Hepatic Venous Research Articles

Role of Interventional Radiology in the Management of Early Vascular Complications After Liver Transplant.

A hepatic vascular complication after liver transplant is a critical situation, often resulting in graft failure and potentially leading to patient death. Early diagnosis and treatment of vascular complications can provide prolonged graft survival and prohibit further complications. This study presents our experiences with endovascular treatment during the first week after liver transplant. Between January 2012 and February 2021, 240 liver transplants were performed, with 43 patients having early endovascular treatment (37 men; mean age 27 ± 2.9 years) at a single center. Early endovascular interventions were carried out 1 to 7 days (mean ± SD of 2.7 ± 0.24 days) after transplant. Patients with vascular complications were grouped by arterial, venous, and portal complications. In addition, arterial complications were subgrouped by occlusive (hepatic artery thrombosis) and nonocclusive (hepatic artery stenosis/splenic artery steal syndrome) complications. Patients had median follow-up of 47 ± 4 months. In the first week after liver transplant, vascular complications included splenic artery steal syndrome in 27 patients (62.7%), hepatic complications in 10 patients (23.2%) (7 with hepatic artery thrombosis, 3 with hepatic artery stenosis), hepatic venous outflow complications in 4 patients (9.3%), and portal vein complications in 2 patients (4.6%). Only 1 patient required revision surgery because of excessive arterial kinking; the remaining patients with arterial complications were successfully managed with multiple endovascular treatment attempts. Patients with splenic artery steal syndrome were treated by selective arterial embolization with coil devices. Resistivity index, peak systolic velocity of hepatic arteries, and portal vein maximal velocity significantly improved (P < .001). Patients with hepatic venous outflow and portal vein complications who had endovascular treatments and vascular structures maintained good results over follow-up. Early endovascular intervention is feasible and safe for hepatic vascular complications following liver transplant, with high success treatment rates with advances in interventional radiology.

Nesidioblastosis: an uncommon complication seen post Roux-en-Y gastric bypass.

Adult-onset nesidioblastosis is a rare complication of Roux-en-Y gastric bypass surgery and may occur months to years after the initial surgical procedure. It is manifested by a hyperinsulinemic, hypoglycemic state. The annual incidence of adult-onset hyperinsulinemic hypoglycemia is believed to be less than 0.1 in 1 000 000 with a mean age of onset of 47 years (1). Here, we describe a patient who presented with worsening hypoglycemic symptoms for 1 year prior to presentation that eventually progressed to hypoglycemic seizures. The onset of this hypoglycemia was 5 years after Roux-en-Y gastric bypass surgery. A full neurological evaluation, which included an EEG, head CT, and MRI, was performed to rule out epilepsy and other seizure-related disorders. After hypoglycemia was confirmed, extensive laboratory studies were obtained to elucidate the cause of the hypoglycemia and differentiate nesidioblastosis from insulinoma. Once the diagnosis of nesidioblastosis was established, a sub-total pancreatectomy was performed, and the patient was discharged and placed on acarbose, a competitive reversible inhibitor of pancreatic α-amylase and intestinal brush border α-glucosidases which slows carbohydrate absorption. The lack of information and understanding of nesidioblastosis due to its rarity makes any knowledge of this rare but important surgical complication essential. As incidence of obesity increases, the number of gastric bypasses being performed increases with it, and understanding this disease process will be essential for the primary care provider. This is the primary reason for the writing of this publication. Nesidioblastosis is a persistent hyperinsulinemic, hypoglycemic state, mostly seen after Roux-en-Y gastric bypass surgery, with symptoms occurring postprandially. The incidence is 0.1-0.3% of all post Roux-en-Y gastric bypass patients. The key diagnostic clue to identifying nesidioblastosis is a positive selective arterial calcium stimulation test, showing a diffuse pattern of increased basal hepatic venous insulin concentration, whereas insulinomas would show focal increases. Pathological specimen of pancreas will show diffuse hypertrophy of beta cells. Management includes acarbose and total or subtotal pancreatectomy, which can be curative. With the prevalence of obesity increasing and more patients turning to Roux-en-Y gastric bypass, more patients may be at risk of this potential surgical complication.

