Yerdel Grade Research Articles

Liver Transplantation in Patients with Portal Vein Thrombosis: Revisiting Outcomes According to Surgical Techniques

Surgical strategies for graft portal vein flow restoration vary from termino-terminal portal vein anastomosis to more complex bypass reconstructions. Although the surgical strategy strongly influences the post-operative outcome, the Yerdel grading is still commonly used to determine the prognosis of patients with portal vein thrombosis (PVT) undergoing liver transplantation (LT). We retrospectively reviewed the cases of LT performed on recipients with complex PVT at two high-volume transplantation centres. We stratified the patients by the type of portal vein reconstruction, termino-terminal portal vein anastomosis (TTA) versus bypass reconstruction (bypass group), and assessed a multivariable survival analysis. The rate of mortality at 90 days was 21.4% for the bypass group compared to 9.8% in the TTA group (p = 0.05). In the multivariable correlation analysis, only a trend for greater risk of early mortality was confirmed in the bypass groups (HR 2.5; p = 0.059). Yerdel grade was uninfluential in the rate of early complications. A wide range of surgical options are available for different situations of PVT which yield an outcome unrelated to the Yerdel grading. An algorithm for PVT management should be based on the technical approach and should include a surgically oriented definition of PVT extension.

A novel approach for portal system reconstruction in liver transplant patients with grade IV portal vein thrombosis: Case study and literature review.

Portal vein thrombosis is a common problem of end-stage liver disease in patients with portal hypertension and Yerdel grade IV thrombosis may be a contraindication for liver transplantation. Advances in surgical technique have indicated the feasibility of liver transplantation with PVT such as Reno-portal anastomosis, cavo-portal hemitransposition, but low graft portal blood perfusion and regional portal hypertension were the limitations. We introduce a new approach for portal system reconstruction in a patient underwent liver transplantation: A 28-year-old male was diagnosed with Budd-Chari syndrome and portal hypertension with grade IV portal vein thrombosis. The "Pull-out" technique was applicated for thrombectomy, which can aid in exposing the superior mesenteric vein and portal vein branches and reducing technical difficulties associated with the identification and dissociation of surrounding anatomical structures. To collect sufficient portal vein blood perfusion and avoid regional portal hypertension, the portal vein system was reconstructed through double-approach procedure: reno-portal anastomosis combined with portal-portal anastomosis. Based on a precision preoperative evaluation, application of the Pull-out technique and double-approach procedure may be an effective method of thrombectomy especially in cases of grade IV portal vein thrombosis.

Efficacy and safety of transjugular intrahepatic portosystemic shunt for the treatment of schistosomiasis-induced portal hypertension: a retrospective case series.

The aim of this study was to evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension caused by schistosomiasis. This study included 43 patients with schistosomiasis-induced portal hypertension treated with TIPS in our institution from December 2015 to May 2021. The demographic, imaging, clinical and follow-up data of patients were recorded retrospectively to evaluate the efficacy and safety of the procedure. All patients were successfully implanted with stents to establish shunt, and 90.7% of the patients were in good postoperative condition with no complications. After TIPS, the Yerdel grade of portal vein thrombosis decreased, and the portal pressure gradient decreased from 27.0 ± 4.9 mmHg to 11.3 ± 3.8 mmHg (P < 0.001). Bleeding was effectively controlled, with a postoperative rebleeding rate of 9.3%, which was an 87.9% reduction from the preoperative rate. The cumulative incidence of postoperative refractory ascites, shunt dysfunction, overt hepatic encephalopathy (OHE) and death were all similar to those of TIPS for nonschistosomiasis portal hypertension. There were no differences in liver and kidney function and blood coagulation indexes before and 3 months after TIPS. Albumin was identified as an independent risk factor for mortality after TIPS for schistosomal liver fibrosis. TIPS can be used as a well-tolerated and effective treatment for schistosomiasis-induced portal hypertension, effectively reduce portal pressure gradient and improve portal vein thrombosis.

