Systematic Venoplasty: A Method To Treat Difficult Mechanical Hepatic Vein Outflow Obstruction in Orthotopic Liver Transplant

Abstract

Mechanical hepatic venous outflow obstruction (HVOT) is rare but potentially serious complication of piggyback orthotropic liver transplant (OLT), which may result in graft loss. Endovascular stent placement or surgical repositioning are well described modalities of treatment. Venoplasty is rarely performed now-a-days as it is reported to be unsuccessful with high recurrence. We report here a case where successive angioplasty of hepatic vein lead to successful treatment of anatomically challenging and technically difficult HVOO. A 49-year-old African American female with hepatitis C cirrhosis underwent successful OLT at our institution. One month after transplant, patient developed gradually progressive abdominal distention and right sided pleural effusion. Fluid retention became diuretics refractory thus patient underwent 2 sessions of large volume thoracentesis for right hydrothorax and paracentesis for ascites. Subsequent evaluation with ultrasound liver with Doppler and CT showed significant stenosis of both right and left hepatic veins with narrowed middle hepatic vein and large venous infarcts. Endovascular stent placement was technically tough in our patient. Major concern regarding stent placement was difficult access due to unfavorable anatomy of anastomosis which could lead to stent malposition with high risk of migration or blocking the drainage of the other two hepatic veins completely. After multidisciplinary team discussion patient underwent two sessions of venoplasty of middle hepatic vein with systematic incremental balloon dilatations at one week interval to drop the pressure gradient across the anastomosis from 20 mm of Hg to 6 mm of Hg. One week post venoplasty, her hepatic hydrothorax and ascites resolved completely, without any recurrence over 2 months. In conclusion, successive angioplasty still could be used as a modality of treating anatomically unfavorable mechanical HVOO in piggyback OLT patient, who are not a candidate for endovascular stent.