Is there a Correlation between Hepatic Venous Indices and Main Pulmonary Artery Diameter?

To search whether there is a correlation between middle hepatic venous indices (HVIs) obtained by pulsed waved doppler ultrasonography (PW-DUS) and the main pulmonary artery (mPA) diameter, calculated by computed tomography (CT). A descriptive cross-sectional study. Department of Radiology, Balikesir University School of Medicine, Turkey, from February to December 2020. After excluding the cases with suspected COVID-19 from the cases sent to the Radiology Department for chest CT exams with the mPA included in the cross-sections, the volunteers were evaluated with PW-DUS. The study group consisted of 66 cases. Two radiologists measured the velocity values of the A, S, and D waves in the recorded PW Doppler spectra. HVIs (A/S, A/S+D, A/A+S+D) were calculated. The mPA diameter was calculated in the axial plane from the pulmonary trunk, 1cm proximally to the bifurcation manually on the workstation. The correlation between the HIVs and mPA diameter was evaluated. Interoperator reliability was also analysed. Thirty-nine males (59%) and 27 (41%) females were included in the study group. The mean HVI values were 0.50 ±0.20, 0.28 ±0.12, and 0.21 ±0.07 for A/S, A/A+S, and A/A+S+D, respectively. The mean mPA diameter was 24.0 ±3.3 mm. Correlation analysis determined that the HVIs were positively correlated with mPA diameter (r=0.730-0.765-0.751, p<0.001). Inter-observer correlation coefficients were found to be compatible between two radiologists. A significant and strong correlation was found between HVIs and mPA diameter. The mPA diameter that reflects the pulmonary artery systolic pressure (PAP) increased as the HVIs increased. Therefore, PW-DUS may be helpful to evaluate PAP as a quantitative method that is cost-effective, easily accessible and radiation-free. Hepatic veins, Pulmonary artery, Multidetector computed tomography, Pulmonary hypertension, Pulsed doppler ultrasonography.

Promoting Surgical Resection through Future Liver Remnant Hypertrophy.

An inadequate future liver remnant (FLR) can preclude curative-intent surgical resection for patients with primary or secondary hepatic malignancies. For patients with normal baseline liver function and without risk factors, an FLR of 20% is needed to maintain postsurgical hepatic function. However, the FLR requirement is higher for patients who are exposed to systemic chemotherapy (FLR, >30%) or have cirrhosis (FLR, >40%). Interventional radiologic and surgical methods to achieve FLR hypertrophy are evolving, including portal vein ligation, portal vein embolization, radiation lobectomy, hepatic venous deprivation, and associating liver partition and portal vein ligation for staged hepatectomy. Each technique offers particular advantages and disadvantages. Knowledge of these procedures can help clinicians to choose the suitable technique for each patient. The authors review the techniques used to develop FLR hypertrophy, focusing on technical considerations, outcomes, and the advantages and disadvantages of each approach. Online supplemental material is available for this article. ©RSNA, 2022.

Effect of Simvastatin on Hepatic Venous Portal Gradient for Maintenance of Lipid Profile of Liver Cirrhosis patients