Therapeutic anticoagulation after liver transplantation is not useful among patients with pre‐transplant Yerdel‐grade I/II portal vein thrombosis: A two‐center retrospective study

BackgroundPortal vein thrombosis (PVT) is no longer a contraindication for liver transplantation (LT). While therapeutic anticoagulation (tAC) is recommended during the waiting period, there is no evidence for its usefulness in the prevention of PVT recurrence after LT. ObjectivesThe aim of our study was to evaluate the role of tAC post‐LT in the prevention of PVT recurrence. Patients/methodsAll adult LTs performed in two high‐volume centers between 2003 and 2018 were retrospectively analysed. Only patients with PVT classified as Yerdel grade I or II and with standard portal reconstruction were included. PVT recurrence and tAC‐associated morbidity within 1 year were compared between patients receiving tAC or not. ResultsDuring the study period, of 2612 LTs performed, 235 (9%) patients with PVT were included; 113 patients (48.1%) received post‐LT tAC (tAC group) while 122 (51.9%) did not (non‐tAC group). The incidence of bleeding events was significantly higher in the tAC group (26 [23%] vs. 5 [4.1%], P < .01) and the initial hospitalization duration was longer (21 vs. 17.5 days, P < .01). Within the first year, PVT recurrence was observed for 9 (3.8%) patients without any difference between the tAC and non‐tAC groups (6 [5.1%] vs. 3 [2.5%], P = .39). The only identified risk factor for PVT recurrence was the recipients’ age (odds ratio= 0.94, P = .03). Graft (P = .11) and patient (P = .44) survival were similar between the two groups. ConclusionTherapeutic anticoagulation is not necessary in the prevention of grade I/II PVT recurrence and is associated with higher morbidity and longer hospital stay.

Liver transplantation in patients with non‐neoplastic portal vein thrombosis: 20 years of experience in a single center

The Yerdel classification is widely used for describing the severity of portal vein thrombosis (PVT) in liver transplant (LT) candidates, but might not accurately predict transplant outcome. We retrospectively analyzed data regarding 97 adult patients with PVT who underwent LT, investigating whether the complexity of portal reconstruction could better correlate with transplant outcome than the site and extent of the thrombosis. 79/97 (80%) patients underwent thrombectomy and anatomical anastomosis (TAA), 18/97 (20%) patients underwent non-anatomical physiological reconstructions (non-TAA). PVT Yerdel grade was 1-2 in 72/97 (74%) patients, and 3-4 in 25/97 (26%) patients. Univariate analysis revealed higher 30-day mortality, 90-day mortality, 1-year mortality, and a higher rate of severe early complications in the non-TAA group than in the TAA group (p = .018, .001, .014, .009, respectively). In the model adjusted for PVT Yerdel grade, non-TAA remained independently associated with higher 30-day, 90-day, and 1-year mortality (p = .021, .007, and .015, respectively). The portal vein re-thrombosis and overall patient and graft survival rates were similar. In our experience, the complexity of portal reconstruction better correlated with transplant outcome than the Yerdel classification, which did not even appear to be a reliable predictor of the surgical complexity and technique.

Modified Cavoportal Hemitransposition for Severe Portal Vein Thrombosis Contributed to Long-term Survival After Deceased Donor Liver Transplantation—Insight Into Portal Modulation for Improving Survival: A Case Report

Severe/massive portal vein thrombosis (PVT) deteriorates peri-liver transplantation outcomes. Cavoportal hemitransposition (CPHT) is a rescue procedure for severe PVT, and short-term outcomes have been well studied. However, CPHT is associated with some long-term issues caused by portal flow modulation via extraordinary reconstruction. We describe a patient with Yerdel grade 4 PVT who underwent a liver transplant and achieved long-term survival with CPHT and a portosystemic shunt. A 50-year-old man with liver cirrhosis underwent a deceased donor liver transplant. Preoperative examinations indicated Yerdel grade 4 PVT; thus, we planned a CPHT. In liver transplant surgery, we confirmed diffusely complete PVT and removed them as possible. After placing a liver graft, we performed CPHT and confirmed that the graft received sufficient portal vein flow. However, the gastroepiploic vein pressure increased significantly. Therefore, we added a portosystemic shunt between the splenic vein and the inferior vena cava, and the pressure improved. The patient was discharged after an uneventful hospital stay, and he reported no unfavorable events for over 12 years. This case study suggested that a modified CPHT with a portosystemic shunt for Grade 4 PVT was useful in preventing post-liver transplant PVT development and improved the outcome.

