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Harinstein ME, Gandolfo C, Gruttadauria S, Accardo C, Crespo G, VanWagner LB, Humar A. Cardiovascular disease assessment and management in liver transplantation. Eur Heart J 2024; 45:4399-4413. [PMID: 39152050 DOI: 10.1093/eurheartj/ehae502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/21/2024] [Accepted: 07/25/2024] [Indexed: 08/19/2024] Open
Abstract
The prevalence and mortality related to end-stage liver disease (ESLD) continue to rise globally. Liver transplant (LT) recipients continue to be older and have inherently more comorbidities. Among these, cardiac disease is one of the three main causes of morbidity and mortality after LT. Several reasons exist including the high prevalence of associated risk factors, which can also be attributed to the rise in the proportion of patients undergoing LT for metabolic dysfunction-associated steatohepatitis (MASH). Additionally, as people age, the prevalence of now treatable cardiac conditions, including coronary artery disease (CAD), cardiomyopathies, significant valvular heart disease, pulmonary hypertension, and arrhythmias rises, making the need to treat these conditions critical to optimize outcomes. There is an emerging body of literature regarding CAD screening in patients with ESLD, however, there is a paucity of strong evidence to support the guidance regarding the management of cardiac conditions in the pre-LT and perioperative settings. This has resulted in significant variations in assessment strategies and clinical management of cardiac disease in LT candidates between transplant centres, which impacts LT candidacy based on a transplant centre's risk tolerance and comfort level for caring for patients with concomitant cardiac disease. Performing a comprehensive assessment and understanding the potential approaches to the management of ESLD patients with cardiac conditions may increase the acceptance of patients, who appear too complex, but rather require extra evaluation and may be reasonable candidates for LT. The unique physiology of ESLD can profoundly influence preoperative assessment, perioperative management, and outcomes associated with underlying cardiac pathology, and requires a thoughtful multidisciplinary approach. The strategies proposed in this manuscript attempt to review the latest expert experience and opinions and provide guidance to practicing clinicians who assess and treat patients being considered for LT. These topics also highlight the gaps that exist in the comprehensive care of LT patients and the need for future investigations in this field.
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Affiliation(s)
- Matthew E Harinstein
- Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Caterina Gandolfo
- Unit of Interventional Cardiology, Department of Cardiothoracic Surgery, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Caterina Accardo
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, UPMC IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Astarcıoglu I, Egeli T, Gulcu A, Ozbilgin M, Agalar C, Cesmeli EB, Kaya E, Karademir S, Unek T. Vascular Complications After Liver Transplantation. EXP CLIN TRANSPLANT 2023; 21:504-511. [PMID: 30880648 DOI: 10.6002/ect.2018.0240] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Vascular complications after liver transplant can be lethal. High levels of suspicion and aggressive use of diagnostic tools may help with early diagnosis and treatment. Here, we share our experiences regarding this topic. MATERIALS AND METHODS Adult and pediatric patients who had liver transplant between February 1997 and June 2018 in our clinic were included in the study. Patients were grouped according to age (pediatric patients were those under 18 years old), male versus female, indication for transplant, type of liver transplant, type of vascular complication, treatment, and survival aftertreatment.We analyzed the statistical incidence of vascular complications according to age, male versus female, and type of liver transplant. RESULTS Our analyses included 607 liver transplant procedures, including 7 retransplants, with 349 (57.4%) from living donors and 258 (42.6%) from deceased donors. Of total patients, 539 were adults (89.8%) and 61 were children (10.2%). Vascular complications occurred in 25 patients (4.1%), with hepatic artery complications seen in 13 patients (2.1%) (10 adults [1.8%] and 3 children [4.9%]), portal vein complications seen in 9 patients (1.5%) (6 adults [1.1%] and 3 children [4.9%]), and hepatic vein complications seen in 3 patients (0.5%) (2 adults [0.36%] and 1 child [1.6%]). Rate of vascular complications was statistically higher in pediatric patients (11.4% vs 3.3%; P = .007) and higher but not statistically in recipients of livers from living donors (5.2% vs 2.7%; P = .19). Twelve patients (48.8%) were treated with endovascular approach, and 11 (0.44%)required surgicaltreatment. Two patients underwent immediate retransplant due to hepatic artery thrombosis. CONCLUSIONS Because vascular complications are the most severe complications afterlivertransplant,there must be close follow-up of vascular anastomoses, particularly early postoperatively, with radiologic methods. In cases of vascular complications, emergent treatment, including endovascular interventions, surgery, and retransplant, must be performed.
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Affiliation(s)
- Ibrahim Astarcıoglu
- From the Department of General Surgery, Hepatopancreaticobiliary Surgery and Liver Transplantation Unit, Dokuz Eylul University Faculty of Medicine, Narlıdere, Izmir, Turkey
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Kirchner VA, O'Farrell B, Imber C, McCormack L, Northup PG, Song GW, Spiro M, Raptis DA, Durand F. What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery, or portal vein thrombosis? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14629. [PMID: 35240723 PMCID: PMC10078564 DOI: 10.1111/ctr.14629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/13/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding (CRD42021244288). RESULTS Of the 2478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding. CONCLUSIONS Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT.