Background: Liver cirrhosis has an essential influence on the lipid profile. Statins have well-known beneficial cardiovascular effects reducing cardiovascular events and mortality. Aim: To compare the change in hepatic venous portal gradient with or without simvastatin for maintenance of lipid profile of liver cirrhosis patients Methods: This Randomized controlled trial was done at Department of Medicine, South medical ward, Mayo hospital, Lahore from October 2021 to March 2022.patients were randomly divided in two groups. In group A, patients were given simvastatin with standard treatment. In group B, patients were given standard treatment only. Before and after 1 month of treatment, lipid profile and HVPG level were assessed again. The change in HVPG and lipid profile was calculated. Data was entered and analyzed in SPSS version 25. Results: The mean age of patients received simvastatin was 55.26 ± 13.24 years and mean age of patients in control was 53.74 ± 16.88 years. In simvastatin group, there were 82 (54.7%) males and 68(45.3%) females. In control group, there were 93 (62.0%) males and 57(38%) females. With simvastatin, the mean HVPG level was reduced from 20.11± 6.21mg/dl to 15.42±4.71 mg/dl after a month (mean change = 4.69 ± 1.50 mg/dl). While in control group, mean HVPG level was reduced from 19.28±7.61 mg/dl to 17.82± 6.52 mg/dl after a month (mean change = 1.46±1.09 mg/dl). The effect size was 23.3% with simvastatin while 7.6% without simvastatin for reduction of HVPG in cirrhotic patients. The difference was observed to be significant (p&lt;0.05). Conclusion: Thus, addition of simvastatin is effective in controlling lipid profile of patients with liver cirrhosis. It also has beneficial role in improving condition of liver cirrhosis patients. Keywords: hepatic venous portal gradient, simvastatin, lipid profile, liver cirrhosis, LDL, HDL, total cholesterol, triglycerides

Locoregional Therapy in the Management of Intrahepatic Cholangiocarcinoma: Is There Sufficient Evidence to Guide Current Clinical Practice?

Intrahepatic cholangiocarcinoma (iCCA) carries a dismal prognosis and, despite increasing incidence, still lacks effective treatments. In this scenario, locoregional therapies (LRT) are gaining interest as they may be effective at local tumor control and complementary to surgical and non-surgical approaches. In this article, we will review the evolving role of LRT performed by interventional radiologists in the management of iCCA. Accumulating retrospective evidence indicates that ablative therapies and transarterial embolizations are of benefit for iCCA with unresectable disease, demonstrating promising safety profiles and prolonged or comparable survival outcomes compared to systemic therapy and surgery. Additionally, for surgical candidates, portal ± hepatic venous embolization can improve the safety of hepatectomy by inducing preoperative hypertrophy of the non-involved liver lobe. LRTs are playing an increasingly important role in the multimodal treatment of iCCA from various perspectives with reduced toxicity relative to traditional treatments. To expand the scope of applications for LRTs in this setting, future prospective randomized studies are needed to confirm their efficacy and advantage.

S2943 Budd-Chiari Syndrome Diagnosis Achieved With High Clinical Suspicion Raised by EUS-Guided Portal Pressures and Liver Biopsy