Over 500 liver transplants including more than 400 living-donor liver transplants in 2019 at Asan Medical Center

More than 400 liver transplants were performed at Asan Medical Center (AMC) in 2011, and over 500 liver transplants including 420 living-donor liver transplants (LDLTs) were performed in 2019. Herein, we report the methodology of these procedures. Since the first adult LDLTs at AMC using the left and right lobes were successfully performed, various innovative techniques and approaches have been developed: modified right lobe, dual graft, donor exchange for ABO incompatibility, expansion of indications and no-touch techniques for hepatocellular carcinoma, intraoperative cine-portogram and additional intervention for large collaterals, management of portal vein thrombosis (PVT) and stenosis, salvage LDLT after major hepatectomy, and timely LDLT for patients with acute-on-chronic liver failure. Four hundred twenty LDLTs in 403 adult and 17 pediatric patients and 85 deceased-donor liver transplants in 74 adult and 11 pediatric patients were performed. The number of deceased-donor liver transplants remained constant since 2011, but the number of LDLTs increased steadily. One hundred thirty patients (25.7%) required urgent liver transplantations and 24 patients with acute-on-chronic liver failure underwent LDLT. PVT including grade 1, 2, 3, and 4 was reported in 91 patients (18.0%), and Yerdel's grade 2, 3, and 4 PVT was reported in 47 patients (51.6%); all patients with PVT were successfully treated. Adult LDLTs for hepatocellular carcinoma and ABO incompatibility accounted for 52.6% and 24.3% of the cases, respectively. In-hospital mortality in 2019 was 2.97%. Continual efforts to overcome challenging problems in LDLT with various innovations and dedication of the team members during the perioperative period to.

Portal Vein Complications After Adult Living Donor Liver Transplantation: Time of Onset and Deformity Patterns Affect Long-Term Outcomes.

Portal vein complications (PVCs) after adult living donor liver transplantation (LDLT) are potentially lethal. We categorized PVCs by the time of onset (early versus late, <1month versus ≥1month, respectively) and deformity patterns (portal vein stenosis [PVS], portal vein thrombosis [PVT], and portal vein occlusion [PVO]) to establish optimal treatment strategies. Overall, 35/322 (10.9%) recipients developed PVCs between 2000 and 2019. Pretransplant PVT (odds ratio [OR], 15.20; 95% confidence interval [CI], 3.70-62.40; P<0.001) was the only independent risk factor for PVS. In contrast, male sex (OR, 5.57; 95% CI, 1.71-18.20; P=0.004), pretransplant PVT (OR, 4.79; 95% CI, 1.64-14.00; P=0.004), and splenectomy (OR, 3.24; 95% CI, 1.23-8.57; P=0.018) were independent risk factors for PVT. PVS was successfully treated with interventional radiology regardless of its time of onset. On the other hand, late PVT and PVO had significantly lower treatment success rates (2/15, 13%) compared with those that occurred in the early period (10/11, 91%) despite aggressive intervention (P<0.001). Deformity patterns had a significant impact on the 5-year cumulative incidence of graft loss as a result of PVC (PVO+Yerdel grades 2-4 PVT group [n=16], 41% versus PVS+Yerdel grade 1 PVT group [n=19], 0%; P=0.02). In conclusion, late grades 2 to 4 PVT and PVO are refractory to treatment and associated with poor prognoses, whereas PVS has a good prognosis regardless of time of onset. A tailored approach according to the time of onset and deformity patterns of PVC is essential.

