An early single-center experience of portal vein thrombosis in living donor liver transplantation: clinical feature, management and outcome.
ABSTRACT Portal vein thrombosis (PVT) has been considered a relative contraindication for living donor liver transplantation (LDLT). However, it is no longer a contraindication of LDLT due to improvement in surgical techniques and approaches to PVT. The aim of this study was to assess the impact of PVT on outcomes in LDLT patients.
We retrospectively analyzed the data from 97 adult patients undergoing LDLT in our center from July 2008 to June 2010. Intraoperative findings and preoperative imaging results were reviewed for PVT grading (Yerdel grading). We analyzed the technical aspects and comparisons of risk factors, perioperative variables, and survivals between patients with and without PVT based on the grades.
In the 97 LDLT patients, 18 patients were confirmed to have PVT (18.5%) including grade I cases (n = 8), grade II (n = 7), and grade III (n = 3). Prior treatment of portal hypertension was found to be an independent risk factor for PVT (P = 0.001). The comparisons between PVT and no PVT groups showed no significant difference in intraoperative and postoperative variables except for postoperative bleeding (P = 0.036). The short-term portal vein patency, in-hospital mortality and survival rates were not significantly different between the PVT and control groups.
The outcomes are similar to non-PVT group in terms of in-hospital mortality, survival rates, and postoperative complications. Therefore, our study suggests that PVT cannot be considered to be a contraindication for LDLT and LDLT could be undertaken without increased morbidity and mortality in patients with PVT, in spite of operative complexity.
- [show abstract] [hide abstract]
ABSTRACT: Portal vein thrombosis (PVT) used to be a contraindication for liver transplantation (LT). This obstacle has been delt with following the improvement of LT-related techniques and therapeutic approaches to thrombosis. But the effect of PVT on LT outcomes is still controversial. We reviewed retrospectively the outcome of LT patients with PVT as well as risk factors and surgical management according to PVT grades. A total of 465 adult LTs were performed from December 2002 through December 2006. Operative findings and the result of preoperative ultrasonography and imaging were reviewed for PVT grading (Yerdel grading). Comparison of risk factors, variables associated with perioperative period and prognosis between recipients with and without PVT is based on the grades. In the 465 LTs, 42 were operatively confirmed to have PVT (9.0%) (19 recipients with grade 1, 14 with grade 2, 7 with grade 3, and 2 with grade 4). Increased age and treatment of portal hypertension were associated with PVT. Grade 1 or 2 PVT was treated by direct anastomosis or single thrombectomy. In grade 3 PVT patients, the donor PV was directly anastomosed to the dilated branch of the recipient portal venous system or to the distal open superior mesenteric vein through an interposition vein graft if needed. Grade 4 PVT was managed by our modified cavoportal hemitransposition technique. The comparison between PVT patients and controls showed no significant difference in operative duration and blood transfusion (P>0.05). The flow rate of the PV was lower in the PVT patients (48.881+/-12.788 cm/s) than in the controls (57.172+/-21.715 cm/s, P<0.05). The PVT patients had such postoperative complications as renal failure and PV rethrombosis (P<0.05). The 1-year survival rates in PVT and non-PVT patients were 78.6% and 76.4% respectively (P>0.05); the 3-year survival rates were 58.8% and 56.4% respectively (P>0.05). PVT is not contraindicated for LT if it is graded. PVT recipients may have post-transplantation complications like renal failure and PV rethrombosis, and operative difficulty and patient survival are similar to those in recipients without PVT. Development of therapeutic approaches and accumulation of experience in dealing with PVT further improve the outcomes of LT in PVT recipients.Hepatobiliary & pancreatic diseases international: HBPD INT 02/2009; 8(1):34-9. · 1.26 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: We sought to review the etiopathogenesis, diagnosis, and