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Affiliation(s)
- Varvara A Kirchner
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, USA.,Department of Surgery, Division of Abdominal Transplantation, Stanford University, Stanford, USA
| | | | - Charles Imber
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Lucas McCormack
- Liver Surgery and Transplantation Unit, Department of Surgery, Hospital Aleman, Buenos Aires, Argentina
| | - Patrick G Northup
- Division of Gastroenterology, Department of Medicine, University of Virginia Health System, Charlottesville, USA
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri A Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - François Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France.,University of Paris, Paris, France.,INSER M U1149, Paris, France
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- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, USA
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4
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Bos I, Blondeau M, Wouters D, Camus C, Houssel-Debry P, van der Plas WS, Nieuwenhuis LM, Bardou-Jacquet E, Lisman T, de Meijer VE, Porte RJ, Rayar M. Therapeutic anticoagulation after liver transplantation is not useful among patients with pre-transplant Yerdel-grade I/II portal vein thrombosis: A two-center retrospective study. J Thromb Haemost 2021; 19:2760-2771. [PMID: 34297481 DOI: 10.1111/jth.15472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is no longer a contraindication for liver transplantation (LT). While therapeutic anticoagulation (tAC) is recommended during the waiting period, there is no evidence for its usefulness in the prevention of PVT recurrence after LT. OBJECTIVES The aim of our study was to evaluate the role of tAC post-LT in the prevention of PVT recurrence. PATIENTS/METHODS All adult LTs performed in two high-volume centers between 2003 and 2018 were retrospectively analysed. Only patients with PVT classified as Yerdel grade I or II and with standard portal reconstruction were included. PVT recurrence and tAC-associated morbidity within 1 year were compared between patients receiving tAC or not. RESULTS During the study period, of 2612 LTs performed, 235 (9%) patients with PVT were included; 113 patients (48.1%) received post-LT tAC (tAC group) while 122 (51.9%) did not (non-tAC group). The incidence of bleeding events was significantly higher in the tAC group (26 [23%] vs. 5 [4.1%], P < .01) and the initial hospitalization duration was longer (21 vs. 17.5 days, P < .01). Within the first year, PVT recurrence was observed for 9 (3.8%) patients without any difference between the tAC and non-tAC groups (6 [5.1%] vs. 3 [2.5%], P = .39). The only identified risk factor for PVT recurrence was the recipients' age (odds ratio= 0.94, P = .03). Graft (P = .11) and patient (P = .44) survival were similar between the two groups. CONCLUSION Therapeutic anticoagulation is not necessary in the prevention of grade I/II PVT recurrence and is associated with higher morbidity and longer hospital stay.
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Affiliation(s)
- Isabel Bos
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marc Blondeau
- Service de Chirurgie Hépatobiliaire et Digestive, CHU Rennes, Rennes, France
| | - Dune Wouters
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Christophe Camus
- Service de Maladies Infectieuses et Réanimation Médicale, CHU Rennes, Rennes, France
- INSERM, Rennes, France
| | | | - Willemijn S van der Plas
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Lianne M Nieuwenhuis
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Ton Lisman
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michel Rayar
- Service de Chirurgie Hépatobiliaire et Digestive, CHU Rennes, Rennes, France
- INSERM, Rennes, France
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Radulova-Mauersberger O, Weitz J, Riediger C. Vascular surgery in liver resection. Langenbecks Arch Surg 2021; 406:2217-2248. [PMID: 34519878 PMCID: PMC8578135 DOI: 10.1007/s00423-021-02310-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/18/2021] [Indexed: 01/04/2023]
Abstract
Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.
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Affiliation(s)
- Olga Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
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Massive Pulmonary Artery Thromboembolism in a Liver Transplant Recipient: Case Study and Literature Review. Transplant Proc 2020; 52:2795-2801. [PMID: 32713815 DOI: 10.1016/j.transproceed.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/04/2020] [Indexed: 11/20/2022]
Abstract
The hypercoagulable state in liver transplant recipients that may manifest as abnormal thrombus formation in large vessel structures, such as cardiac chambers and the pulmonary arteries, poses a substantial threat for the patient and graft survival. Massive pulmonary embolism is a rare, albeit potentially lethal, complication that may occur at any stage of liver transplant surgery. In this study, we present the case of a major perioperative thromboembolic event in a liver transplant recipient that had taken place in the early post-transplant period during the second-look surgery that was then successfully treated by catheter-directed clot removal. We will attempt to identify potential factors that may have been associated with abnormal thrombus formation.
