What are the prevalence and causes of inferior vena cava (IVC) complications following whole-liver orthotopic liver transplantation (OLTX)?

Answer

The development of posttransplantation IVC stenosis or thrombosis is an uncommon complication that occurs in approximately 1-4% of cases. IVC stenosis and thrombosis tend to occur at the superior and inferior caval anastomoses. Causes include technical problems, IVC compression due to fluid collection or a hematoma, and mass effect from hepatic regeneration. Patients with suprahepatic lesions tend to present with signs and symptoms of Budd-Chiari syndrome; examples of these include pleural effusion, hepatic enlargement, and ascites. IVC obstruction can cause lower-extremity edema, which can be a prominent feature of infrahepatic stenosis. Clinically, leg swelling helps distinguish a suprahepatic caval complication from a PV problem; both of these complications are associated with features of portal hypertension.^[23]

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Media Gallery

Drawing of the basic anastomoses of an adult-to-adult living-donor liver transplantation. At the author's institution, the right lobe is usually harvested from adult donors and transplanted in orthotopic position after the recipient's native liver is extirpated. Although large vessels and bile ducts must be ligated, control of hemorrhage and bile leakage from the cut surface is possible by performing tissue coagulation with a harmonic scalpel.
Drawing of an orthotopic liver transplant and the basic surgical anastomoses.
Spectral Doppler ultrasonographic waveform of the right hepatic artery in a 60-year-old man, 8 years after orthotopic liver transplantation. The image demonstrates the typical rounded tardus parvus waveform morphology, which is indicative of upstream arterial thrombosis or severe stenosis. Subsequent angiography confirmed occlusion at the hepatic arterial anastomosis.
Magnetic resonance angiogram in a transplantation patient with hepatic artery thrombosis. Magnetic resonance angiogram of the recipient celiac axis depicts complete occlusion of the hepatic artery.
Magnetic resonance angiogram demonstrates intrahepatic arterial segments reconstituted from mesenteric collaterals. Collateralization explains how, in some patients, intrahepatic flow can be present in the setting of complete extrahepatic arterial occlusion.
Digital subtraction angiogram shows complete hepatic artery thrombosis in a liver transplant recipient.
Digital subtraction angiogram depicts redundant donor-recipient hepatic artery. A stenotic hairpin turn is noted.
Digital subtraction angiogram obtained during balloon angioplasty of a stenotic artery.
Digital subtraction angiogram shows a widely patent hepatic artery after angioplasty.
Multiple ischemic biliary strictures documented during interventional external-internal drainage procedure.
Early posttransplantation evaluation of the portal vein by using spectral Doppler ultrasonography depicts a normal waveform with peak flow velocity of approximately 31 cm/s.
Spectral Doppler ultrasonogram of the portal vein was obtained at the onset of graft dysfunction. Compared with the baseline examination, markedly accelerated flow to 150 cm/s was documented. Subsequent catheter venography was performed that documented a high-grade venous stenosis. The stenosis was treated successfully by using balloon angioplasty and stent placement.
Transjugular portography demonstrates extensive portal vein thrombus in the whole-liver allograft of a 40-year-old woman whose clinical condition rapidly deteriorated on postoperative day 39.
After aggressive percutaneous thrombolysis, balloon dilatation, mechanical thrombectomy, and systemic anticoagulation, patency of the portal vein has been restored. Follow-up portography shows that the portal vein is open. Competing collaterals communicating with the superior mesenteric vein (arrow) and the inferior mesenteric vein (arrowhead) were noted. Subsequently, the collateral gonadal vein draining the superior mesenteric vein to the inferior vena cava was embolized with coils to improve hepatopetal flow.
The portal-venous phase computed tomography (CT) scan shows somewhat amorphous and irregular fluid-density material surrounding the portal vein and tracking along the portal triads. This is the typical appearance of a branching biloma that results from the diffuse, extensive extravasation of bile from ischemic ducts. This type of bile duct injury is caused by either severe hepatic artery stenosis or hepatic artery thrombosis.
Contrast-enhanced computed tomography (CT) scan shows a 4 x 5-cm hepatic artery pseudoaneurysm in the porta hepatis. Its contrast enhancement is equivalent to that of the arterial blood pool. The peripheral hypoattenuation is consistent with mural thrombus.

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Author

Paul D Russ, MD Professor, Department of Radiology, Sections of Abdominal Imaging and Ultrasound, University of Colorado School of Medicine

Paul D Russ, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Gregory Thomas Everson, MD, FACP Professor of Medicine, Director, Section of Hepatology, Division of Gastroenterology, University of Colorado School of Medicine

Gregory Thomas Everson, MD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, American Federation for Medical Research, American Gastroenterological Association, American Society of Transplant Surgeons, Colorado Medical Society

Disclosure: Received grant/research funds from Roche for clinical trial; Received honoraria from Roche for speaking and teaching; Received grant/research funds from Pharmassett for clinical trial; Received grant/research funds from Schering-Plough for clinical trial; Received grant/research funds from Vertex for clinical trial; Received grant/research funds from Source for research; Received grant/research funds from GSK for clinical trial; Received grant/research funds from GlobeImmune for clinical trial; .

Marcelo Kugelmas, MD Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine

Marcelo Kugelmas, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society of Transplantation

Disclosure: Nothing to disclose.

Rondle M Moubry, II, MD Assistant Professor, University of Colorado School of Medicine; Assistant Chief, Denver Veterans Affairs Medical Center

Rondle M Moubry, II, MD is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR Clinical Director of Radiology and Consultant Radiologist, Department of Radiology, King's College Hospital, UK

John Karani, MBBS, FRCR is a member of the following medical societies: British Institute of Radiology, Radiological Society of North America, Royal College of Radiologists, Cardiovascular and Interventional Radiological Society of Europe, European Society of Radiology, European Society of Gastrointestinal and Abdominal Radiology, British Society of Interventional Radiology

Disclosure: Nothing to disclose.

Additional Contributors

Kavita Garg, MD Professor, Department of Radiology, University of Colorado School of Medicine

Kavita Garg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Neela Lamki, MD, FACR, FRCPC Professor, Department of Radiology, Sultan Qaboos University, Oman; Adjunct Professor, Department of Radiology, Baylor College of Medicine

Neela Lamki, MD, FACR, FRCPC is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Texas Medical Association, Texas Radiological Society, Society of Abdominal Radiology, Association of Program Directors in Interventional Radiology

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Thomas E Bak, MD, Janette D Durham, MD, Douglas E Elliott, MD, Igal Kam, MD, James F Trotter, MD, Thomas Trouillot, MD, and Michael E Wachs, MD, to the development and writing of the source article.

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