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Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis. 2023
Yiliam Fundora, and
Amelia J Hessheimer, and
Luca Del Prete, and
Lorenzo Maroni, and
Jacopo Lanari, and
Oriana Barrios, and
Mathias Clarysse, and
Mikel Gastaca, and
Manuel Barrera Gómez, and
Agnès Bonadona, and
Julius Janek, and
Andrea Boscà, and
Jose María Álamo Martínez, and
Gabriel Zozaya, and
Dolores López Garnica, and
Paolo Magistri, and
Francisco León, and
Giulia Magini, and
Damiano Patrono, and
Jiří Ničovský, and
Abdul Rahman Hakeem, and
Silvio Nadalin, and
Lucas McCormack, and
Pilar Palacios, and
Krzysztof Zieniewicz, and
Gerardo Blanco, and
Javier Nuño, and
Baltasar Pérez Saborido, and
Juan Echeverri, and
J Steve Bynon, and
Paulo N Martins, and
Víctor López López, and
Murat Dayangac, and
J Peter A Lodge, and
Renato Romagnoli, and
Christian Toso, and
Julio Santoyo, and
Fabrizio Di Benedetto, and
Concepción Gómez-Gavara, and
Fernando Rotellar, and
Miguel Ángel Gómez-Bravo, and
Rafael López Andújar, and
Edouard Girard, and
Andrés Valdivieso, and
Jacques Pirenne, and
Laura Lladó, and
Giacomo Germani, and
Matteo Cescon, and
Koji Hashimoto, and
Cristiano Quintini, and
Umberto Cillo, and
Wojciech G Polak, and
Constantino Fondevila
General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain.
Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.
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