Introduction: Budd Chiari syndrome (BCS) is a rare syndrome due to hepatic venous obstruction in the absence of cardiac cause, mostly secondary to thrombosis. As high as 80%of patients present with ascites. The diagnosis should be suspected in patient with acute or chronic liver disease without identified cause. Venous obstruction can be seen on Doppler ultrasound, CT, or MRI of the hepatic veins and inferior vena cava. In some cases, hepatic venogram is needed for its diagnostic and therapeutic advantages. We report a 50-year-old woman with BCS who underwent successful wire recanalization, angioplasty and thrombolysis of the right hepatic vein. Case Description/Methods: 50-year-old woman with no significant past medical history presented with abdominal distension and bilateral lower extremity swelling of two weeks duration. On exam, abdomen was distended with positive signs of fluid collection with +3 bilateral lower extremity edema. Labs revealed total bilirubin 3.3 direct bilirubin 1.4, ALP 477, ALT 38, AST 96, PT 14.4, INR 1.35. Ultrasound showed Heterogeneous appearance of liver and large volume ascites. Doppler study showed normal hepatic and portal venous flow. Abdominal MRI showed hepatic steatosis and caudate lobe hypertrophy. Large volume paracentesis was done with analysis showing SAAG of 3.1, WBC 364, Neutrophils 8. EGD revealed large esophageal varices. Viral hepatitis panel, ceruloplasmin, alpha-1antitripsin, ASMA, AMA antibodies were negative. EUS guided liver biopsy and portal pressure measurement was done showing venous pressure gradient of 13 consistent with portal hypertension. Liver biopsy showed grade 2 fibrosis and zone 3 congestion. Hepatic venogram showed chronically occluded right hepatic vein on which successful wire recanalization was done. Pt was worked up for hypercoagulable state and was found to have JAK 2 mutation and Protein C deficiency. Apixaban, Beta blocker and diuretics were started. Patient showed significant improvement with ascites and MELD score. Discussion: First line investigation for diagnosis of BCS is doppler ultrasound. Doppler US and MRI venography didn’t reveal the hepatic venous thrombosis in our patient. However, high index of suspicion, finding of elevated IVC pressure on EUS, and caudate lobe hypertrophy found on imaging as well as congestion liver biopsy findings led us to further investigate with hepatic venogram which confirmed the diagnosis and provided therapeutic advantages. Table 1. - Prothrombotic risk factors for BCS ACG Clinical Guideline A. Acquired thrombophilia B. Inherited thrombophilia C. Systemic factors D. Hormonal factors Myeloproliferative disorderPolycythemia veraEssential thrombocytosisIdiopathic myelofibrosisJAK 2 mutationPNH Hyperhomocysteinemia Factor V LeidenProthrombin gene G20210A mutationMTHFR C677T mutationThalassemiaPC deficiencyProtein C deficiencyAntithrombin deficiency SarcoidosisVasculitisBehcet’s diseaseConnective tissue diseaseInflammatory bowel diseases OCP usePregnancy Disorders of the Hepatic and Mesenteric Circulation Simonetto, Douglas A.; Singal, Ashwani K.; Garcia-Tsao, Guadalupe; Caldwell, Stephen H.; Ahn, Joseph; Kamath, Patrick S. Official journal of the American College of Gastroenterology | ACG115(1):18-40, January 2020. doi: 10.14309/ajg.0000000000000486

S2993 Extensive Hepatic Fibrosis Mimicking Primary Liver Malignancy

Introduction: Liver cirrhosis is a pathophysiological outcome of sustained liver inflammation. Sustained hepatic insults generate a process of fibrogenesis, in which an excessive extracellular matrix deposition replaces normal liver parenchyma. We present a patient with newly diagnosed liver cirrhosis who was found to have a liver mass suggestive of primary liver malignancy on imaging; however, multiple biopsies confirmed the mass to be fibrosis with mild hepatitis. Case Description/Methods: A 40-year-old male presented for the evaluation of new bilateral lower extremity edema. He reported a long history of alcohol use but otherwise denied prior medical history and no medication use. Laboratory work on admission was pertinent for a total bilirubin of 3.5, AST 162, ALT 57, alkaline phosphatase 176, albumin 3.0, and a non-reactive viral hepatitis panel. CT abdomen/pelvis revealed a heterogeneous liver suggestive of cirrhosis along with a 6.8 cm x 8.7 cm mass with irregular margins situated between the right and left lobes of the liver. On 3-phase MR imaging, the lesion demonstrated progressive enhancement in the portal venous phase and hepatic venous phase, with retention of contrast on 5-minute delayed images [Image 1a, b, c]. Overall, these findings suggested infiltrative cholangiocarcinoma. Additional imaging ruled out multifocal disease, and tumor markers CEA and AFP were unremarkable. Subsequently, a diagnostic laparotomy with liver biopsy was performed. The biopsy demonstrated fibrosis with atypical ductular proliferation, but the presence of low-grade infiltrative cholangiocarcinoma could not be ruled out. To rule out biopsy sampling error, two additional biopsies later that month concurred cirrhotic liver segments with areas of mild hepatitis. Tumor markers CK20 and CDX2 were negative, and no atypical cells were present. It was concluded that this liver lesion represented extensive hepatic fibrosis and mild hepatitis due to ongoing alcohol use, but no malignancy. Discussion: Liver cirrhosis is a major risk factor for the development of primary liver cancers such as hepatocellular carcinoma and cholangiocarcinoma. Triple-phase CT or MR imaging plays a key role in diagnosing these cancers; however, as demonstrated in our case, certain benign lesions such as liver fibrosis can mimic primary liver malignancy. Improved recognition of these benign lesions is necessary to avoid unnecessary and potentially harmful interventions.Figure 1.: 1a) Pre-contrast MR T2 weighted image showing a large central hepatic mass and lobular contour of liver consistent with cirrhosis. 1b) Post-gadolinium T1 fat-saturated MR image demonstrating enhancement of the liver lesion in the hepatic venous phase. The lesion showed high retention index of contrast on 5-minute delayed images (not included). 1c) Diffusion-weighted MR image showing the liver lesion with significantly restricted diffusion suggestive of infiltrative type of cholangiocarcinoma.

