Ann Liver Transplant.  2022 May;2(1):64-68. 10.52604/alt.21.0032.

Inferior vena cava stenting for middle hepatic vein deprivation-induced graft outflow vein obstruction in a patient who underwent living donor live transplantation: A case report with 22-year follow-up

• Ha TY
• Hwang S
• Ko GY
• Ahn CS
• Moon DB
• Song GW
• Jung DH
• Park GC
• Lee SG

• KMID: 2560883
• DOI: http://doi.org/10.52604/alt.21.0032

Abstract

Inferior vena cava (IVC) stenting is known to be effective for treating IVC stenosis following liver transplantation (LT). We present the 22-year posttransplant course of a recipient of adult living donor LT (LDLT) who survived after IVC stenting. The patient was a 48-year-old male with hepatitis B virus-associated liver cirrhosis. The recipient underwent LDLT using a right liver graft without middle hepatic trunk or reconstruction. He was 170 cm in height and 65 kg in body weight. The model for endstage liver disease score and graft-to-recipient ratio were 26 and 1.54%, respectively. Early computed tomography (CT) scan showed massive congestion of the right anterior section. Massive ascites was drained through abdominal drains and drainage volume was increased to 14 L/day at 30 days after LT. Simulative analysis of serial CT images revealed that excessive regeneration of the right posterior section compressed the IVC, which induced outflow occlusion of the inferior right hepatic vein. A self-made wall stent was inserted to relieve the IVC occlusion at 38 days after LT, which resulted in disappearance of pressure gradients within the retrohepatic IVC. Soon after stenting of this IVC, the amount of ascites was progressively decreased. The abdominal drain was successfully removed at 102 days after LT, and the patient was discharged at 106 days after LT. For 22 years after LDLT, the patient has been doing well without any noticeable complications. In conclusion, we believe that IVC stenting seems to be an effective treatment to cope with IVC stenosis due to various causes following LT.

Keyword

Middle hepatic vein; Right liver graft; Hepatic venous congestion; Stenosis; Living donor liver transplantation

Figure

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  Figure 1 Laboratory findings during the early posttransplant period. ALT, alanine transaminase.

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  Figure 2 Posttransplant computed tomography scan showing progressive resolution of hepatic venous congestion at the right anterior section. IVC, inferior vena cava.

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  Figure 3 Changes in the amount of drained ascitic fluid during the first three months after transplantation. IVC, inferior vena cava.

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  Figure 4 Illustration presenting the mechanism of IVC compression by excessive regeneration of the right posterior section and its expansion by IVC stenting. IVC, inferior vena cava; RHV, right hepatic vein; IRHV, inferior right hepatic vein.

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  Figure 5 Serial posttransplant computed tomography scans showing the venous drainage status at the right hepatic vein (RHV) and inferior right hepatic vein (IRHV) levels.

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  Figure 6 Posttransplant computed tomography images with 3-dimensional reconstruction taken at 18 years after transplantation showing good patency of the inferior vena cava stent.

Reference

1. Raia S, Nery JR, Mies S. 1989; Liver transplantation from live donors. Lancet. 2:497. DOI: 10.1016/S0140-6736(89)92101-6.

2. Strong RW, Lynch SV, Ong TH, Matsunami H, Koido Y, Balderson GA. 1990; Successful liver transplantation from a living donor to her son. N Engl J Med. 322:1505–1507. DOI: 10.1056/NEJM199005243222106. PMID: 2336076.

3. Hashikura Y, Makuuchi M, Kawasaki S, Matsunami H, Ikegami T, Nakazawa Y, et al. 1994; Successful living-related partial liver transplantation to an adult patient. Lancet. 343:1233–1234. DOI: 10.1016/S0140-6736(94)92450-3.

4. Lee S, Park K, Hwang S, Lee Y, Choi D, Kim K, et al. 2001; Congestion of right liver graft in living donor liver transplantation. Transplantation. 71:812–814. DOI: 10.1097/00007890-200103270-00021. PMID: 11330547.

5. Lee S, Park K, Hwang S, Kim K, Ahn C, Moon D, et al. 2003; Anterior segment congestion of a right liver lobe graft in living-donor liver transplantation and strategy to prevent congestion. J Hepatobiliary Pancreat Surg. 10:16–25. DOI: 10.1007/s10534-002-0789-5. PMID: 12918453.

6. Hwang S, Jung DH, Ha TY. 2021; Fifteen-year-long journey with hepatocellular carcinoma from diagnosis during pregnancy to recurrence after liver transplantation: a case report of intractable tumor recurrence. Ann Liver Transplant. 1:194–201. DOI: 10.52604/alt.21.0017.

7. Huber TJ, Hammer S, Loss M, Müller-Wille R, Schreyer AG, Stroszczynski C, et al. 2014; Primary stent angioplasty of the inferior vena cava after liver transplantation and liver resection. Cardiovasc Intervent Radiol. 37:949–957. DOI: 10.1007/s00270-013-0745-5. PMID: 24091757.

8. Donaldson J, Obuchowski NA, Le RT, Lomaglio L, Unger RH, Bayona MDP, et al. 2019; Stenting for inferior vena cava stenosis after liver transplant. AJR Am J Roentgenol. 213:1381–1387. DOI: 10.2214/AJR.18.20915. PMID: 31573847.

9. Lee JM, Ko GY, Sung KB, Gwon DI, Yoon HK, Lee SG. 2010; Long-term efficacy of stent placement for treating inferior vena cava stenosis following liver transplantation. Liver Transpl. 16:513–519. DOI: 10.1002/lt.22021. PMID: 20213830.

10. Moon DB, Hwang S, Ahn CS, Ha TY, Song GW, Jung DH, et al. 2021; Technical refinement of inferior vena cava replacement using a synthetic vascular graft in living donor liver transplantation. Ann Liver Transplant. 1:153–159. DOI: 10.52604/alt.21.0025.