterialization for liver transplantation with extensive portomesenteric vein thrombosis: a case report. Transplant Proc 2005; 36:2267-8. [PMID: 15561214 DOI: 10.1016/j.transproceed.2004.07.073] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We report herein a case of extensive thrombosis of portal venous system including mesenteric vein in a 70-year-old man who suffered from end-stage post-hepatitis C cirrhosis and who underwent orthotopic liver transplantation. There was no way to divert portal blood flow to the new liver because such an extensive thrombosis of portomesenteric venous system. There are some case reports of portocaval hemitransposition with some success but high mortality. We decided to arterialize the portal vein of the liver allograft with the recipient hepatic artery and the donor hepatic artery was anastomosed to the supraceliac aorta. He recovered slowly from the operation. At 1 year after the transplantation, he is doing well with perfect liver function tests. This case challenges our belief that portal blood flow is essential for the liver because of hepatotrophic factors.
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Affiliation(s)
- S Nivatvongs
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Müller V, Brummer D, Erhardt W, Henke J, Kissler H, Bauer M, Amann K, Ott R, Hohenberger W. Arterialisation of the portal vein as a model for the induction of hepatic fibrosis: description of microsurgical models in the rat. Transpl Int 2005; 17:822-33. [PMID: 15827755 DOI: 10.1007/s00147-004-0751-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2003] [Revised: 02/12/2004] [Accepted: 03/05/2004] [Indexed: 11/25/2022]
Abstract
Within the framework of liver transplantation, arterialisation of the portal vein in the case of non-recanalisable thrombosis has been reactivated. However, one of the consequences of this vascular reconstruction is the development of hepatic fibrosis. Clinical experience has shown that the development of fibrosis can be avoided by reducing portal inflow. We present, as a model for the induction of hepatic fibrosis, techniques of PVA, including transplantation. For PVA, several different techniques were used: the first with reduction of the portal inflow over a stent inserted in the right renal artery (PVA-B), the second with unrestricted flow using an aortic-portal segment (PVA-APS). The third technique was orthotopic liver transplantation with unrestricted portal arterialisation (OLTx-APS). Portal blood flow was measured with an ultrasonic flow probe. To determine the degree of hepatic fibrosis the amount of hydroxyproline was measured. Quantification of relative transcript levels of procollagen I was effected with real-time PCR using the TaqMan technology on a lightcycler instrument. The extracellular matrix was visualised with picro-sirius staining. Measurements with the ultrasonic probe showed a significant increase in flow rates, both with reduced (PVA-B) and unrestricted inflow (PVA-APS; OLTx-APS). The lowest survival rate (58%) was found in the group with unrestricted portal inflow. The reason for this was a high rate of thrombosis in the in the portal vascular tree (4 out of 12). In the OLTx-APS group four animals died within the first 3 postoperative days (69%), as a result of protracted postoperative shock. The overall survival rate was the highest (85%) in the group undergoing PVA with reduction of the portal inflow. PVA with unrestricted inflow was followed by a significant increase in extracellular collagen, which showed a clear correlation with the increase in the amount of hydroxyproline, the level of the mRNA for procollagen I and picro-sirius staining. With the operative PVA techniques presented herein, different arterial flow rates in the portal vein can be investigated. In our opinion these techniques represent an excellent animal model for studying the genesis of fibrosis and antifibrotic substances. By regulating the blood flow in the arterialised portal vein hepatic fibrosis can be reduced or even avoided. After a brief period of learning the microsurgical techniques, the surgeon can limit clamping times and achieve good results with these techniques.
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Affiliation(s)
- Volker Müller
- Department of Surgery, University of Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany.