surgical options for 253 patients with portal vein thrombosis (PVT) undergoing orthotopic liver transplantation (OLT) to assess the the impact of PVT on outcomes. We retrospectively analyzed the data from 2508 adult patients undergoing 2614 OLTs in our center from September 1998 to July 2007. PVT was scored according to the operative findings and Yerdel grading of PVT. No prisoners were used as donors for this study. Two hundred fifty-three patients were diagnosed with PVT (10.09%): there were 104 grade I; 114, grade II; 29, grade III; and 6, grade IV PVT. Sex and previous splenectomy increased the risk for PVT. In grade I and II cases, we performed simple thrombectomy, eversion thrombectomy, or improved eversion thrombectomy (IET, innovated by our center), producing smooth postoperative recoveries with a 0% in-hospitality mortality. In grade III cases, 18 underwent successful IET. Of 11 subjects who had eversion thrombectomy, six failed, and the distal superior mesentery vein or dilated splanchnic collateral tributary had to be used as the inflow vessel in four patients, and portal vein arterialization were performed in the other two patients, all of whom experienced a smooth postoperative recovery except one who died of hepatic failure and pulmonary infection 2 weeks after the operation. The in-hospitality mortality was 3.45%. In grade IV cases, three underwent successful IET, but another three cases failed, with two of them requiring a renal vein as the inflow vessel, and other one undergoing portocaval hemitransposition, with one postoperative death due to hepatic failure and another of cancer recurrence, an in-hospitality mortality rate of 33.33%. The transfusion requirement among PVT patients was significantly higher than that in non-PVT patients (9.32 +/- 3.12 U vs 6.02 +/- 2.40 U; P < .01). Blood loss in PVT patients who underwent the IET technique was significantly lower than that for an eversion thrombectomy (2800.36 +/- 930.52 mL vs 5700.21 +/- 162.50 mL P < .05). The overall actuarial 1-year survival rate in PVT patients was similar to the controls (86.56% vs 89.40%; P > .05). OLT was successfully performed for PVT patients. The grade of PVT decided the surgical strategy. Similar 1-year survival rates were attained between PVT patients and controls undergoing OLT.Transplantation Proceedings 11/2009; 41(9):3761-5. · 0.95 Impact Factor
Article: Liver transplantation in adults.Hepatology 2(5):637-40. · 12.00 Impact Factor
Copyright © 2011, the Korean Surgical Society
J Korean Surg Soc 2011;81:35-42
Journal of the Korean Surgical Society
pISSN 2233-7903ㆍeISSN 2093-0488
Received October 29, 2010, Accepted May 17, 2011
Correspondence to: Dong Lak Choi
Division of Hepatobiliary and Transplantation Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, 3056-6
Daemyeong 4-dong, Nam-gu, Daegu 705-718, Korea
Tel: ＋82-53-650-4063, Fax: ＋82-53-650-4950, E-mail: email@example.com
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is properly cited.
An early single-center experience of portal vein
thrombosis in living donor liver transplantation:
clinical feature, management and outcome
Joo Dong Kim, Dong Lak Choi, Young Seok Han
Division of Hepatobiliary and Transplantation Surgery, Department of Surgery, Catholic University of Daegu School of Medicine,
Purpose: Portal vein thrombosis (PVT) has been considered a relative contraindication for living donor liver transplantation
(LDLT). However, it is no longer a contraindication of LDLT due to improvement in surgical techniques and approaches to
PVT. The aim of this study was to assess the impact of PVT on outcomes in LDLT patients. Methods: We retrospectively ana-
lyzed the data from 97 adult patients undergoing LDLT in our center from July 2008 to June 2010. Intraoperative findings and
preoperative imaging results were reviewed for PVT grading (Yerdel grading). We analyzed the technical aspects and com-
parisons of risk factors, perioperative variables, and survivals between patients with and without PVT based on the grades.
Results: In the 97 LDLT patients, 18 patients were confirmed to have PVT (18.5%) including grade I cases (n = 8), grade II (n =
7), and grade III (n = 3). Prior treatment of portal hypertension was found to be an independent risk factor for PVT (P = 0.001).
