Solution to recurrent suprahepatic caval stenosis after liver transplantation: Cardiac surgery after repeated dilatations and stenting

Abstract

We report the unique course of a 54-year-old female patient after liver transplantation (LT) for Budd-Chiari syndrome in 1999. Because of hepatic artery thrombosis, early re-LT was performed with the classic inferior vena cava (IVC) reconstruction technique (suprahepatic and infrahepatic anastomoses). The patient suffered from severe ascites within 3 months of the surgery, and cavography showed 80% suprahepatic caval stenosis at the diaphragmatic level with a peak gradient of 17 mm Hg. She was treated with several balloon dilatations and then with caval stenting1 (Fig. 1A,B,D). One stent migrated in the right ventricle and was surgically removed (Fig. 1C). Despite a computed tomography (CT) scan showing normal stent positioning and echography indicating an absence of a measurable pressure gradient through the stent itself, massive ascites (5 L/day) persisted. Surgical exploration was undertaken, and peritoneal biopsies revealed a lymphogranulocytic inflammatory process with the involvement of vessel walls without fibrinoid necrosis (Fig. 2A). After steroid therapy, the ascites gradually disappeared. Five years later, ascites presented again. Recurrent suprahepatic caval stenosis and severe tricuspid valve regurgitation were diagnosed. Because of the progressive clinical ineffectiveness of endovascular dilatations (which were performed at closer and closer intervals over the course of 8 years) and renal function deterioration, re-intervention (ie, cardiac surgery) became necessary 13 years after LT. With extracorporeal circulation (including a phase of total hypothermic circulatory arrest), the patient underwent successful IVC reconstruction and tricuspid valve replacement2 (Fig. 2B,C). The postoperative course was complicated by prolonged right heart failure, which required inotropic support and diuretics. Despite that, the patient was discharged on postoperative day 32. A CT scan performed 8 months later showed no residual IVC stenosis (Fig. 2D). Echocardiography showed good left ventricle and tricuspid prosthesis functioning with mild right ventricle impairment. During the 1-year follow-up, no recurrence of ascites was observed. At the time of this writing, the patient was doing well with normal liver and renal tests and good quality of life. To our knowledge, this case represents the longest follow-up of a metallic stent in the IVC, and it documents the long-term failure of the transcatheter treatment of post-LT suprahepatic caval stenosis. Stefano Salizzoni, M.D., Ph.D.1 Renato Romagnoli, M.D.2 Pietro Rispoli, M.D., Ph.D.3 Paolo Strignano, M.D.2 Roberta Suita, M.D.3 Ezio David, M.D.4 Michele La Torre, M.D.1 Mauro Rinaldi, M.D.1 1Division of Cardiac Surgery, 2Liver Transplantation Center, 3Division of Vascular Surgery, and 4Department of Pathology II San Giovanni Battista Hospital City Hospital of Health and Science of Turin Department of Surgical Sciences University of Turin Turin, Italy