Simultaneous IVC/SVC Endovascular Sharp Recanalization in A Patient with Budd-Chiari Syndrome, Systemic Lupus Erythematosus and Antiphospholipid Syndrome, A Case Report

Abstract:&#x0D; Background: Budd‐Chiari syndrome (BCS) is a rare life-threatening condition and is caused by an obstruction to the hepatic venous outflow. We herein report a case of BCS complicated with inferior vena cava (IVC) and superior vena cava (SVC) stenosis that was managed by a simultaneous IVC/SVC sharp recanalization.&#x0D; Case presentation: A forty-year-old lady came to the clinic complaining of distended abdomen. She is a known case of antiphospholipid syndrome and systemic lupus erythematosus. Triphasic liver computed tomography showed a heterogeneous liver with nutmeg appearance and attenuation of hepatic veins with caudate hypertrophy. There was a severe dilatation of the azygos and hemiazygos veins with multiple posterior mediastinal and retrocrural tortuous collaterals recanalizing the IVC distally. Contrast enhanced CT of the chest showed a chronic complete occlusion of the left brachiocephalic vein with enlargement of the left superior intercostal vein, hemiazygos, and azygos veins. SVC was patent with multiple calcific foci of the wall likely related to chronic thrombosis. Through the right femoral access, inferior venacavogram was obtained, which showed suprahepatic IVC complete occlusion. Then, an upper venous access was obtained through the right internal jugular vein. Followed by a venogram which showed a complete occlusion at the right brachiocephalic vein with extensive collaterals were noted. Sharp recanalization from the jugular access of the brachiocephalic vein/SVC was performed targeting the balloon within the SVC that was advanced from the azygos vein, which followed by placing a covered stent graft. Then Multiple balloon angioplasties were made at the level of suprahepatic IVC followed by placing a non-covered stent.&#x0D; Conclusion: It was a Successful recanalization for the completely occluded suprahepatic IVC and placement of IVC stent, and a Successful recanalization for the completely occluded right brachiocephalic vein and placement of a stent.

Comparison of Three Inferior Vena Cava Reconstruction Techniques in Adult Orthotopic Liver Transplantation: Result From King Chulalongkorn Memorial Hospital, Thailand

BackgroundIn orthotopic liver transplantation (OLT), 3 caval reconstruction techniques are being performed worldwide. These are conventional, piggyback technique, and side-to-side cavocaval anastomosis (CCA). Each has its own advantages and drawbacks. Herein we report the result from our hospital comparing the 3 techniques. MethodsWe retrospectively reviewed the detail of OLT performed from January 2008 to March 2020. Data being collected included type of caval reconstruction, blood loss, operative time, ischemic time, length of stay in the intensive care unit (ICU) and total hospital stay, and several postoperative complications. ResultsIn the given period, 11 conventional, 90 piggyback, and 113 CCA caval reconstruction were done. There were no statistically significant differences in blood loss, operative time, cold ischemic time, and length of ICU and hospital stay. The CCA group had the lowest warm ischemic time (40 minutes) followed by the piggyback technique (43 minutes) and the conventional technique (47 minutes; P < .001). Regarding postoperative complications, there were no statistically significant differences in rate of primary nonfunction, early allograft dysfunction, hepatic artery/portal vein/biliary complication, or rate of acute kidney injury. The hepatic venous outflow complication rate was indifferent between 3 groups. ConclusionsThe present study showed no difference in outflow obstruction rate among the 3 techniques. The choice for reconstruction should rely on the preference of each institute and the suitability of each patient. The CCA technique may provide the lowest warm ischemic time.

