CASE 2673 Published on 07.02.2007

Portal vein stricture after orthotopic liver transplantation: Treatment with transjugular portal vein stenting

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Sedati P, Pelle G, Paciucci L, Telesca M, Sandolo F

Patient

62 years, male

Categories
No Area of Interest ; Imaging Technique CT, CT
Clinical History
Six months after a hepatic transplantation, a 62-year-old male patient presented with signs and symptoms of portal hypertension.
Imaging Findings
A 62-year-old man with HCV-related cirrhosis had undergone an orthotopic liver transplantation in our institute. Six months later, he presented with symptoms of portal hypertension. A multidetector-CT scan showed a significant stricture of the portal vein at the level of the surgical anastomosis, an atrophy of the right hepatic lobe and findings of portal hypertension. In order to relieve the stenosis, the placement of a stent within the portal vein was decided. We used a tranjugular approach to the portal vein, in order to reduce the risk of bleeding and to have a less angulated approach to the stricture. The right hepatic vein was catheterised and the catheter-needle was advanced through the liver parenchyma; the right portal vein was entered and catheterised. A portal venogram revealed a tight stricture of the portal vein at the surgical anastomosis, approximately 4 cm in length. The portosytemic gradient was 19.5 mmHg. The stricture was pre-dilated with an 8 mm angioplasty balloon, and then a self-expandable metallic stent (3.8 cm in length) was placed across the stricture and dilated to a diameter of 7 mm . Direct transjugular portography done after stent placement revealed no residual stenosis. The portosytemic gradient after stent placement was 8 mmHg. A multidetector-CT scan performed seven days after stenting showed correct stent placement, complete relief of the stricture, and a marked decrease of hepatofugal circulation. The patient had an uneventful postprocedural course, and his clinical condition improved significantly. The patient was monitored with Doppler-US and did not present with stricture recurrence at a follow-up after 24 months.
Discussion
Orthotopic liver transplantation has become the treatment of choice for patients with end-stage nonmalignant liver disease. The four vascular anastomoses in orthotopic liver transplantation are at the level of suprahepatic vena cava, infrahepatic vena cava, portal vein, and hepatic artery. Vascular complications may develop independently or concomitantly at all the above mentioned levels. The optimal portal vein anastomosis is and end-to-end anastomosis between the donor and recipient portal veins just to the right of the recipient coronary vein. Portal vein stenosis occurs most often at the anastomotic site. Because of the large size of the vein and the generally uncomplicated anastomosis, significant portal vein stenosis is a very uncommon complicaton after liver transplantation, occurring in 0.5%–3% of all transplants, usually several years after the transplantation and most often in children. Portal vein complications result from a faulty surgical technique, vessel misalignment, the differences in the calibre of anastomosed vessels provoking turbulent flow, hypercoagulable status, previous portal vein surgery, or previous thrombosis in the recipient portal vein system. Portal vein stenosis may be asymptomatic and is detected by routine Doppler sonography or presents with an elevation of liver enzymes as well as signs of portal hypertension. A non-invasive diagnosis of portal vein stenosis can be made with ultrasonography and hCT techniques. However, angiographic studies are sometimes necessary to make a definitive diagnosis. The treatment includes a percutaneous transluminal angioplasty with or without stent placement, surgical thrombectomy, placement of a venous jump graft, creation of a portosystemic shunt, or even retransplantation. A close surveillance of the vascular anastomoses and a multidisciplinary approach to the treatment of vascular complications after a liver transplantation considerably reduces graft-loss and patient mortality.
Differential Diagnosis List
Stenosis of the portal vein after a liver transplantation.
Final Diagnosis
Stenosis of the portal vein after a liver transplantation.
Case information
URL: https://eurorad.org/case/2673
DOI: 10.1594/EURORAD/CASE.2673
ISSN: 1563-4086