Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

Yiliam Fundora; Amelia J. Hessheimer; Luca Del Prete; Lorenzo Maroni; Jacopo Lanari; Oriana Barrios; Mathias Clarysse; Mikel Gastaca; Manuel Barrera Gómez; Agnès Bonadona; Julius Janek; Andrea Boscà; Jose María Álamo Martínez; Gabriel Zozaya; Dolores López Garnica; Paolo Magistri; Francisco León; Giulia Magini; Damiano Patrono; Jiří Ničovský; Abdul Rahman Hakeem; Silvio Nadalin; Lucas McCormack; Pilar Palacios; Krzysztof Zieniewicz; Gerardo Blanco; Javier Nuño; Baltasar Pérez Saborido; Juan Echeverri; J. Steve Bynon; Paulo N. Martins; Víctor López López; Murat Dayangac; J. Peter A. Lodge; Renato Romagnoli; Christian Toso; Julio Santoyo; Fabrizio Di Benedetto; Concepción Gómez-Gavara; Fernando Rotellar; Miguel Ángel Gómez-Bravo; Rafael López Andújar; Edouard Girard; Andrés Valdivieso; Jacques Pirenne; Laura Lladó; Giacomo Germani; Matteo Cescon; Koji Hashimoto; Cristiano Quintini; Umberto Cillo; Wojciech G. Polak; Constantino Fondevila

doi:10.1016/j.jhep.2023.01.007

Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

Yiliam Fundora, Amelia J. Hessheimer, Luca Del Prete, Lorenzo Maroni, Jacopo Lanari, Oriana Barrios, Mathias Clarysse, Mikel Gastaca, Manuel Barrera Gómez, Agnès Bonadona, Julius Janek, Andrea Boscà, Jose María Álamo Martínez, Gabriel Zozaya, Dolores López Garnica, Paolo Magistri, Francisco León, Giulia Magini, Damiano Patrono, Jiří NičovskýAbdul Rahman Hakeem, Silvio Nadalin, Lucas McCormack, Pilar Palacios, Krzysztof Zieniewicz, Gerardo Blanco, Javier Nuño, Baltasar Pérez Saborido, Juan Echeverri, J. Steve Bynon, Paulo N. Martins, Víctor López López, Murat Dayangac, J. Peter A. Lodge, Renato Romagnoli, Christian Toso, Julio Santoyo, Fabrizio Di Benedetto, Concepción Gómez-Gavara, Fernando Rotellar, Miguel Ángel Gómez-Bravo, Rafael López Andújar, Edouard Girard, Andrés Valdivieso, Jacques Pirenne, Laura Lladó, Giacomo Germani, Matteo Cescon, Koji Hashimoto, Cristiano Quintini, Umberto Cillo, Wojciech G. Polak, Constantino Fondevila^*

^*Corresponding author for this work

Surgery

Research output: Contribution to journal › Article › Academic › peer-review

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Abstract

Background & Aims: 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. Methods: 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. Results: 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). Conclusions: 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. Impact and implications: 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.

Original language	English
Pages (from-to)	794-804
Number of pages	11
Journal	Journal of Hepatology
Volume	78
Issue number	4
DOIs	https://doi.org/10.1016/j.jhep.2023.01.007
Publication status	Published - Apr 2023

Bibliographical note

Funding Information:
AJH and CF have received research funding from Guanguong Shunde Innovative Design Institute and Instituto de Salud Carlos III . The remainder of the authors have no conflicts of interest to declare.

Publisher Copyright:
© 2023 European Association for the Study of the Liver

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Fundora, Y., Hessheimer, A. J., Del Prete, L., Maroni, L., Lanari, J., Barrios, O., Clarysse, M., Gastaca, M., Barrera Gómez, M., Bonadona, A., Janek, J., Boscà, A., Álamo Martínez, J. M., Zozaya, G., López Garnica, D., Magistri, P., León, F., Magini, G., Patrono, D., ... Fondevila, C. (2023). Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis. Journal of Hepatology, 78(4), 794-804. https://doi.org/10.1016/j.jhep.2023.01.007

@article{b435b7f021f64864b043595697972344,

title = "Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis",

abstract = "Background \& Aims: 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. Methods: 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. Results: 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). Conclusions: 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. Impact and implications: 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.",

author = "Yiliam Fundora and Hessheimer, \{Amelia J.\} and \{Del Prete\}, Luca and Lorenzo Maroni and Jacopo Lanari and Oriana Barrios and Mathias Clarysse and Mikel Gastaca and \{Barrera G{\'o}mez\}, Manuel and Agn{\`e}s Bonadona and Julius Janek and Andrea Bosc{\`a} and \{{\'A}lamo Mart{\'i}nez\}, \{Jose Mar{\'i}a\} and Gabriel Zozaya and \{L{\'o}pez Garnica\}, Dolores and Paolo Magistri and Francisco Le{\'o}n and Giulia Magini and Damiano Patrono and Ji{\v r}{\'i} Ni{\v c}ovsk{\'y} and Hakeem, \{Abdul Rahman\} and Silvio Nadalin and Lucas McCormack and Pilar Palacios and Krzysztof Zieniewicz and Gerardo Blanco and Javier Nu{\~n}o and \{P{\'e}rez Saborido\}, Baltasar and Juan Echeverri and Bynon, \{J. Steve\} and Martins, \{Paulo N.\} and \{L{\'o}pez L{\'o}pez\}, V{\'i}ctor and Murat Dayangac and Lodge, \{J. Peter A.\} and Renato Romagnoli and Christian Toso and Julio Santoyo and \{Di Benedetto\}, Fabrizio and Concepci{\'o}n G{\'o}mez-Gavara and Fernando Rotellar and G{\'o}mez-Bravo, \{Miguel {\'A}ngel\} and \{L{\'o}pez And{\'u}jar\}, Rafael and Edouard Girard and Andr{\'e}s Valdivieso and Jacques Pirenne and Laura Llad{\'o} and Giacomo Germani and Matteo Cescon and Koji Hashimoto and Cristiano Quintini and Umberto Cillo and Polak, \{Wojciech G.\} and Constantino Fondevila",

