Systematic Review
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2018; 10(10): 752-760
Published online Oct 27, 2018. doi: 10.4254/wjh.v10.i10.752
Thrombosis prophylaxis in pediatric liver transplantation: A systematic review
Mirco Nacoti, Giulia Maria Ruggeri, Giovanna Colombo, Ezio Bonanomi, Federico Lussana
Mirco Nacoti, Giulia Maria Ruggeri, Giovanna Colombo, Ezio Bonanomi, Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy
Federico Lussana, Hematology and Bone Marrow Transplant Unit, Papa Giovanni XXIII Hospital, Bergamo 24127, Italy
Author contributions: Nacoti M was responsible for the concept, design, analysis of data and drafting; Ruggeri GM and Colombo G were responsible for selection of the papers and variables and drafting; Bonanomi E was responsible for concept and critical revision; Lussana F was responsible for the concept, design, searching strategy, drafting and critical revision.
Conflict-of-interest statement: The authors of this manuscript have no conflicts of interest to disclose.
PRISMA 2009 Checklist statement: The manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Mirco Nacoti, MD, Staff Physician, Department of Anesthesia and Intensive Care, Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Via Piazza OMS 1, Bergamo 24127, Italy.
Telephone: +39-35-2675150 Fax: +39-35-2674989
Received: May 2, 2018
Peer-review started: May 4, 2018
First decision: May 23, 2018
Revised: July 13, 2018
Accepted: August 1, 2018
Article in press: August 1, 2018
Published online: October 27, 2018

To review current literature of thrombosis prophylaxis in pediatric liver transplantation (PLT) as thrombosis remains a critical complication.


Studies were identified by electronic search of MEDLINE, EMBASE and Cochrane Library (CENTRAL) databases until March 2018. The search was supplemented by manually reviewing the references of included studies and the references of the main published systematic reviews on thrombosis and PLT. We excluded from this review case report, small case series, commentaries, conference abstracts, papers which describing less than 10 pediatric liver transplants/year and articles published before 1990. Two reviewers performed study selection independently, with disagreements solved through discussion and by the opinion of a third reviewer when necessary.


Nine retrospective studies were included in this review. The overall quality of studies was poor. A pooled analysis of results from studies was not possible due to the retrospective design and heterogeneity of included studies. We found an incidence of portal vein thrombosis (PVT) ranging from 2% to 10% in pediatric living donor liver transplantation (LDLT) and from 4% to 33% in pediatric deceased donor liver transplantation (DDLT). Hepatic artery thrombosis (HAT) was observed mostly in mixed LDLT and DDLT pediatric population with an incidence ranging from 0% to 29%. In most of the studies Doppler ultrasonography was used as a first line diagnostic screening for thrombosis. Four different surgical techniques for portal vein anastomosis were reported with similar efficacy in terms of PVT reduction. Reduced size liver transplant was associated with a low risk of both PVT (incidence 4%) and HAT (incidence 0%, P < 0.05). Similarly, aortic arterial anastomosis without graft interposition and microsurgical hepatic arterial reconstruction were associated with a significant reduced HAT incidence (6% and 0%, respectively). According to our inclusion and exclusion criteria, we did not find eligible studies that evaluated pharmacological prevention of thrombosis.


Poor quality retrospective studies show the use of tailored surgical strategies might be useful to reduce HAT and PVT after PLT; prospective studies are urgently needed.

Keywords: Pediatric liver transplantation, Prophylaxis, Hepatic artery thrombosis, Surgical technique, Portal vein thrombosis

Core tip: Graft loss and patient death after pediatric liver transplantation (PLT) are most frequently caused by hepatic artery thrombosis and portal vein thrombosis. For this reason, the prevention of hepatic artery and vein thrombosis represents a primary interest for clinicians and researchers, considering the scarcity of hepatic allografts. In our systematic review, we found only nine poor quality retrospective studies showing that tailored surgical strategies might be useful to reduce thrombosis. We did not find eligible studies evaluating pharmacological prevention strategies. Prospective studies are urgently needed to standardize thrombosis prevention in PLT.