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Muller V, Brummer D, Erhardt W, Henke J, Kissler H, Bauer M, Amann K, Ott R, Hohenberger W. Arterialisation of the portal vein as a model for the induction of hepatic fibrosis: description of microsurgical models in the rat. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00517.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Müller V, Brummer D, Kissler H, Yedibela S, Bauer M, Erhardt W, Henke J, Amann K, Tannapfel A, Hohenberger W, Ott R. Effects of Portal Vein Arterialization on Regeneration and Morphology in Liver Transplantation: Investigations Using the Rat Model. Transplantation 2004; 78:1159-65. [PMID: 15502713 DOI: 10.1097/01.tp.0000137204.19612.7a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Portal vein arterialization (PVA) has been proposed as a technical variant in liver transplantation in the case of non-recanalizable thrombosis. The present study investigates the effects of the arterialized portal vein on the function, morphology, and regenerative behavior of the liver. METHODS Different PVA techniques, including orthotopic liver transplantation, were used in a rat model. Portal blood flow was measured using a ultrasonic flowmeter. The regeneration capacity was determined on the basis of the increase of liver weight and the proliferating cell nuclear antigen index. The amount of hydroxyproline and the transcript levels of procollagen I were measured to determine the degree of fibrosis. The extracellular matrix was visualized with Picro-Sirius staining. RESULTS The measurements obtained with an ultrasonic probe revealed a significant increase in portal blood flow after PVA. The regeneration capacity in the groups after PVA with no flow reduction was comparable to that of the control. Liver transplantation and PVA with no flow reduction was followed by a significant increase (four- to sixfold) in the amount of hydroxyproline and the level of the mRNA for procollagen I. In the Picro-Sirius staining, periportal and perivascular fibrosis with incipient formation of septa was seen. After reduction of the portal blood flow, these effects were significantly less pronounced. CONCLUSIONS These operative techniques represent an excellent small animal model for studying the mechanism of liver regeneration and the genesis of fibrosis in liver and vessel tissue. The presenting findings indicate that the negative effects of "overarterialization" may be largely avoided by reducing portal blood flow. This implies that permanent PVA in clinical liver transplantation should be performed only in conjunction with a down-regulation of portal flow.
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Affiliation(s)
- Volker Müller
- Department of Surgery, University of Erlangen-Nuremberg, Krankenhausstrasse 12, D-91054 Erlangen, Germany.
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Schleimer K, Stippel DL, Kasper HU, Suer C, Tawadros S, Hoelscher AH, Beckurts KTE. Improved microcirculation of a liver graft by controlled portal vein arterialization. J Surg Res 2004; 116:202-10. [PMID: 15013357 DOI: 10.1016/j.jss.2003.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Indexed: 11/20/2022]
Abstract
BACKGROUND The clinical results of portal vein arterialization (PVA) in liver transplantation are controversial without a standardized portal flow regulation. The aim of these experiments was to perform a flow-regulated PVA in liver transplantation, to examine the microcirculation and early graft function after heterotopic auxiliary liver transplantation (HALT) with flow-regulated PVA, and to compare this technique with HALT with porto-portal anastomosis. Using the recently developed orthogonal polarization spectral (OPS) imaging, for the first time the microcirculation of liver grafts with PVA was visualized. MATERIALS AND METHODS HALT was performed in Lewis rats. The portal vein was either completely arterialized via the right renal artery in a standardized splint-technique (Group I, n = 8) or anastomosed end-to-end to the recipient's portal vein (Group II, n = 8). RESULTS After reperfusion, the average blood flow in the portal vein was within the normal range in Group I (1.7 +/- 0.4 ml/min/g liver weight) and significantly higher than in Group II (1.2 +/- 0.2 ml/min/g liver weight). The functional sinusoidal density in Group I (335 +/- 48/microm) was significantly higher than in Group II (232 +/- 58/microm), whereas the diameter of the sinusoids and the postsinusoidal venules yielded no significant differences between both groups. The bile production was comparable (27 +/- 8 versus 29 +/- 11 microl/h/g liver weight). CONCLUSIONS In our experiments it was possible to achieve an adequate flow regulation in the arterialized portal vein with good results concerning microcirculation and early graft function. We recommend that further investigations on liver transplantation with PVA should be performed with portal flow regulation, before PVA is employed in clinical transplantation.
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Affiliation(s)
- Karina Schleimer
- Department of Visceral and Vascular Surgery, University of Cologne, Joseph-Stelzmann-Strasse 9, 50931, Cologne, Germany.
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