The Impact of Portal Vein Thrombosis on Liver Transplant Outcomes: Does Grade or Flow Rate Matter?

Portal vein thrombosis (PVT) makes the technical aspect of liver transplantation challenging and also affects outcomes. Our aim was to study impact of PVT grade and postreperfusion portal flow on posttransplant outcomes. Patients who underwent transplantation with PVT between January 2007 and May 2017 were selected (n = 126). Data on grade of PVT and portal vein flow were collected. Patients were classified into 2 groups; low grade (Yerdel Grade I, n = 73) and high grade (Yerdel Grade II or III, n = 53). Using portal flow rate, patients were divided into high flow (≥1000 mL/min, n = 95) and low flow (<1000 mL/min, n = 31). Additional analyses of flow by graft weight and complications were performed. Postoperatively, incidence of biliary strictures were significantly greater in high-grade PVT compared with low grade (P = 0.02). Incidence of postoperative portal vein thrombosis was higher in low flow after reperfusion compared with high flow (P = 0.02), as was bile leak (P = 0.02). On identifying factors associated with graft loss, moderate to severe ascites preoperatively, high PVT grade and bile leak were associated with worse graft survival. Subanalysis performed combining grade and flow showed that low grade, high flow had the highest graft survival while high grade, low flow had the lowest (P = 0.006). High-grade PVT with low flow also appeared to be an independent risk factor for biliary complications (P = 0.01). In conclusion, biliary complications, especially strictures are more common in high-grade PVT and graft survival is worse in high-grade PVT and low portal flow.

3:27 PM Abstract No. 320 Management of portal vein thrombosis in cirrhotic patients

To compare the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) to anticoagulation and no treatment in cirrhotic patients with portal vein thrombosis (PVT). This single-center retrospective study evaluated 64 consecutive cirrhotic patients with imaging diagnosis of PVT between November 2005 and July 2019. 15 patients were excluded due to lack of adequate follow-up imaging. Of the remaining 49 patients, 11 (22%) were female. The median age was 61.5 (range, 24-80) years. 9 (18%) patients were treated with TIPS, 12 (24%) with anticoagulation, and 28 (57%) received no treatment. Demographic and clinical data were collected by reviewing the electronic medical record. PVT was evaluated using contrast-enhanced CT or MRI. Thrombus burden in the main portal (MPV), superior mesenteric (SMV), and splenic (SV) vein was graded as follows: grade 1, < 25%; grade 2, 26-50%; grade 3, 51-75%; and grade 4, > 75% of the luminal diameter. Yerdel scoring system was also used to evaluate the extent of portomesenteric thrombus. Thrombus burden at 6 and 12 months was compared to baseline imaging. Patient survival was estimated using Kaplan-Meier analysis. The extent of baseline thrombus was compared using Kruskal-Wallis test. Treatment response was analyzed by chi square test. There was no statistically significant difference in baseline thrombus burden between the 3 groups (MPV, P = 0.345; SMV, P = 0.244; SV, P = 0.541; Yerdel grade, P = 0.230). At 6 months, 87.5%, 58.3%, and 4.8% patients demonstrated complete or partial recanalization in the TIPS, anticoagulation, and no treatment groups respectively (TIPS/no treatment, P <0.0001; TIPS/anticoagulation, P = 0.163). At 12 months, 100%, 57.1%, 11.1% patients demonstrated complete or partial recanalization in the TIPS, anticoagulation, and no treatment groups respectively (TIPS/no treatment, P <0.0001; TIPS/ anticoagulation, P = 0.051). The overall survival between the 3 groups was not significantly different (P = 0.788) TIPS has significantly higher recanalization rate compared to no treatment and has a trend towards higher recanalization rate than that of anticoagulation at 6 and 12 months in cirrhotic patients with PVT.

Liver Transplant for Patients With Preexisting Portal Vein Thrombosis: A Single-Center Experience.

