Thrombectomy and cavocavostomy for inferior vena cava thrombosis and torsion after piggyback liver transplantation

Abstract

Inferior vena cava (IVC) complications after orthotopic liver transplantation continue to be rare but serious concerns.1,2 Although numerous surgical and percutaneous techniques have been suggested for the management of different IVC complications, there is no consensus about a standard method of treatment. Here we describe a unique case in which a liver allograft caused kinking of the recipient's IVC and subsequent thrombosis after piggyback liver transplantation. Our case involves a 48-year-old male with end-stage liver disease secondary to hepatitis C. He underwent piggyback liver transplantation in which the suprahepatic allograft IVC was anastomosed with 3 recipient hepatic veins. On postoperative day 3, the patient developed significant hemodynamic instability and was re-explored through the same bilateral subcostal incision. An intraoperative Doppler examination revealed patent hepatic veins with pulsatile flow but also a nearly occlusive thrombus in the recipient's IVC extending from the suprarenal IVC to the retrohepatic IVC inferior to the piggyback anastomosis. The absence of an outflow obstruction was confirmed by the lack of a pressure gradient across the piggyback anastomosis, which was demonstrated by the direct measurement of the pressures of the recipient's suprahepatic IVC and the donor's IVC. Graft rotation and IVC kinking inferior to the piggyback anastomosis were also observed to be causing IVC stenosis. The decision was made to perform a thrombectomy through a venotomy on the suprarenal IVC with Fogarty balloons. Once an adequate caval flow was obtained, vascular clamps were applied inferior to the piggyback anastomosis and slightly superior to the renal veins. The lower aspect of the donor's IVC was untied and anastomosed to the opening on the recipient's IVC (the site of the thrombectomy) in an end-to-side fashion (Fig. 1). By anchoring the donor's IVC in 2 separate locations, we were able to relieve the kinking of the IVC. End-to-side cavocavostomy. Reprinted with permission from Transplantation Proceedings.3 Copyright 2001, Elsevier Science, Inc. Three days after the re-exploration, a Doppler ultrasound examination revealed normal directional flow and patency of the hepatic vasculature. A retrievable Gunther Tulip IVC filter was inserted to prevent any further risk of a pulmonary embolism. The patient's remaining postoperative course was unremarkable. The laboratory values on April 2011 were as follows: total bilirubin, 1.4 mg/dL; aspartate aminotransferase, 41 U/L; alanine aminotransferase, 32 U/L; and creatinine, 1.5 mg/dL. Recent abdominal magnetic resonance imaging demonstrated the patency of the cavocavostomy (Fig. 2). Magnetic resonance imaging (May 2011) demonstrating the patency of the cavocavostomy (black arrows). It is well known that graft rotation is an infrequent but serious complication after orthotopic liver transplantation because of its potential association with IVC obstructions. Our patient developed graft rotation and subsequent IVC kinking because of a size discrepancy between the graft and the recipient's right upper quadrant cavity. In addition, we believe that the construction of a significant portion of the piggyback anastomosis in the anterior wall of the IVC (where a substantial separation existed between the right hepatic vein and the confluence of the middle and left hepatic veins) may have further contributed to the graft rotation, which led to the IVC kinking and the subsequent caval flow obstruction and thrombosis. Although cavocaval anastomoses after piggyback liver transplantation have been reported, they have been used primarily to address IVC outflow obstructions.3, 4 We addressed graft rotation and kinking of the recipient's IVC by anchoring the donor's IVC in 2 separate locations. By using both IVC thrombectomy and an additional cavocaval anastomosis, we were able to successfully provide stability to the graft and re-establish adequate blood flow through the piggyback anastomosis. Our patient was still alive and doing well more than 3 years after liver transplantation. The utilization of IVC thrombectomy and infrahepatic cavocavostomy provided excellent management of graft rotation, IVC kinking, and retrohepatic/infrahepatic IVC thrombosis. In our view, this should be considered another option for the treatment of patients with similar complications after orthotopic liver transplantation. Aaron M. Williams B.A.*, Jonathan C. Hundley M.D.*, Michael F. Daily M.D.*, Malay B. Shah M.D.*, James T. Lee M.D.*, Roberto Gedaly M.D.*, * Division of Transplantation Department of Surgery College of Medicine University of Kentucky Lexington, KY.