Catastrophic Thromboembolic Disease After Liver Transplantation: Should we Routinely Monitor Coagulation Factors?

Abstract

Introduction: Liver transplantation results in a dynamic reset of the hemostatic pathway. Routine perioperative monitoring of protein C, protein S, and antithrombin III levels is not currently recommended. We present two patients who underwent orthotopic liver transplantation (OLT) who developed catastrophic thromboembolic disease several weeks following surgery. Case Report: Case 1: 53 y/o female underwent OLT for PBC. No prior history of VTE. 46 days s/p OLT she presented with left sided hemiplegia, facial droop, and slurred speech. CT head showed evidence of ischemia in the distribution of right MCA. Also noted to have development of a pulmonary embolism. Labs demonstrated protein S 20%, protein C 32%, and antithrombin III 72%. Serial imaging showed progression of clot burden with development of thrombi within the IVC, hepatic vein, and portal vein. Doppler of the extremities demonstrated clots within the external iliac and common femoral vein. Echocardiogram was normal. Case 2: 69 y/o male underwent OLT for cirrhosis secondary to HCV and HCC. No prior history of VTE. 47 days s/p OLT he presented with cholangitis. CT abdomen showed hepatic bilomas and thrombosis of the hepatic artery. 8 days later, noted to have left hemi-neglect, facial droop, and weakness. CT head showed evolving ischemic stroke in distribution of right MCA. Labs demonstrated protein C 60%, protein S 62%, and antithrombin III 74%. CTA chest demonstrated multiple pulmonary emboli. Echocardiogram was normal. Discussion: While most coagulant factors reach normal limits within 24 hours of OLT, normalization of certain factors such as protein C, protein S, and antithrombin III are delayed. The hypercoagulable state that is observed in the immediate post-operative period appears to be due to multiple factors including dynamic shifts in the balance of pro- and anti-coagulant proteins. We describe 2 patients who presented with extensive arterial and venous thromboembolic disease with reduction in certain anti-coagulant proteins. Though in an active clot, certain clotting factors are consumed, our case series questions if routine monitoring of certain proteins may be indicated to prevent post-OLT thromboembolic disease. Additional research is needed to determine if routine peri-operative monitoring of coagulation factors with a targeted chemoprophylaxis strategy will reduce the incidence of perioperative thromboembolic disease.