Living Donor Liver Transplantation for Budd-Chiari Syndrome: A Propensity Score-Matched Analysis.

There are unique technical and management challenges associated with living donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS). The outcomes of LDLT for BCS in comparison to other indications remain unclear and warrant elucidation. Data of 24 BCS patients who underwent LDLT between January 2012 and June 2019 were analyzed. There were 20 adults and 4 children. The early and long-term outcomes of adult LDLT BCS patients were compared to a control group of LDLT patients for other indications and matched using propensity scoring methodology. Primary BCS was observed in 18 (90%) patients. Caval replacement was performed in 7 (35%) patients. Early and late hepatic venous outflow tract (HVOT) complications were seen in 1 (5%) and 3 (15%) patients. Preoperative acute kidney injury was identified as a risk factor for mortality in the BCS cohort (p = 0.013). On comparison, BCS recipients were younger with fewer comorbidities, more large volume ascites and higher rates of PVT. They also had longer cold ischemia time, increased blood loss and transfusion requirements, increased hospital stay, and higher late outflow complications. The 1-year and 3-year survivals were similar to non-BCS cohort (84.2% vs. 94% and 71.3% vs. 91.9%, respectively, log rank test p = 0.09). LDLT is a good option for symptomatic BCS who have failed non-transplant interventions. The clinical and risk factor profile of BCS recipients is distinct from non-BCS recipients. By following an algorithmic management protocol, we show on propensity-score matched analysis that outcomes of LDLT for BCS are similar to non-BCS indications.

Characterization of Doppler spectrum of hepatic veins in dogs with pulmonary hypertension

Pulmonary hypertension (PH) triggers hemodynamic changes within the right heart, which may affect hepatic venous flow. The aims of this study were three-fold: to investigate, prospectively, the reliability of the hepatic vein Doppler waveform to diagnose and characterize the magnitude of PH in dogs; to evaluate whether a correlation exists between hepatic venous flow waves and the structural and functional characteristics of the right ventricle (RV); and to determine whether age, gender, body weight, heart rate (HR), heart rhythm and systolic blood pressure affect the hepatic venous waveform pattern.A cross-sectional observational study was carried out in 43 dogs with varying degrees of PH and a control group of 15 healthy dogs. The velocities of the hepatic A, S, V and D spectral waves and the phasic pattern varied according to the severity of PH. Weak to moderate correlations were documented between hepatic vein waves and age, HR, and the structural and functional variables of the RV. A D Wave cut-off of 11.6 cm ∙ s-1 had a sensitivity of 100% and specificity of 35% for differentiation of dogs with severe PH from healthy dogs. Doppler assessment of hepatic venous flow was shown to be a reliable technique for screening dogs for PH.

Stereotactic radiofrequency ablation of tumors at the hepatic venous confluence.

Radiofrequency ablation (RFA) is subject to "heat-sink" effects, particularly for treatment of tumors adjacent to major vessels. In this retrospective study, 104 patients with 137 tumors (40 HCC, 10 ICC and 54 metastatic liver tumors) close to (≤1cm from) the hepatic venous confluence underwent stereotactic RFA (SRFA) between June 2003 and June 2018. Median tumor size was 3.7cm (1.4-8.5) for HCC, 6.4cm (0.5-11) for ICC and 3.8cm (0.5-13) for metastases. Endpoints comprised safety, local tumor control, overall and disease-free survival. The overall major complication rate was 16.0% (20/125 ablations), where 8 (40%) were successfully treated by the interventional radiologist in the same anesthetic session and did not prolong hospital stay. 134/137 (97.8%) tumors were successfully ablated at initial SRFA. Local recurrence (LR) developed in 19/137 tumors (13.9%). The median and overall survival (OS) rates at 1-, 3-, and 5- years from the date of the first SRFA were 51.5 months, 73.5%, 67.0%, and 49.7% for HCC, 14.6 months, 60.0%, 32.0% and 32.0% for ICC and 38.1 months, 91.4%, 56.5% and 27.9% for metastatic disease, respectively. SRFA represents a viable alternative to hepatic resection for challenging tumors at the hepatic venous confluence.

