Portal Vein Thrombosis in Liver Transplantation R. Charco, J. Fuster, C. Fondevila, J. Ferrer, E. Mans, and J.C. Garcı´a-Valdecasas ABSTRACT In the initial experience of liver transplantation, complete thrombosis and portal vein occlusion were considered to be absolute contraindications for liver transplantation. The incidence of portal thrombosis in patients being prepared for transplantation varies between 5% and 15% according to published series. There are 2 surgical techniques to solve absent or low portal vein flow due to thrombosis. The most widely used technique is thrombectomy and the second technique is insertion of a shunt with a venous graft in the permeable portion of the superior mesenteric vein or in a vein in the splanchnic territory. Portal thrombosis recurrence rates vary among series, ranging from 0% to 25% or even 30%, depending on its extension and severity and also on time the transplantation was performed. Although overall survival is somewhat lower, there are no significant differ- ences in most of the series when patients with portal thrombosis who underwent transplantation are compared with those without. I N THE INITIAL experience of liver transplantation (LT), complete thrombosis and portal vein occlusion were considered to be absolute contraindications for LT. 1 It has been demonstrated that LT can be performed with good results in patients with portal thrombosis. 2–4 Never- theless, it must be taken into account that the results of transplantation in this type of patient depend mainly on the extension as well as the severity of thrombosis along the mesenteric-portal confluence. However, it should be borne in mind that these patients are prone to advanced liver disease (Child C) with portal hypertension and that, very often, they are carriers of spontaneous or surgical spleno- renal shunts. In conclusion, they have diminished or even absent portal flow. The incidence of portal thrombosis in patients being prepared for transplantation varies between 5% and 15% according to published series. 5,7 IMAGING STUDIES Doppler ultrasound is the first imaging test that should be performed in the assessment of these candidates for LT. Although some series state that the sensitivity of this test is low 8 for detecting portal thrombosis, most report sensitivity and specificity ranging from 70% to 100%. 5 In most cases, if ultrasound showed diminished or absent portal flow, it would be convenient to perform an angiogram, which could be done using magnetic resonance (MR) or conventional arteriography, to avoid any false-positive results and also to assess the extension of thrombosis, demonstrate the perme- ability of the mesenteric confluence, and, thus, proceed with the ensuring surgical strategy planning. CLASSIFICATION OF PORTAL VEIN THROMBOSIS There are different classifications of thrombosis according to extension and severity varying from those mainly anatomi- cal to those oriented toward the possible surgical strategies to be performed. From a practical point of view, portal throm- boses can be classified as follows: (1) thrombosis confined to the portal vein, which could be partial or complete; (2) thrombosis extending all the way to the proximal portion of the superior mesenteric vein with permeability of the mesen- teric confluence; (3) diffuse thrombosis of the splanchnic system with presence of dilated collateral veins; and (4) diffuse thrombosis with presence of fine collateral veins. SURGICAL MANAGEMENT It is not uncommon for portal occlusion due to thrombosis to be an intraoperative finding, thus, in these patients, the surgical strategy to follow should be improvised in the operating room (OR). The reason for this previous diagno- sis being absent is that on occasions the ultrasound had been performed some months earlier, when the patient was From the Liver Transplantation Unit, IMDiM, Hospital Clinic i Provincial, Barcelona, Spain. Address reprint requests to Ramón Charco, MD, Liver Trans- plantation Unit, IMDiM, Hospital Clinic i Provincial, C/ Villarroel, 170 08036 Barcelona, Spain. E-mail: rcharco@clinic.ub.es 0041-1345/05/$–see front matter © 2005 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2005.09.120 360 Park Avenue South, New York, NY 10010-1710 3904 Transplantation Proceedings, 37, 3904 –3905 (2005)