ABSTRACT
Living-donor liver transplant for hepatocellular carcinoma located on hepatocaval confluence or in contact with the inferior vena cava is technically challenging, and candidates for this kind of procedure should be carefully selected. It is difficult to rule out major vascular invasion except after hepatectomy and histologic examination; in addition, the possible dissemination of cancer cells during recipient hepatectomy is a considerable risk. Herein, we report the first case in Saudi Arabia of right lobe living-donor liver transplant combined with inferior vena cava reconstruction using cryopreserved iliac vein graft after en bloc resection of the liver with part of the diaphragm, anterior wall of retrohepatic inferior vena cava, and a 5-cm hepatocellular carcinoma in segment 7. Our patient achieved so far 3-year disease-free survival. Tumor recurrence and risk of thrombosis related to inferior vena cava reconstruction are the main concerns; therefore, long-term follow-up of those patients is mandatory.
Subject(s)
Carcinoma, Hepatocellular/surgery , Iliac Vein/transplantation , Liver Neoplasms/surgery , Liver Transplantation/methods , Living Donors , Vascular Grafting/methods , Vena Cava, Inferior/surgery , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/pathology , Computed Tomography Angiography , Female , Humans , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/pathology , Middle Aged , Neoplasm Invasiveness , Phlebography/methods , Saudi Arabia , Treatment Outcome , Vena Cava, Inferior/diagnostic imaging , Vena Cava, Inferior/pathologyABSTRACT
BACKGROUND: Whilst causes of hepatic artery thrombosis (HAT) after liver transplantation (LT) are multifactorial, early HAT (E-HAT) remains pertinent complication impacting on graft and patient survival. Currently there is no screening tool that would identify patients with increased risk of developing E-HAT. METHODS: We analyzed the native procoagulant state of LT recipients, identified through pretransplant thromboelastographic (TEG) data among other known risk factors, to identify risk factors for E-HAT. RESULTS: The outcomes of 828 adult patients undergoing LT between 2008 and 2013 were analyzed. Overall, 79 (9.5%) patients experienced HAT, E-HAT was diagnosed in 23, and in the remainder this was "late" HAT. The maximum amplitude (MA) on preoperative TEG was significantly higher in patients diagnosed with E-HAT compared with those who did not (71.2 mm vs 57.9 mm; P < 0.0001). Receiver operating characteristic analysis with the cutoff value for MA of 65 mm or greater returned area under the curve of 0.750 (P < 0.001) predicting E-HAT with a sensitivity of 70%. A total of 7% of patients with an MA of 65 mm or greater went on to develop E-HAT (hazard ratio, 5.28; 95% confidence interval, 2.10-12.29; P < 0.001), whereas only 1.2% patients with an MA less than 65 mm experienced E-HAT. CONCLUSIONS: Preoperative TEG may reliably identify group of recipients at greater risk of developing E-HAT, and intense surveillance and anticoagulation prophylaxis may avoid this serious complication after LT.
Subject(s)
Hepatic Artery , Liver Transplantation/adverse effects , Thrombelastography , Thrombosis/diagnosis , Adult , Female , Humans , Male , Middle Aged , Retrospective Studies , RiskABSTRACT
Refinements of surgical techniques in liver transplant during the last 10 years have offered more successful outcomes for recipients with portal vein thrombosis. Patency of the portal vein after a thrombectomy can be neither adequately evaluated, nor objectively assessed; therefore, we suggest that rerouting part of the portal flow through a "passing loop," with or without augmenting the portal flow, may be a salvage procedure, when there is a possible postoperative rethrombosis of the portal vein.
Subject(s)
Blood Vessel Prosthesis Implantation/methods , Iliac Vein/transplantation , Liver Cirrhosis/surgery , Liver Transplantation/methods , Portal Vein/surgery , Venous Thrombosis/surgery , Adult , Bioprosthesis , Blood Flow Velocity , Blood Vessel Prosthesis , Blood Vessel Prosthesis Implantation/instrumentation , Cryopreservation , Female , Humans , Liver Circulation , Liver Cirrhosis/complications , Liver Cirrhosis/diagnosis , Living Donors , Portal Vein/physiopathology , Thrombectomy , Treatment Outcome , Ultrasonography, Doppler, Color , Vascular Patency , Venous Thrombosis/complications , Venous Thrombosis/diagnosis , Venous Thrombosis/physiopathologyABSTRACT
Liver retransplant is the only treatment for patients with irreversible graft failure. However, given the severe shortage of organs, there is an ethical question of equity in the distribution of this resource. Liver retransplant is more expensive and is associated with lower patient/graft survival rates than equivalent rates after primary transplant. Both primary nonfunction and hepatic artery thrombosis account for nearly all cases of early liver retransplant. Late indications of liver retransplant include chronic rejection, biliary complications, or recurrence of primary disease such as hepatitis C, autoimmune hepatitis, and primary sclerosing cholangitis. Donor data are not available when a patient is listed for liver retransplant; therefore, prognostic factors related to the recipient is a more practical way of making the decision to offer liver retransplant is made. In the Model of End-stage Liver Disease era liver retransplant for "late" indications is more complex and selection criteria are more stringent. We review the literature for predictive factors influencing outcome of liver retransplant, especially in those with recurrent disease.