The first years of liver transplantation: experiences at a single center.

BackgroundThe aim of this study was to analyze the first stages of progress in liver transplantation (LT) at a single center in Vietnam.MethodsThis study analyzed data from patients and donors who participated in the LT program between August 2018 and December 2021 at University Medical Center, Ho Chi Minh City. Study measures included any difficulties encountered, as well as the post-LT outcomes for living donor LT (LDLT) and deceased donor LT (DDLT). The chi-square test and Kaplan Meier survival analysis were used to test the factors that influenced the outcomes.ResultsA total of 18 adult recipients with LT (LDLT, n=16; DDLT, n=2) were included (mean age, 55.2±2.6 years; male, 88.9%). The most common post-LT complications were middle hepatic venous stenosis (20%) and graft rejection (22.2%). These complications were observed in LDLT patients. For DDLT, graft rejection (50%) was the only complication recorded. The survival rates for recipients at 3 months, 6 months, and 1 year were 100%, 88.9%, and 88.9%, respectively. The LDs had their right livers without the middle hepatic veins harvested, and biliary leakage (6.25%) was the only complication observed. There were no deaths among recipients or LDs during the operations or hospital stays.ConclusionsThis study provides key details about the process of LT, and these positive outcomes support LT as an important therapy for end-stage liver disease and early hepatocellular carcinomas.

Hepatic Venous Outflow Obstruction in Adult Deceased Donor Liver Transplantation: Classic Piggyback Implantation Versus a Modified Technique that Widens the Ostium of the Recipient's Left and Middle Hepatic Veins

The classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques. Retrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study. From January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n=11) and 0.95% (n=7), respectively (P=0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P=0,31). This modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.

Abstract No. 232 Correlation between the hepatic venous transplant anastomotic gradient and hepatic congestion on transjugular liver biopsy in post-liver transplant patients

Transjugular liver biopsy and intravascular pressure measurement is utilized to detect the presence of post-liver transplant complications, including congestive hepatopathy (CH). Hepatic venous anastomotic pressure gradients are conventionally utilized as part of clinical decision making in patients with suspected CH in addition to histologic manifestations within the liver biopsy specimen. This study aimed to determine if the free hepatic venous to right atrial pressure gradient correlated with the histologic diagnosis of CH.

Erectile Dysfunction in Cirrhosis: Its Prevalence and Risk Factors

Erectile dysfunction (ED) is common in men with cirrhosis. The aim of this study was to assess the prevalence of ED and the factors associated with ED in men with cirrhosis. 400 men with cirrhosis [Child-Turcotte-Pugh (CTP) class A, 44.0%; CTP class B, 41.0%; and CTP class C, 15.0%] having high Karnofsky performance score, and living in a stable monogamous relationship with a female partner were included in the study. International Index of Erectile Function (IIEF) questionnaire, and Short-Form (36) Health Survey (SF-36) were used to assess erectile function and the health-related quality of life (HRQOL), respectively. ED was found in 289 (72.3%) patients. Patients with ED reported significantly lower SF-36 scores across all the eight domains of SF-36 (i.e., physical functioning score, role physical score, bodily pain score, general health perception score, vitality score, social functioning score, role emotional score, and mental health score); physical component summary score, and mental physical component summary score, compared with those without ED. On multivariate analysis, factors associated with ED were older age, longer duration of cirrhosis, CTP-C (vs. CTP-A), higher hepatic venous pressure gradient (HVPG), presence of generalized anxiety disorder (GAD), presence of major depression, and lower appendicular skeletal muscle index measured by dual-energy X-ray absorptiometry (DEXA ASMI). ED is common in men with cirrhosis, and men with ED have poor HRQOL compared with those without ED. Older age, longer duration of cirrhosis, CTP-C (vs. CTP-A), higher HVPG, presence of GAD, presence of major depression, and lower DEXA ASMI are associated with ED.

