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Development of extensive inferior vena cava thrombosis due to the ligation of a large mesenteric-caval shunt during liver transplantation: A case report

View Article: PubMed Central - PubMed

ABSTRACT

We report a case of IVC thrombosis caused by ligation of large mesenteric-caval shunt.

This case serves as a note of caution when addressing a major portosystemic shunts in LT.

The position of large collateral ligation should be carefully considered in LT.

The position of large collateral ligation should be carefully considered in LT.

No MeSH data available.


Related in: MedlinePlus

Gradual resolution of IVC thrombus. The IVC thrombus (arrow heads) was slowly minimized with anticoagulant therapy, although it still remained. Hepatic and renal veins were consistently patent. IVC, inferior vena cava; LRV, left renal vein; POD, post-operative day.
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fig0020: Gradual resolution of IVC thrombus. The IVC thrombus (arrow heads) was slowly minimized with anticoagulant therapy, although it still remained. Hepatic and renal veins were consistently patent. IVC, inferior vena cava; LRV, left renal vein; POD, post-operative day.

Mentions: A standard immunosuppression protocol using calcineurin inhibitor, mycophenolate mofetil, and steroid was applied. Immediate graft function was excellent, but a routine Doppler ultrasound study on post-operative day (POD) 1 showed thrombus inside the infra-hepatic IVC (Fig. 3A). A CT scan on POD 1 showed that this thrombus originated from the location of the ligated collateral vessel of the IMV (Fig. 3B). The thrombus extended to the intrahepatic IVC, but bilateral renal veins and graft hepatic veins were not disturbed. A hypercoagulable workup, including protein S, protein C, and anti-phospholipid antibody, revealed no abnormalities in thrombophilia tests in this patient. Because the thrombus extended toward the intrahepatic IVC, total hepatic vascular exclusion might be required for surgical removal of this thrombus, which could cause liver graft damage, and was considered too challenging in this case. The thrombus was thought to be too large to remove completely with interventional radiology. Fortunately, the patient was hemodynamically stable and his liver function normalized. We eventually selected anticoagulation therapy, including intravenous urokinase, heparin, and antithrombin-III administration. Despite meticulous anticoagulation therapy (a bolus of 300,000 IU of urokinase daily until POD 13 and intravenous continuous infusion of heparin until POD 46), the IVC thrombus could not be dissolved. However, his general condition gradually recovered. For pulmonary embolism prophylaxis, an IVC filter was initially considered, but we concluded that there was no space for its implantation. Therefore, to avoid pulmonary embolism, he was restricted to bed rest for 1 month after DDLT, but physiotherapy was effective for recovering his activities of daily living. He was discharged from hospital on POD 77. Currently (2 years after LT), he is in good condition with satisfactory liver and renal function. The size of IVC thrombus was slowly reduced with long-time warfarin administration, but complete dissolve of the thrombus was not achieved so far (Fig. 4).


Development of extensive inferior vena cava thrombosis due to the ligation of a large mesenteric-caval shunt during liver transplantation: A case report
Gradual resolution of IVC thrombus. The IVC thrombus (arrow heads) was slowly minimized with anticoagulant therapy, although it still remained. Hepatic and renal veins were consistently patent. IVC, inferior vena cava; LRV, left renal vein; POD, post-operative day.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5121213&req=5

fig0020: Gradual resolution of IVC thrombus. The IVC thrombus (arrow heads) was slowly minimized with anticoagulant therapy, although it still remained. Hepatic and renal veins were consistently patent. IVC, inferior vena cava; LRV, left renal vein; POD, post-operative day.
Mentions: A standard immunosuppression protocol using calcineurin inhibitor, mycophenolate mofetil, and steroid was applied. Immediate graft function was excellent, but a routine Doppler ultrasound study on post-operative day (POD) 1 showed thrombus inside the infra-hepatic IVC (Fig. 3A). A CT scan on POD 1 showed that this thrombus originated from the location of the ligated collateral vessel of the IMV (Fig. 3B). The thrombus extended to the intrahepatic IVC, but bilateral renal veins and graft hepatic veins were not disturbed. A hypercoagulable workup, including protein S, protein C, and anti-phospholipid antibody, revealed no abnormalities in thrombophilia tests in this patient. Because the thrombus extended toward the intrahepatic IVC, total hepatic vascular exclusion might be required for surgical removal of this thrombus, which could cause liver graft damage, and was considered too challenging in this case. The thrombus was thought to be too large to remove completely with interventional radiology. Fortunately, the patient was hemodynamically stable and his liver function normalized. We eventually selected anticoagulation therapy, including intravenous urokinase, heparin, and antithrombin-III administration. Despite meticulous anticoagulation therapy (a bolus of 300,000 IU of urokinase daily until POD 13 and intravenous continuous infusion of heparin until POD 46), the IVC thrombus could not be dissolved. However, his general condition gradually recovered. For pulmonary embolism prophylaxis, an IVC filter was initially considered, but we concluded that there was no space for its implantation. Therefore, to avoid pulmonary embolism, he was restricted to bed rest for 1 month after DDLT, but physiotherapy was effective for recovering his activities of daily living. He was discharged from hospital on POD 77. Currently (2 years after LT), he is in good condition with satisfactory liver and renal function. The size of IVC thrombus was slowly reduced with long-time warfarin administration, but complete dissolve of the thrombus was not achieved so far (Fig. 4).

View Article: PubMed Central - PubMed

ABSTRACT

We report a case of IVC thrombosis caused by ligation of large mesenteric-caval shunt.

This case serves as a note of caution when addressing a major portosystemic shunts in LT.

The position of large collateral ligation should be carefully considered in LT.

The position of large collateral ligation should be carefully considered in LT.

No MeSH data available.


Related in: MedlinePlus