The comparisons between PVT and no PVT groups showed no significant difference in intraoperative and postoperative var-
iables except for postoperative bleeding (P = 0.036). The short-term portal vein patency, in-hospital mortality and survival
rates were not significantly different between the PVT and control groups. Conclusion: The outcomes are similar to non-PVT
group in terms of in-hospital mortality, survival rates, and postoperative complications. Therefore, our study suggests that
PVT cannot be considered to be a contraindication for LDLT and LDLT could be undertaken without increased morbidity
and mortality in patients with PVT, in spite of operative complexity.
Key Words: Portal vein, Thrombosis, Liver transplantation, Outcome assessment
In the early period of liver transplantation (LT), portal
vein thrombosis (PVT) was considered a contraindication
for operation because of the technical difficulties it en-
tailed, especially the inability to gain an adequate portal
supply [1-3]. In 1985, Shaw et al.  reported the first suc-
cessful deceased donor liver transplantation (DDLT) for a
PVT patient and since then, many innovative surgical
techniques have been introduced such as thrombectomy,
portal vein (PV) reconstruction using vein grafts, and cav-
oportal hemitransposition [5-9]. Current PVT patients are
no longer regarded to be contraindicated for LT and the re-
sults for patients with PVT is now comparable to that of
Joo Dong Kim, et al.
patients without PVT [1,2,9,10]. Nevertheless, PVT is con-
sidered to add high risk to LT because of the complexity of
LT procedures, resulting in significant surgical morbidity
and mortality [10,11].
In living donor liver transplantation (LDLT), the issue
of subjecting a healthy donor to potentially significant
morbidity and mortality has led to a critical reassessment
of the recipient selection criteria that are considered ac-
ceptable in DDLT . In addition, there are some techni-
cal difficulties due to these innovations for preexisting
PVT patients; necessity of distal dissection of vascular
pedicle of the hilum and restricted availability of deceased
donor vein graft [10,11].
Therefore, based on greater technical difficulties and
the results from DDLT in this group of patients, the pres-
ence of PVT has often been considered to be a relative or
absolute contraindication in LDLT [13,14].
From this point of view, the purpose of this report is to
analyze single-center experiences in management of PVT,
and to assess the impact of PVT on the outcomes in adult
We retrospectively studied the records of 97 LDLT pa-
tients using data collected prospectively among 109 cases
of consecutive adult LDLT performed at our center from
July 2008 to June 2010. In our center, PVT has not been a
contraindication for LDLT except where the preoperative
radiologic studies demonstrate a gross tumor thrombus in
the main portal vein. All PVT patients were diagnosed us-
ing abdominal computed tomography (CT) performed
within 3 months before transplantation, and intra-
operative detection. For standardization purposes, 12 pa-
tients were excluded for the following reasons: 1) no avail-
ability of preoperative and postoperative CT scans, 2) in-
sufficient records of the intraoperative findings, or 3) tu-
mor thrombus confirmed by postoperative pathology.
PV flow was monitored routinely after transplantation
by Doppler ultrasound at post-transplant days 1,4, and 7,
and dynamic CT scan at days 14 and 21.
PVT was diagnosed preoperatively and/or intra-
operatively in 18 cases (18.5%). These patients with pre-
operatively and/or intraoperatively confirmed PVT formed
the study group. Patients without PVT and transplanted
during the same period were used as the control group.
All patients with confirmed PVT were retrospectively
classified into four grades according to the extent of
thromboses, as described by Yerdel et al. : Grade I:
minimally or partially thrombosed PV, in which the
thrombus is mild or, at the most, confined to ＜50% of the
vessel lumen with or without minimal extension into the
superior mesenteric vein (SMV). Grade II showed ＞50%
occlusion of the PV, including total occlusion with or with-
out minimal extension into the SMV. Grade III were com-
plete thromboses of both PV and proximal SMV with an
open distal SMV. Grade IV was complete thrombosis of the
portal vein as well as the proximal and distal SMV.
The preoperative, intraoperative, and postoperative pa-
rameters in these two groups were compared. The patients
with PVT and those with non-PVT were followed up for a
median time of 15.3 months (range, 1.2 to 36.5 months) and
14.9 months (range, 2.4 to 36.3 months).
