Modulation of graft vascular inflow guided by flowmetry and manometry in liver transplantation

doi:10.1016/S1499-3872(11)60110-0

Hepatobiliary & Pancreatic Diseases International

Volume 10, Issue 6, December 2011, Pages 649-656

https://doi.org/10.1016/S1499-3872(11)60110-0 Get rights and content

Background

Survival of the partial graft after living donor liver transplantation owes much to its tremendous regenerative ability. With excellent venous outfow capacity, a graft within a wide range of graft-to-standard-liver-volume ratios can cope with portal hypertension that is common in liver transplant recipients. However, when the ratio range is exceeded, modulation of graft vascular infow becomes necessary for graft survival. The interplay between graft-to-standard-liver-volume ratio and portal pressure, in the presence of portosystemic shunt or otherwise, requires individualized modulation of graft portal and arterial infows. Boosting of portal infow by shunt ligation can be guided by transonic fowmetry, whereas muting of portal infow by splenic artery ligation can be monitored by portal electronic manometry

Method

We describe four cases to illustrate the above.

Results

One patient had hepatic artery thrombosis resulting from splenic artery steal syndrome which was the sequela of small-for-size syndrome. Emergency splenic artery ligation and re-anastomosis of the hepatic artery successfully muted the portal infow and boosted the hepatic arterial infow. Another patient with portal vein thrombosis underwent thrombendvenectomy. Portal infow was boosted with ligation of portosystemic shunt, which is often present in these patients with portal hypertension. The coexistence of splenic aneurysm and splenorenal shunt required ligation of both in the third patient. The fourth patient, with portal pressure and fow monitoring, avoided ligation of a coronary vein which became a main portal infow after portal thrombendvenectomy.

Conclusions

Management of graft infow modulation guided selectively by transonic fowmetry or portal manometry was described.

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Cited by (29)

