Ligating coronary vein varices: An effective treatment of "coronary vein steal" to increase portal flow in liver transplantation.

Abstract

Potential conflict of interest: Nothing to report. TO THE EDITOR: We read with great interest the article by Gupta et al.,1 which reported 3 cases of liver transplantation (LT) in recipients with large coronary vein varices (CVVs). On the basis of their findings, the authors recommended routine portal vein flow (PVF) measurement after reperfusion, followed by shunt ligation in case of PVF < 1000 mL/minute or shunt diameter of >1 cm. Since September 2013, we have performed PVF measurements (VeriQ; Medistim ASA, Oslo, Norway) at our institution for every LT recipient with a portosystemic shunt (PSS) identified on preoperative cross‐sectional imaging. Among 170 LTs performed until December 2015, we identified 16 recipients with PSS, including 11 splenorenal shunts (SRSs), 4 CVVs, and 1 mixed PSS (Table 1). A renoportal anastomosis was performed in 2 patients with extensive thrombosis. The remaining patients had PVF measurement before and after a PSS clamping test, followed by PSS ligation, except for 2 patients: the first (number 8) had a SRS and a baseline PVF of 2000 mL/minute with only 10% increase after left renal vein (LRV) clamping test; the second (number 11) had received a relatively small graft (graft‐to‐recipient weight ratio: 1.2%) and his PVF increased by 74%, reaching 345 mL/minute/100 g of liver weight after CVV clamping test; shunt ligation was subsequently abandoned to avoid portal hyperperfusion. During follow‐up, 1 patient (number 16) with poor PVF during LT despite SRS ligation developed extensive mesoportal thrombosis 2 weeks after LT and died 5 months afterward. All remaining patients had an uneventful postoperative course with hepatopetal PVF on control Doppler ultrasounds. Table 1 - Patient Hemodynamics Before and After Clamping of the PSS Patient Age, Years Sex Shunt Type Portal Vein Thrombosis PVF Before Clamping (mL/minute) PVF After Clamping (mL/minute) PVF Variation After Clamping (%) Portal Anastomosis Additional Maneuver Shunt Ligated 1 24 Male CVV No 2300 2800 +22 Portoportal None CVV 2 64 Male SRS Yes 1400 — — Renoportal None None 3 56 Male SRS No 2300 3200 +39 Mesoportal Venous conduit LRV 4 58 Male SRS Yes 1100 1600 +46 Portoportal Thrombectomy LRV 5 67 Female SRS Yes 800 — — Renoportal None None 6 50 Male SRS Yes 1500 2300 +53 Portoportal Thrombectomy LRV 7 53 Male SRS No 2200 3600 +64 Portoportal None LRV 8 47 Female SRS No 2000 2200 +10 Portoportal None None 9 23 Male SRS No 2000 2400 +20 Portoportal None LRV 10 65 Female CVV Yes 1100 1700 +55 Mesoportal Venous conduit CVV 11 56 Male CVV Yes 2300 4000 +74 Portoportal Thrombectomy None 12 54 Male CVV + SRS No 1700 — — Coronary portal None LRV 13 64 Female SRS No 1700 2000 +18 Portoportal None LRV 14 62 Female SRS No 1500 2200 +47 Portoportal None LRV 15 57 Male CVV No 2400 2800 +17 Portoportal None CVV 16 61 Male SRS Yes 300 600 +100 Portoportal Thrombectomy LRV On the basis of this experience, we would like to emphasize 2 points in addition to the statements made by Gupta et al.1 First, we believe that in patients with baseline PVF > 1000 mL and CVV > 1 cm, PVF measurement must be performed after a PSS clamping test to verify the absence of portal hyperperfusion (ie, PVF > 250 mL/minute per 100 g of liver weight),2 especially for smaller grafts. In our series, the patient for whom CVV ligation was abandoned due to portal hyperperfusion had a satisfactory postoperative course, whereas it could be hypothesized that he would have developed small‐for‐size syndrome in the case of a shunt ligation.2 Second, we consider that PVF measurement is even more fundamental in cases of SRS because disconnecting SRS implies LRV ligation, a complex maneuver that could cause kidney injury.3 Hence, for patients with SRS, we recommend shunt ligation only when LRV clamping test results in at least a 15%‐20% increase of PVF. Prospective studies are warranted to refine PSS management strategy during LT with the contribution of intraoperative PVF measurement.