Management of Extensive Portal Vein Thrombosis

Transcription

1 Management of Extensive Portal Vein Thrombosis Deok-Bog Moon, Sung-Gyu Lee, Chul-Soo Ahn, Shin Hwang, Ki-Hun Kim, Gi-Won Song, Dong-Hwan Jung, Gil-Chun Park, Kyu-Bo Sung 1, Gi- Young Ko 1, Dong-Il Kweon 1 Hepato-Biliary Surgery & Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine 1 : Department of Radiology

2 Grading of PV Thrombosis Grade 1 : < 50% of main PV(MPV) Grade 2 : >50% - 100% of MPV Grade 3 : Complete thrombosis of MPV & proximal SMV Grade 4 : Complete thrombosis of MPV, and proximal & distal SMV Yerdel MA, et al. Transplantation 2000

3 Non-tumorous Portal Vein Thrombosis at AMC (February, 2008 December, 2012) Total number of PVT in LT : 223 / 1679 patients (13.3%) LDLT : 188 / 1399 patients (14.4%) DDLT : 35 /280 patients (12.5%) Degree of PVT Partial PVT : 171 patients (76.7%) Complete PVT : 52 patients (23.3%) Grade 1: 93 patients (41.7%) Grade 2: 120 patients (53.8%) Grade 3: 7 patients (3.1%) Grade 4: 3 patients (1.3%)

4 Grade 1 & 2 in Deceased Donor Whole Liver Transplantation Thrombectomy and low dissection Method of choice for revascularization in grades 1 and 2 PVT patients. It provides a suitable segment of donor portal vein distal to the thrombus Yerdel MA, et al. Transplantation 2000

5 Grade 3 in Deceased Donor Whole Liver Transplantation Interposition of a donor iliac vein graft Between the donor distal SMV and the graft portal vein. The conduit is placed anterior to the pancreas and posterior to the pylorus region. Yerdel MA, et al. Transplantation 2000

6 Grade 4 in Deceased Donor Whole Liver Transplantation A collateral of the portal system is used as an inflow vessel. In this case, a dilated coronary vein. Yerdel MA, et al. Transplantation 2000

7 Grade 4 in Deceased Donor Whole Liver Transplantation Multivisceral transplantation Cavo-portal hemitransposition Vianna R, et al. Transplantation 2005 Tzakis A, et al. Transplantation 1998

8 PV Thrombosis in Living Donor Liver Transplantation Basically, management is not so different from DDLT. However, special consideration is necessary.

9 Special Considerations in Living Donor Liver Transplantation Donor PV Small & short Type III donor PV Absence of cadaveric fresh graft Recipient PV Adequate size PV stenosis Large-diametered PV after thrombectomy Quality of native PV wall after thrombectomy Preservation of Rt. & Lt. PV for dual-graft LDLT Completeness of thrombectomy Presence of portal flow steal or sizable collaterals

10 Mismatch of PV (too large) between Donor & Recipient GSV fence Donor PV Recipient PV

11 Mismatch of PV (too small) between Donor & Recipient

12 Necessity of Portal Bifurcation in Type II, III Donor PV or Dual-graft LDLT Thrombectomy of native PV bifurcation GSV plasty to adjust PV size Re-enforcement of weakened traumatized wall GSV fence of donor PV at bench to make single opening Y-graft using GSV

13 Absence of Cadaveric Fresh Vessel for Interposition Graft (Grade 2,3,4 PVT) Renoportal anastomosis SMV-to-PV anastomosis SRS ES-PTFE LRV B

14 IOP is Very Useful Tools in LDLT & DDLT also. Precisely visualizing the significant spontaneous portosystemic collaterals not detected by intra-op Doppler Monitoring the completeness of collateral ligation. Treating remained PVT &/or stenosis, and collaterals through PV stenting or Coil embolization Deok-Bog Moon, Sung-Gyu Lee, et al. Liver Transplantation 2007

15 Completeness of Thrombectomy in Grade 1, 2, 3 PVT Complete PV thrombectomy Incomplete PV thrombectomy

16 Presence of Portal Flow Steal through the Preexisting Sizable Collaterals Pre-OP CT scan Intra-OP portogram after thrombectomy & engraftment IVC Splenorenal shunt LRV Lt.gonadal vein

17 Management of PVT at AMC (I) in Grade 1, 2, and some of 3 PV thrombectomy with low dissection and eversion thrombectomy. Evaluation of Portal flow Before interruption of sizable collaterals After interruption of sizable collaterals Measurement of PV diameter Less than 1 cm : PV plasty with GSV More than 1 cm : No plasty Engraftment & Surgical interruption of sizable collaterals

18 Management of PVT at AMC (II) in Grade 1, 2, and some of 3 Intraoperative cine-portography (IOP) Remained thrombosis or stenosis at intrapancreatic PV or proximal SMV Decision of Ballooning &/or PV stenting Measurement of luminal diameter primarily Less than 1 cm : Ballooning & /or PV stent placement More than 1 cm : Observation after confirmation of no portal flow steal Degree of luminal narrowing subsequently Less than 50% of cross-sectional area : Observation More than 50% of cross-sectional area : PV stenting

19 Management of PVT at AMC (February, 2008 December, 2012) Ligation of sizable collaterals: 171 patients (76.7%) Methods Partial (n=171 ) Complete (n=52) Thrombectomy 93 (54%) 10 (19%) Thrombectomy & PV plasty 17 (10%) 3 (6%) Thrombectomy & PV plasty & PV stenting or ballooning Thrombectomy & PV stenting or ballooning 20 (12%) 9 (17%) 41 (24%) 17 (33%) Interposition graft 0 12# (23%) Choledochal varix-portal anastomosis 0 1 (2%) #: Renoportal anastomosis 6, SMV 3, IMV 1, Coronary 1, Mesenteric collateral 1

20 Survivals of PVT Patients after LT (February, 2008 December, 2012) Overall Survival LDLT & DDLT LDLT DDLT P=0.0012

21 PV Complication-Free Survival Rate after LDLT in PVT patients (February, 2008 December, 2012) Partial & Complete PVT Yerdel grades : Partial PVT : Complete PVT : Grade 1 : Grade 2 : Grade 3 : Grade 4

22 PV Related Complications after LT in PVT patients (February, 2008 December, 2012) No. PVT Initial management Complication Outcome 1 Partial Incomplete thrombectomy Rethrombosis Dead 2 Partial Thrombectomy & PV stent PV tearing Dead 3 Partial Thrombectomy & PV stent Portal flow steal through Lt.GV Dead 4 Partial Incomplete thrombectomy Rethrombosis Dead 5 Partial Thrombectomy only PV stenosis (10mo) Alive 6 Partial Thrombectomy only PV stenosis (2wks) Alive 7 Partial Thrombectomy & PV stent Portal flow steal through IMV Dead 8 Complete Thrombectomy only PV stenosis (4mo) Alive 9 Partial Thrombectomy only PV stenosis Alive 10 Partial Thrombectomy & ballooning PV rupture Alive 11 Complete Thrombectomy only PV stenosis Alive

23 Conclusions Nonneoplastic PVT in cirrhotic patients must be related to the Post-LT mortality. However, multi-disciplinary approaches at AMC using thrombectomy, GSV plasty, interruption of collaterals, IOP with PV stenting/ballooning & collateral embolization, and interposition graft from large collateral vein decreased PVT-related complications and showed same excellent results despite difference of severity. Total splanchnic PVT without sizable collaterals is still a problem awaiting solution in LDLT.