Assessment of risk factors for PVT and outcomes
Analyzed potential risk factors for PVT included; age,
sex, primary disease or Child-Turcott-Pugh (CTP) score,
the average model for end-stage liver disease (MELD)
sore, preoperative platelet count, preoperative pro-
thrombin time, living donor characteristics, quality of do-
nated liver, previous treatment for portal hypertension
(splenectomy, shunt operation, transjugular intrahepatic
portosystemic shunt [TIPS], or sclerotherapy), and pres-
ence of malignancy.
Surgery time, amount of operative red blood cell (RBC)
transfusion, duration of hospital and intensive care unit
(ICU) stays were analyzed. Postoperative complications
(postoperative bleeding, biliary complication, PVT or
stenosis, hepatic artery complication, infection, rejection)
were compared. In-hospital mortality and patient survival
were compared according to the presence of PVT.
Continuous variables are represented as a mean ± SD
An early single-center experience of portal vein thrombosis in living donor liver transplantation
Table 1. Recipient, donor, and graft characteristics of LDLT in patients with and without PVT
PVT (n = 18)Non-PVT (n = 79) P-value
Recipient gender (M:F)
HBV/HCV related liver cirrhosis without HCC
HBV/HCV related liver cirrhosis with HCC
Alcoholic liver cirrhosis
Preoperative platelet (×103/μL)
Preoperative prothrombin time (INR)
Previous treatment of portal HTN (Y:N)
Donor age (yr)
Donor gender (M:F)
Graft fatty change (%)
Graft-to-recipient weight ratio (%)
Type of graft
Single (right/left liver)
50.8 ± 7.3
50.5 ± 8.2
9.1 ± 1.8
17.3 ± 8.1
1,261.1 ± 1,440.2
55.1 ± 31.3
1.88 ± 0.63
30.0 ± 7.7
1.11 ± 3.66
0.98 ± 0.19
8.7 ± 2.8
17.7 ± 10.3
1,383.5 ± 1,892.8
68.9 ± 27.7
1.92 ± 0.88
27.7 ± 7.9
2.72 ± 5.23
1.06 ± 0.25
Values are presented as mean ± SD or number (%).
LDLT, living donor liver transplantation; PVT, portal vein thrombosis; HBV, hepatitis B virus; HCV, hepatitis C virus; HCC, hepatocellular
carcinoma; CTP, Child-Turcott-Pugh; MELD, the average model for end-stage liver disease; INR, international normalized ratio; HTN,
hypertension; Y, yes; N, no.
a)Cryptogenic liver cirrhosis, fulminent hepatic failure, primary biliary cirrhosis.
and categorical data were analyzed using the Fisher’s ex-
act test. A Mann-Whitney U test was used to compare the
group means. The Kaplan-Meier method was used to es-
timate survival curves, and survival curves were com-
pared by means of the log-rank test. All analyses were
carried out using SPSS ver. 14.0 (SPSS Inc., Chicago, IL,
USA). A P-value less than 0.05 was considered
Incidence and grading of PVT
PVT was diagnosed in 18 of the total 97 adult patients
(18.5%) who underwent LDLT including 8 cases (44.4%) of
grade I; 7 (38.9%) of grade II; 3 (16.7%) of grade III.
Preoperative risk factors for PVT (Table 1)
Age, gender, primary disease, CTP score, MELD score,
presence of hepatocellular carcinoma (HCC), ascites, pre-
operative platelet count, and prothrombin time showed
no relationship to PVT (P ＞ 0.05). Living donor character-
istics and quality of donated liver had no significant differ-
ences between the two groups. However, previous treat-
ment of portal hypertension (splenectomy, shunt oper-
ation, TIPS, sclerotherapy) was associated with PVT (P =
Intraoperative and postoperative variables be-
tween PVT and non-PVT groups (Table 2)
The mean duration of operation in the patients with
PVT (598.2 ± 115.4 minutes) was longer than in those with-
out PVT (572.6 ± 97.6 minutes), but this was not statisti-
cally significant (P = 0.483). The overall mean RBC trans-
fusion requirement in the patients with PVT (1,018.2 ±
816.2 mL) was not significantly different to that in those
without PVT (1,203.7 ± 1,021.7 mL, P = 0.485). The mean
ICU stay was similar in both groups (4.47 ± 1.12 days vs.