Inferior sinus venosus defect and anomalous hepatic venous return to the coronary sinus leading to an Eisenmenger syndrome.

Inferior sinus venosus defect associated with left hepatic vein drainage to the coronary sinus is an extremely rare condition. We report the case of a 41-year-old man suffering from pulmonary arterial hypertension related to this unusual CHD. Planning of heart-lung transplantation in this case required accurate anatomical description.

A mesh-based model of liver vasculature: implications for improved radiation dosimetry to liver parenchyma for radiopharmaceuticals

PurposeTo develop a model of the internal vasculature of the adult liver and demonstrate its application to the differentiation of radiopharmaceutical decay sites within liver parenchyma from those within organ blood.MethodComputer-generated models of hepatic arterial (HA), hepatic venous (HV), and hepatic portal venous (HPV) vascular trees were algorithmically created within individual lobes of the ICRP adult female and male livers (AFL/AML). For each iteration of the algorithm, pressure, blood flow, and vessel radii within each tree were updated as each new vessel was created and connected to a viable bifurcation site. The vascular networks created inside the AFL/AML were then tetrahedralized for coupling to the PHITS radiation transport code. Specific absorbed fractions (SAF) were computed for monoenergetic alpha particles, electrons, positrons, and photons. Dual-region liver models of the AFL/AML were proposed, and particle-specific SAF values were computed assuming radionuclide decays in blood within two locations: (1) sites within explicitly modeled hepatic vessels, and (2) sites within the hepatic blood pool residing outside these vessels to include the capillaries and blood sinuses. S values for 22 and 10 radionuclides commonly used in radiopharmaceutical therapy and imaging, respectively, were computed using the dual-region liver models and compared to those obtained in the existing single-region liver model.ResultsLiver models with virtual vasculatures of ~ 6000 non-intersecting straight cylinders representing the HA, HPV, and HV circulations were created for the ICRP reference. For alpha emitters and for beta and auger-electron emitters, S values using the single-region models were approximately 11% (AML) to 14% (AFL) and 11% (AML) to 13% (AFL) higher than the S values obtained using the dual-region models, respectively.ConclusionsThe methodology employed in this study has shown improvements in organ parenchymal dosimetry through explicit consideration of blood self-dose for alpha particles (all energies) and for electrons at energies below ~ 100 keV.

State of the Art, Current Perspectives, and Controversies of Budd-Chiari Syndrome: A Review.

BackgroundBudd-Chiari syndrome (BCS) is an eponym that includes a group of conditions characterized by partial or complete hepatic venous tract outflow obstruction, and the site of obstruction may involve one or more hepatic veins, inferior vena cava, or the right atrium. The classification of BCS is based on etiology, site of obstruction, and duration. Its etiology is very heterogeneous; in particular, hepatic vein thrombosis is the most common type of obstruction and myeloproliferative disorder, the most common thrombophilic disorder, in the West. In Asian countries, the type of obstruction, thrombophilic disorders, clinical features, and treatment strategies vary widely from region to region. Although the cause can be identified in 90% of patients with the help of gene mutation testing, BCS remains under-recognized in many countries. A higher prevalence of acute cases has been reported in the West than in the East. This global and regional heterogeneity raises several challenges regarding the evaluation, management strategy, and individualized approach of BCS. This study aimed to conduct a systematic review of BCS to elucidate treatment strategy options.MethodsPubMed, Embase, Cochrane Library, and Google Scholar databases were searched systematically.ResultsSixty-nine pertinent articles were retrieved and included in the present study.ConclusionsFurther research on the following three topics would help define individualized treatment strategies. The first is a better understanding of the molecular pathways underlying the thrombophilic conditions implicated in the pathogenesis of BCS. The second is the role of the genotype and gene mutations in the determination of coagulation status of patients with BCS. The third is the definition of clear criteria and development of a common prognostic index to risk stratify the patients at presentation and consequently detect candidates for invasive therapies.