Portal vein thrombosis is not uncommon in liver cirrhosis patients. Previously, portal vein throm-bosis had been considered as a contraindication to liver transplant because of technical challenges for adequate restoration of portal inflow followed by high morbidity and mortality. However, alternative options for portal vein thrombosis during liver transplant have been introduced, and portal vein thrombosis is now no longer considered as an absolute contraindication for liver transplant. Herein, we introduce our ex-periences and outcomes of liver transplant for patients with portal vein thrombosis. Between March 2014 and June 2018, 65 patients underwent liver transplant at our institution, with 13 (20%) having portal vein thrombosis preoperatively. The characteristics and management of these patients were reviewed retrospectively, and outcomes were compared with those of patients without portal vein thrombosis. The type of portal vein thrombosis included Yerdel grade 1 in 7 patients (53.8%), grade 2 in 4 patients (30.8%), grade 3 in 1 patient (7.7%), and grade 4 in 1 patient (7.7%). For restoration of portal inflow, eversion thrombectomy was performed in 11 patients (84.6%), renoportal bypass in 1 patient (7.7%) with grade 4 portal vein thrombosis, and superior mesenteric vein jump graft in 1 patient (7.7%) with grade 2 portal vein thrombosis. There was no portal vein-related morbidity except for 1 patient who needed portal vein stent because of stricture. Outcomes after liver transplant were comparable among patients with and without portal vein thrombosis. Although the surgical procedure has a technical complexity, liver transplant is no longer a contraindication for patients with portal vein thrombosis because of various alternative options, allowing similar outcomes among patients with and without portal vein thrombosis.

Impact of portal vein thrombosis in outcomes of liver transplantation according to Yerdel’S grade

Aims: To analyze the incidence of PVT in candidates to OLT in our center, as well as to compare morbidity and mortality among those affected by this complication according to Yerdel´s grade and those who are free of it. Methods: Prospective comparative study in candidates undergone to OLT with PVT and control group without this complication in 653 recipients from January 2002 to December 2013. Age, gender, MELD, indication of transplant, type of thrombosis, surgical technique, red blood cell transfusion, GPT peak andl one year overall survival were analyzed. Results: 87 patients presented PVT (13.3%) among the 653 candidates transplanted. Regarding the type of thrombosis, 72.2% were partial and 26.2% were complete. The surgical technique used in 77% of the candidates with PVT were thrombectomy. Significant differences were observed in the consumption of red blood cell concentrates between the group with PVT versus no PVT (p = 0.001). Postoperative portal vein thrombosis was higher in PVT group when we compare with non-PVT group (p = 0.046). No significant differences were found in the GPT peak. We have found worse survival, although not statistically significant, in patients with PVT Yerdel grade 2-3-4 when we compared with grade 1 or non PVT patients. Conclusions: Patients with Yerdel grade 1 PVT have survival similar to those without PVT. Cases with PVT grades 2, 3, 4 tend to have a lower survival rate. The preoperative PVT is a risk factor for post-transplant PVT, as a result of lower portal flow obtained after reperfusion in these patients.

Adult Living Donor Liver Transplantation for Patients With Portal Vein Thrombosis: A Single-center Experience.

BackgroundLiving donor liver transplantation (LDLT) for patients with portal vein thrombosis (PVT) is associated with several technical challenges for its complicated procedures and poor outcomes. Some institutions still consider preexisting PVT as a relatively contraindication for LDLT.MethodsBetween April 2010 and May 2016, 129 adults underwent LDLT at our institution, and 28 (21.7%) of whom had preexisting PVT. Portal vein thrombosis was diagnosed using preoperative imaging techniques and intraoperative findings. The characteristics and outcomes of the cases were retrospectively evaluated.ResultsThe type of PVT included Yerdel grade 1 in 21 (75.0%) cases, grade 2 in 3 (10.7%) cases, and grade 3 in 4 (14.3%) cases. There were no cases of Yerdel grade 4 PVT. After removing thrombus inside the vessel, we performed simple portal vein anastomosis in 25 (89.3%) cases, patch technique with vascular graft in 1 case (3.6%), and an interposition technique with vascular graft in 2 cases (7.1%). Compared with the non-PVT group, cold ischemic time was longer (P = 0.012) and the rate of postoperative PVT was higher (P = 0.001) in PVT group. In the comparison between the recipient without and with postoperative PVT, the existence of preoperative PVT was the independent risk factor in the multivariate analysis (hazard ratio, 7.511; 95% confidence interval 1.382-40.820; P = 0.020).ConclusionsAlthough it had a technically complicated operation, LDLT could be safely performed in the patients with PVT in our institution.