Management of Large, Spontaneous Portosystemic Shunts in Liver Transplantation: Case Report and Review of Literature
2020, Transplantation Proceedings
Citation Excerpt :
In cadaveric liver transplants with a whole liver graft, it is generally accepted that a portal vein flow over 1000 mL/min or 100 to 130/mL/100 g GW is sufficient to maintain appropriate organ perfusion [12] or between 180 mL/min/100 g GW [13] and 250 mL/minute/100 g GW [14] when managing partial grafts. Previous experience on portal flow modulation in split or living donor shows both the risk of an excessive portal vein flow [15,16] as an insufficient portal vein flow [16,17]. Systematic ligation of large spontaneous portosystemic shunts will increase significantly the portal vein flow, but requires an extensive dissection with the additional risk of bleeding due to portal hypertension and has been associated with an increased risk of inferior cava vein thrombosis [18].
The presence of collateral circulation in liver cirrhosis patients with portal hypertension is quite frequent due to re-permeabilization of closed embryonic channels. In some cases, these shunts could measure over 1 cm wide, therefore, containing a significative blood flow.
Its management during liver transplantation could be challenging due to possible complications resulting from either ligation of the shunts or from ignoring them.
We present the case of a patient with recurrent hepatic encephalopathy (HE) and a large spontaneous portosystemic shunt (SPSS) who submitted to liver transplant and review the literature identifying options, complications, and outcomes with the aim of facilitating decision making.
A 68-year-old, Spanish man diagnosed with liver cirrhosis with portal hypertension and recurrent episodes of HE is proposed for LT. The patient’s Child-Pugh score was A6-B7, and the Model for End-stage Liver Disease score was 12. Preoperatively, a computed tomography scan showed a large SPSS running to the inferior cava vein. During the surgery, a small-sized portal vein and a large shunt measuring almost 3 cm wide were identified.
After reperfusion, portal vein flow was 1000 to 1100 mL/min. Owing to the previous HE and the risk of low portal flow, the shunt was closed increasing the portal flow to 1800 mL/min. The patient was discharged without any complications.
The presence of large SPSSs are frequent during LT. Decision making intraoperatively can be challenging due to possible complications derived from ligation of the SPSS or from ignoring it. Either preoperative assessment of a further HE risk or portal vein flow measurement after reperfusion are essential to achieve a correct resolution.
Partial portal vein arterialization using right gastroepiploic artery: A novel solution for portal hypoperfusion
2018, Hepatobiliary and Pancreatic Diseases International
Graft inflow modulation in adult-to-adult living donor liver transplantation: A systematic review
2017, Transplantation Reviews
Citation Excerpt :
Of these, 344 papers were excluded for the following reasons: 342 not concerning inflow modulation for LDLT, 1 temporary shunt procedure and 1 article reporting outcomes of deceased donor grafts. Finally, 32 articles were selected for full-text review, and of these, 20 more were excluded: 2 did not report outcomes of patients undergoing inflow modulation [46,48], 3 were case reports [49–51], 2 were review articles [52,53], 1 was a letter to the editor [54], and 12 were redundant series from the same institute [36,45,55–64]. Other papers from the same institution were attentively reviewed and were included if they did not report outcomes of patients already included in other articles.
Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension following reperfusion and the hyperdynamic splanchnic state are reported as the major triggering factors of SFSS. Intra- and postoperative strategies to prevent or to reduce its onset are still under debate.
We analyzed graft inflow modulation (GIM) during adult LDLT considering the indications, efficacy of the available techniques, changes in hemodynamics and outcomes.
A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central. Treatment outcomes including in-hospital mortality and morbidity, re-transplantation rate, 1-, 3-, and 5-year patient overall survival and 1-, 3-, and 5-year graft survival rates, hepatic artery and portal vein flows and pressures before and after inflow modulation were analyzed.
From 563 articles, 12 studies dated between 2003 and 2014 fulfilled the selection criteria and were therefore included in the study. These comprised a total of 449 adult patients who underwent inflow modulation during adult-to-adult LDLT. Types of GIM described were splenic artery ligation, splenectomy, meso-caval shunt, spleno-renal shunt, portocaval shunt, and splenic artery embolization. Mortality and morbidity ranged between 0 and 33% and 17% and 70%, respectively. Re-transplantation rates ranged between 0% and 25%. GIM was associated with good survival for both graft and recipients, reaching an 84% actuarial rate at 5 years. Through the use of GIM, irrespective of the technique, a statistically significant reduction of PVF and PVP was obtained.
GIM is a safe and efficient technique to avoid or limit portal hyperperfusion, especially in cases of SFSG, decreasing overall morbidity and improving outcomes.
New insights after the first 1000 liver transplantations at The University of Hong Kong
2016, Asian Journal of Surgery
Citation Excerpt :
The absence of significant portal hypertension in patients is a factor favoring the adoption of left livers. A high graft portal flow of over 400 mL/100 g/min calls for portal manometry by insertion of a catheter via the inferior mesenteric vein, and a portal pressure of over 20 mmHg calls for portal inflow modulation with splenic artery ligation.41 DDLGs are a public resource while living donor liver grafts are dedicated gifts.
One thousand liver transplantations have been performed at the only liver transplant center in Hong Kong over a period of 22 years, which covered the formative period of living donor liver transplantation. These 1000 transplantations, which marked the journey of liver transplantation from development to maturation at the center, should be educational. This research was to study the experience and to reflect on the importance of technical innovations and case selection.
The first 1000 liver transplantations were studied. Key technical innovations and surgical therapeutics were described. Recipient survival including hospital mortality was analyzed. Recipient survival comparison was made for deceased donor liver transplantation and living donor liver transplantation indicated by hepatocellular carcinoma and other diseases.
Among the 1000 transplantations, 418 used deceased donor grafts and 582 used living donor grafts. With the accumulation of experience, hospital mortality improved to < 2% in the past 2 years. In the treatment of diseases other than hepatocellular carcinoma, living donor liver transplantation was superior to deceased donor liver transplantation, with a 10-year recipient survival around 90%.
Transplant outcomes have been improving consistently over the series, with a very low hospital mortality and a predictably high long-term survival.
Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts during Liver Transplantation: Splenectomy or Left Renal Vein Ligation?
2015, Transplantation Proceedings
Management of splenorenal shunt (SRS) during whole liver transplantation is still controversial. Splenectomy (SP) permits its radical removal, at the price of a specific related morbidity. Left renal vein ligation (LRVL) performs a downstream ligation with potential renal repercussions. This study aimed to compare these techniques regarding portal revascularization and postoperative outcomes.
From 1994 to 2012, 22 SPs and 7 LRVLs were performed for large SRS (>1 cm) management.
There was no difference in operating times or transfusion rates. In both groups, efficient portal flow was initially obtained in all cases. After a median follow-up of 79 months, 2 patients in the SP group presented an altered portal flow owing to persistence of a not disconnected mesentericogonadic or splenorenal shunt. Postoperative morbidity, including infection and portal vein thrombosis, was not significantly different (32% vs 14%). SP allowed a faster correction of the thrombocytopenia. The LRVL group had a moderate and temporary impairment of renal function.
SP and LRVL represent 2 effective procedures to avoid vascular steal in the presence of SRS, but they require a patent portal vein. SP appears to be associated to specific but acceptable intraoperative morbidity, permits treatment of associated splenic artery aneurysm, and enables a faster correction of thrombocytopenia. However, the presence of a remote hilum SRS or another large portosystemic shunt represents a cause of failure of the procedure. LRVL is a safer and less demanding procedure that can suppress portal steal whatever the location of the SRS, but at the price of moderate renal morbidity.
Outcomes of Living Donor Transplantation: The Western Perspective
2015, Transplantation of the Liver: Third Edition

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Case ReportModulation of graft vascular inflow guided by flowmetry and manometry in liver transplantation

Background

Method

Results

Conclusions

Liver Transpl

Am J Transplant

J Surg Res

Am J Transplant

Lancet

Liver Transpl

Am J Transplant

Transplant Proc

Am J Transplant

Flowmetry-based portal inflow manipulation for a small-for-size liver graft in a recipient with spontaneous splenorenal shunt

Clin Transplant

Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation

Ann Surg

Estimating liver weight of adults by body weight and gender

World J Gastroenterol

A shunt equation for estimating the splenic component of portal hypertension

Am J Surg

Effects of splenic artery occlusion on portal pressure in patients with cirrhosis and portal hypertension

Liver Transpl

Modulation of portal graft inflow: a necessity in adult living-donor liver transplantation?

Ann Surg

Mechanism and role of intrinsic regulation of hepatic arterial blood flow: hepatic arterial buffer response

Am J Physiol

Portal and hepatic arterial blood flow measurements of human transplanted liver by implanted Doppler probes: interest for early complications and nutrition

Surgery

Case Report
Modulation of graft vascular inflow guided by flowmetry and manometry in liver transplantation