note = "Funding Information: AJH and CF have received research funding from Guanguong Shunde Innovative Design Institute and Instituto de Salud Carlos III . The remainder of the authors have no conflicts of interest to declare. Publisher Copyright: {\textcopyright} 2023 European Association for the Study of the Liver",

year = "2023",

month = apr,

doi = "10.1016/j.jhep.2023.01.007",

language = "English",

volume = "78",

pages = "794--804",

journal = "Journal of Hepatology",

issn = "0168-8278",

publisher = "Elsevier",

number = "4",

}

Fundora, Y, Hessheimer, AJ, Del Prete, L, Maroni, L, Lanari, J, Barrios, O, Clarysse, M, Gastaca, M, Barrera Gómez, M, Bonadona, A, Janek, J, Boscà, A, Álamo Martínez, JM, Zozaya, G, López Garnica, D, Magistri, P, León, F, Magini, G, Patrono, D, Ničovský, J, Hakeem, AR, Nadalin, S, McCormack, L, Palacios, P, Zieniewicz, K, Blanco, G, Nuño, J, Pérez Saborido, B, Echeverri, J, Bynon, JS, Martins, PN, López López, V, Dayangac, M, Lodge, JPA, Romagnoli, R, Toso, C, Santoyo, J, Di Benedetto, F, Gómez-Gavara, C, Rotellar, F, Gómez-Bravo, MÁ, López Andújar, R, Girard, E, Valdivieso, A, Pirenne, J, Lladó, L, Germani, G, Cescon, M, Hashimoto, K, Quintini, C, Cillo, U, Polak, WG & Fondevila, C 2023, 'Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis', Journal of Hepatology, vol. 78, no. 4, pp. 794-804. https://doi.org/10.1016/j.jhep.2023.01.007

TY - JOUR

T1 - Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

AU - Fundora, Yiliam

AU - Hessheimer, Amelia J.

AU - Del Prete, Luca

AU - Maroni, Lorenzo

AU - Lanari, Jacopo

AU - Barrios, Oriana

AU - Clarysse, Mathias

AU - Gastaca, Mikel

AU - Barrera Gómez, Manuel

AU - Bonadona, Agnès

AU - Janek, Julius

AU - Boscà, Andrea

AU - Álamo Martínez, Jose María

AU - Zozaya, Gabriel

AU - López Garnica, Dolores

AU - Magistri, Paolo

AU - León, Francisco

AU - Magini, Giulia

AU - Patrono, Damiano

AU - Ničovský, Jiří

AU - Hakeem, Abdul Rahman

AU - Nadalin, Silvio

AU - McCormack, Lucas

AU - Palacios, Pilar

AU - Zieniewicz, Krzysztof

AU - Blanco, Gerardo

AU - Nuño, Javier

AU - Pérez Saborido, Baltasar

AU - Echeverri, Juan

AU - Bynon, J. Steve

AU - Martins, Paulo N.

AU - López López, Víctor

AU - Dayangac, Murat

AU - Lodge, J. Peter A.

AU - Romagnoli, Renato

AU - Toso, Christian

AU - Santoyo, Julio

AU - Di Benedetto, Fabrizio

AU - Gómez-Gavara, Concepción

AU - Rotellar, Fernando

AU - Gómez-Bravo, Miguel Ángel

AU - López Andújar, Rafael

AU - Girard, Edouard

AU - Valdivieso, Andrés

AU - Pirenne, Jacques

AU - Lladó, Laura

AU - Germani, Giacomo

AU - Cescon, Matteo

AU - Hashimoto, Koji

AU - Quintini, Cristiano

AU - Cillo, Umberto

AU - Polak, Wojciech G.

AU - Fondevila, Constantino

N1 - Funding Information: AJH and CF have received research funding from Guanguong Shunde Innovative Design Institute and Instituto de Salud Carlos III . The remainder of the authors have no conflicts of interest to declare. Publisher Copyright: © 2023 European Association for the Study of the Liver

PY - 2023/4

Y1 - 2023/4

N2 - Background & Aims: 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. Methods: 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. Results: 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). Conclusions: 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. Impact and implications: 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.

AB - Background & Aims: 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. Methods: 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. Results: 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). Conclusions: 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. Impact and implications: 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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U2 - 10.1016/j.jhep.2023.01.007

DO - 10.1016/j.jhep.2023.01.007

M3 - Article

C2 - 36690281

AN - SCOPUS:85149800421

SN - 0168-8278

VL - 78

SP - 794

EP - 804

JO - Journal of Hepatology

JF - Journal of Hepatology

IS - 4

ER -

Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

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