5.32 ± 5.6 days, P = 0.632). The mean hospital stay was also
similar (32.2 ± 11.6 days vs. 34.5 ± 23.1 days, P = 0.612).
Joo Dong Kim, et al.
Table 2. Comparative analysis of operative and postoperative variables with or without PVT
PVT (n = 18)Non-PVT (n = 79) P-value
Operation time (min)
RBC transfusion (mL)
ICU stay (day)
Admission stay (day)
Postoperative complications (%)
Biliary complication (biliary stricture, bile leak)
Infection (regardless type)
Portal vein complication (stenosis, rethrombosis)
Hepatic artery complication (stenosis, thrombosis)
598.2 ± 115.4
1,018.2 ± 816.2
4.47 ± 1.18
32.24 ± 11.61
572.7 ± 97.6
1,203.7 ± 1,021.7
5.32 ± 5.64
34.52 ± 23.06
PVT, portal vein thrombosis; RBC, red blood cell; ICU, intensive care unit.
Fig. 1. Survival curves in the portal vein thrombosis (PVT) and non-PVT groups (A), and in the PVT and non-PVT groups after excluding
Postoperative complications of PVT patients (Table 2)
The incidence of postoperative bleeding in the patients
with PVT was significant higher than in those without
PVT (22.2% vs. 6.3%, P = 0.049). But, the rate of portal vein
rethrombosis or stenosis, hepatic artery complication, in-
fection, biliary complication (bile leak, biliary stricture),
and rejection were similar in the PVT and non-PVT
PV patency and patient’s survival of PVT group
The PV patency of the PVT group in their follow-up pe-
riod was similar to the non-PVT group. Only one of the pa-
tients with PVT developed a rethrombosis. A relapar-
otomy and intraoperative PV stenting were performed at
the 13th day after transplantation.
The in-hospital mortality for patients with PVT was
similar to that of patients without PVT (5.6% vs. 3.8%, P
= 0.548). The 1-and 3-year actuarial survival rate in the
PVT group were 87.7% and 75.2%, respectively, but
there was no statistical difference between the PVT
group and the non-PVT groups (log-rank test, P = 0.357)
Considering the influence of HCC on survival, we ex-
cluded patients with cancer from both groups, leaving 36
patients in the PVT group and the controls, still there was
no significant difference between the two groups
(log-rank test, P = 0.979) (Fig. 1B).
An early single-center experience of portal vein thrombosis in living donor liver transplantation
Table 3. Surgical procedures for thrombectomy and reconstruction as grade
Grade No.Treatment Outcome
I8Simple thrombectomy (n = 3)
Eversion thrombectomy (n = 3)
Eversion thrombectomy (n = 6)
PV reconstruction with interposition graft (n = 1)
Eversion thrombectomy (n = 1)
PV reconstruction with interposition graft/PV stent (n = 1)
RP-A (n = 1)
IOP PV stent (n = 1)
IOP, intraoperative; PV, portal vein; RP-A, renoportal anastomosis.
Fig. 2. Portal vein (PV) reconstruction with interposition vein graft in case of failed eversion thrombectomy. Preoperative computed
tomography (CT) scan of this case showed that portal vein is completely obstructed (white arrow) and PV thrombosis propagated to
portomesenteric junction (A). Interposition vein graft was used for portal vein reconstruction (B) and intraoperative PV stenting (black arrow)
was performed due to residual thrombus (C). Patency of interposition graft was demonstrated by postoperative CT scan (D).
Surgical management of PVT was dependent on the
characteristics of the thrombus; its size (partial or com-
plete) or extension degree through the portal venous
system. Surgical procedures for PVT are shown in Table 3.
Most patients with grade I and II thrombosis were man-