Pretransplantation Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt Creation for Chronic Portal Vein Thrombosis: Final Analysis of a 61-Patient Cohort

PurposeTo report the final analysis of the safety and efficacy of portal vein (PV) recanalization (PVR) and transjugular intrahepatic portosystemic shunt (TIPS) creation (PVR-TIPS) in patients with PV thrombosis (PVT) in need of liver transplantation. Materials and MethodsSixty-one patients with cirrhosis and PVT underwent PVR-TIPS to improve transplantation candidacy. Median patient age was 58 years (range, 22–75 y), and median pre-TIPS Model for End-Stage Liver Disease score was 14 (range, 7–42). The most common etiologies of cirrhosis were nonalcoholic fatty liver disease in 18 patients (30%) and hepatitis C in 13 patients (21%). Twenty-seven patients (44%) had partial PVT, and 34 patients (56%) had complete thrombosis. Forty-nine patients (80%) had Yerdel grade 2 PVT, and 12 (20%) had Yerdel grade 3 PVT. Twenty-nine patients (48%) had cavernous transformation of the PV. ResultsPVR-TIPS was technically successful in 60 of 61 patients (98%). PV/TIPS patency was maintained in 55 patients (92%) at a median follow-up of 19.2 months (range, 0–105.9 mo). Recurrent PV/TIPS thrombosis occurred in 5 patients (8%), all of whom initially presented with complete PVT. The most common adverse events were TIPS stenosis in 13 patients (22%) and transient encephalopathy in 11 patients (18%). Twenty-four patients (39%) underwent transplantation, 23 of whom (96%) received an end-to-end anastomosis. There were no cases of recurrent PVT following transplantation, with a median imaging follow-up of 32.5 months (range, 0.4–75.4 mo). Five-year overall survival rate was 82%. ConclusionsPVR-TIPS is a safe, effective, and durable treatment option for patients with chronic PVT who need liver transplantation.

Section 6. Management of extensive nontumorous portal vein thrombosis in adult living donor liver transplantation.

Patent portal vein (PV) and adequate portal inflow is essential for successful living donor liver transplantation (LDLT). In extensive portal vein thrombosis (PVT) patients, however, complete PV thrombectomy is not feasible particularly at intrapancreatic portion, and subsequently portal flow steal through preexisting sizable collaterals or rethrombosis can occur. To overcome those problems, we introduced interruption of sizable collaterals and intraoperative cine-portogram (IOP), which is useful for diagnosis and treatment of residual PVT and sizable collaterals. Fourteen percent of adult LDLT (188/1399) had PVT from February 2008 to December 2012 and were subdivided into Yerdel's grades 1, 2, 3, and 4 based on preoperative imaging and operative findings. Considering the severity of PVT and presence of sizable collaterals, the managements were as follows: thrombectomy alone, additional PV plasty, PV stenting, interposition graft, or additional interruption of collaterals. The Yerdel's grade of PVT patients were 1 (42%), 2 (54%), 3 (3%), and 4 (1%). One hundred one (77%) patients underwent interruption of sizable collaterals. The most common management for PVT was thrombectomy alone in grades 1 and 2, thrombectomy plus PV stenting and/or ballooning in grade 3, and interposition graft in grade 4. In LDLT for PVT patients, 1-year mortality was 9%, and PV-related complication occurred in 5%. The severity of PVT made no difference in the outcome. Multi-disciplinary approaches including surgical correction of PVT, IOP, and interruption of sizable collaterals resulted in excellent outcome, and it was not affected by the severity of PVT.