Liver Transplantation Using Cavoportal Hemitransposition— A Life-Saving Procedure in the Presence of Extensive Portal Vein Thrombosis M. Olausson, J. Norrby, L. Mjo ¨ rnstedt, H. Liden, and S. Friman L IVER transplantation in the presence of recipient portal vein thrombosis is currently a relative contra- indication. Standard techniques to overcome portal vein thrombosis in OLT include portal vein thrombectomy and different types of venous graft jump reconstruction. 1 To establish portomesenterical blood flow in OLT the presence of veins, for example, the superior mesenteric vein or collaterals in the mesenteric venous system is required. If the portal vein thrombosis extends and occludes the whole portomesenteric system, it represents an absolute contrain- dication for OLT with few exceptions, because the por- tomesenterical blood flow cannot be established. The only possibilities of overcoming the problem with extensive portal vein thrombosis is to use a multivisceral transplan- tation or the recently new surgical technique, cavoportal hemitransposition. 2 With this method the portal vein of the graft is anastomosed end-to-end to the inferior vena cava of the recipient. We report the first seven transplantations using this technique performed at our center during 1999 and 2000. PATIENTS All liver transplants recipients were on a standard immunosuppres- sive regime and received grafts from hemodynamically stable donors with normal liver functions test at time of harvesting. Seven transplantations were performed in six patients, three males and three females. Mean age was 54 years. One patient had hepatitis C cirrhosis, one had cryptogenic cirrhosis, one had alcohol cirrhosis, two had primary sclerosing cholangitis, and one had cirrhosis due to irradiation therapy. The diagnosis of the portomesenterial system was done preoperatively in five patients and preoperatively in one. Other preoperative risk factors included renal failure at time of surgery (2/6), extensive previous abdominal surgery (4/6), hospital bound (ICU or ward) (4/6), previous irradiation due to malignancy (1/6), or history of coagulation disorder (1/6). Fol- low-up time was 3 to 13 months. All patients were transplanted with a direct end-to-end anasto- mosis between the caval vein of the recipient and the portal vein of the donor liver. One patient received a combined liver and kidney transplant. RESULTS None of the transplanted livers had signs of stasis due to too high blood flow through the cavoportal anastomosis. The first patient died after an initial good liver function. On the 6th postoperative day, she experienced septicemia and respiratory failure and was reintubated. On the 8th postop- erative day, she had multiorgan failure and died. The second patient, transplanted with a combined liver and kidney transplant, had a hepatic artery thrombosis, which was corrected surgically. The third patient was a 62-years- old male with Laennec cirrhosis. Preoperative evaluation with Doppler ultrasonography did not reveal any signs of extensive portal vein thrombosis. However, a diffuse por- tomesenterical vein thrombosis was found at transplanta- tion. Cavoportal hemitransposition was the only option. The graft functioned promptly. One month postoperatively the patient developed mild lower limb edema and labora- tory tests showed a minor elevation of creatinine. Four months postoperatively the there was progressive lower limb edema and also some ascites. Angiography showed diffuse thrombosis extending from iliac vein to the level of the cavoportal anastomosis. Because the patient was doing clinically well it was not treated surgically. After the finding the patient was begun on anticoagulation therapy, and the edema has now disappeared 6 months postoperatively. The 6th case was a 61-year-old male with a history of gastric carcinoma and total gastrectomy (1989), preopera- tive irradiation (1990), bowel obstruction, and fistulas with abscess (1992). After a 16-hour transplant operation with colon perforation and massive blood loss, the abdomen was left open over the closure of the colon injury. Patient was transferred to the ward after 1 week. Two weeks after transplantation, the patient had to be taken back to the operating room for a right hemicolectomy, due to colon perforation. A Roux-en-Y anastomosis was performed due to bile leakage. The abdomen was left open. The patient recovered, but 1 week later showed signs of renal failure, From the Sahlgrenska University Hospital, Department of Transplantation and Liver Surgery, Gothenburg, Sweden. Supported with grants from Go ¨ teborgs Universitet (LUA) and the Swedish Medical Research Council (MFR) K1999-73x- 012228-03A. Address reprint requests to Professor M. Olausson, Salgren- ska Univ. Hospital, Department of Transplantation and Liver Surgery, 41345 Goteborg, Sweden. © 2001 by Elsevier Science Inc. 0041-1345/01/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(00)02494-5 Transplantation Proceedings, 33, 1327–1328 (2001) 1327