Successful Minimally Invasive Management of Late Portal Vein Thrombosis After Splenectomy Due to Splenic Artery Steal Syndrome Following Liver Transplantation: A Case Report M. Sainz-Barriga, U. Baccarani, A. Risaliti, D. Gasparini, M. Sponza, G.L. Adani, P.L. Toniutto, C. Avellini, G. Ramacciato, and F. Bresadola ABSTRACT Portal vein thrombosis (PVT) after liver transplantation (OLT), which occurs in 1% to 2.7% of cases, can compromise patient and graft survival. Percutaneous transhepatic portal vein angioplasty offers an option to treat PVT, diminishing surgically related morbidity and the need for retransplantation. We describe a case of late PVT after OLT, which was successfully treated by a minimally invasive percutaneous transhepatic approach using both mechanical fragmentation and pharmacologic lysis of the thrombus followed by anticoagulation. The patient has had a good clinical course with normal graft function and patent portal blood flow at 6-month follow-up. This case report confirms the possibility of successful recanalization of the portal vein in a patient with late PVT after liver transplantation. Sustained anticoagulation/antiaggregation therapy for at least 6 months after the procedure is advisable. P ORTAL VEIN thrombosis (PVT) after orthotopic liver transplantation (OLT) is an infrequent complication, occurring in 1% to 2.7% of cases. 1,2 It can compromise patient and graft survival when it occurs early after OLT. 2,3 Clinical symptoms and outcome of late PVT depend on the degree of existing portocaval collateral circulation, 3 and the presence of additional complications involving the graft arterial flow or portal hypertension. 2 Portal hypertension may manifest clinically as ascites, splenomegaly, variceal bleeding, diffuse abdominal pain, and graft dysfunction. The diagnosis is established using clinical criteria and an abdominal Doppler ultrasound (US) examination and con- firmed by means of selective angiography of the celiac trunk. 4 Asymptomatic cases of PVT detected during rou- tine US examination account up to 53% of cases. 2 Pretransplant PVT is often partial and thus difficult to diagnose preoperatively. It may be successfully managed during surgery by thrombectomy, with a recurrence rate of 2.4% to 28.5%. 5 Variations in standard end-to-end portal vein anastomosis and splenectomy concomitant with or after OLT are associated with a significant increased inci- dence of PVT (6.3% vs 1.09% [P = .022], and 10% vs 2.2% [P = .0017], respectively). 2 Technical problems, such as vessel malrotation or kinking due to a long vessel stump account for only a small percentage of portal vein compli- cations. 2,6,7 In the early form of PVT, treatment can be undertaken by means of surgical thrombectomy and recon- struction of the portal anastomosis, 2,3 or by percutaneous fragmentation and stent placement. 6,8,9 Cases of spontane- ous resolution have been reported in instances of the late form, requiring only symptomatic treatment, 2,3 with the occurrence of portal rechanneling. In cases of symptoms or graft dysfunction, some series have reported successful treatment by mesentericocaval or splenorenal shunting, TIPS application for intrahepatic PVT, and local thrombol- ysis. 2,10 If these fail, then retransplantation is required. Minimally invasive treatment like percutaneous mechanical fragmentation and thrombolytic therapy represent alterna- tive treatments for late PVT that decrease surgery-related morbidity and the need for emergency retransplantation. From the Department of Surgery and Transplantation Unit, University of Udine, Udine, Italy (M.S.-B., U.B., G.L.A., F.B.); Liver and Multivisceral Transplant Unit, University of Modena, Modena, Italy (A.R., G.R.); Department of Radiology and Vascu- lar and Interventional Radiology Unit, Udine, Italy (D.G., M.S.); DPMSC Medical Liver Transplantation Unit (P.L.T.); and Mor- phologic and Medical Research Department (C.A.), University of Udine, Udine, Italy. Address reprint requests to Dr Mauricio Sainz-Barriga, Trans- plantation Unit, Department of Surgery, University Hospital Udine, P. le S. Maria della Misericordia, 33100 Udine, Italy. E-mail: mauricio.sainz@wanadoo.es 0041-1345/04/$–see front matter © 2004 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2004.02.040 360 Park Avenue South, New York, NY 10010-1710 558 Transplantation Proceedings, 36, 558 –559 (2004)