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7
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Al-Ghamdi TH, Jarrad A, Bashir AY, Lorf T, Obed A. Thrombolysis in Postoperative Pulmonary Embolism Following Liver Transplantation: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e918857. [PMID: 32066651 PMCID: PMC7048324 DOI: 10.12659/ajcr.918857] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Postoperative pulmonary embolism following liver transplantations is still one of the most fatal complications, especially during the early postoperative phase. The use of a thrombolytic agent such as the recombinant tissue-type plasminogen activator (rtPA) is considered a contraindication early after major abdominal surgery such as liver transplantation. However, thrombolysis after major surgery in the early postoperative period carries a substantial risk of surgical site hemorrhage. CASE REPORT A 55-year-old patient presented with a hepatic mass diagnosed as a combined cholangio/hepatocellular carcinoma. Following the criteria of the University of San Francisco, California (UCSF) for liver transplantation, the case was selected for liver transplantation. The patient received neoadjuvant therapy. After the liver transplantation, on the second postoperative day, an acute, severe dyspnea with sudden onset occurred on the surgical ward. A computed tomography angiography showed a drawn-out embolus, which sprawled into both pulmonary main arteries and occluded them subtotally. A thrombolysis with rtPA was started. Within the first 60 minutes of administration of rtPA, the circulation stabilized effectively, so that epinephrine could be tapered down to zero and the patient was promptly extubated. About 6 hours after administration of rtPA, a sudden and pronounced bleeding via one of the intraperitoneal drains occurred, hemoglobin concentration dropped from 9.7 g/dL to 6.4 g/dL. After immediate re-laparotomy, circulation and hemoglobin concentration were absolutely stable. CONCLUSIONS Even with anticipated high risk of bleeding, thrombolysis with rtPA can be used as a life-savings treatment in a case of pulmonary embolism after liver transplantation.
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Affiliation(s)
- Thamer H Al-Ghamdi
- Department of Surgery, Faculty of Medicine, Al Baha University, Al Baha, Saudi Arabia
| | - Anwar Jarrad
- Hepatology, Gastroenterology and Hepatobiliary/Transplant Unit, Jordan Hospital, Amman, Jordan
| | | | - Thomas Lorf
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Aiman Obed
- Department of General and Transplant Surgery, Jordan Hospital, Amman, Jordan
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8
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Faccia M, Ainora ME, Ponziani FR, Riccardi L, Garcovich M, Gasbarrini A, Pompili M, Zocco MA. Portal vein thrombosis in cirrhosis: Why a well-known complication is still matter of debate. World J Gastroenterol 2019; 25:4437-4451. [PMID: 31496623 PMCID: PMC6710174 DOI: 10.3748/wjg.v25.i31.4437] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) represents a well-known complication during the natural course of liver cirrhosis (LC), ranging from asymptomatic cases to life-threating conditions related to portal hypertension and hepatic decompensation. Portal flow stasis, complex acquired hypercoagulable disorders and exogenous factors leading to endothelial dysfunction have emerged as key factors for PVT development. However, PVT occurrence remains unpredictable and many issues regarding its natural history, prognostic significance and treatment are still elusive. In particular although spontaneous resolution or disease stability occur in most cases of PVT, factors predisposing to disease progression or recurrence after spontaneous recanalization are not clarified as yet. Moreover, PVT impact on LC outcome is still debated, as PVT may represent itself a consequence of liver fibrosis and hepatic dysfunction progression. Anticoagulation and transjugular intrahepatic portosystemic shunt are considered safe and effective in this setting and are recommended in selected cases, even if the safer therapeutic option and the optimal therapy duration are still unknown. Nevertheless, their impact on mortality rates should be addressed more extensively. In this review we present the most debated questions regarding PVT, whose answers should come from prospective cohort studies and large sample-size randomized trials.
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Affiliation(s)
- Mariella Faccia
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maria Elena Ainora
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Laura Riccardi
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Matteo Garcovich
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maurizio Pompili
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome 00168, Italy
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9
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Feltracco P, Barbieri S, Carollo C, Bortolato A, Michieletto E, Bertacco A, Gringeri E, Cillo U. Early circulatory complications in liver transplant patients. Transplant Rev (Orlando) 2019; 33:219-230. [PMID: 31327573 DOI: 10.1016/j.trre.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Feltracco
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy.
| | - Stefania Barbieri
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Cristiana Carollo
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Andrea Bortolato
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Elisa Michieletto
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Alessandra Bertacco
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
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10
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Flynn E, Huang JY, Hardikar W, Herd L, Hodgson A, Monagle P. Antithrombotic management and thrombosis rates in children post-liver transplantation: A case series and literature review. Pediatr Transplant 2019; 23:e13420. [PMID: 31012220 DOI: 10.1111/petr.13420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/05/2019] [Accepted: 03/20/2019] [Indexed: 12/14/2022]
Abstract
Thrombosis is a major postoperative complication in pediatric liver transplantation. There is marked heterogeneity in prophylactic antithrombotic therapies used, without established guidelines. This review summarizes current worldwide incidence of thrombotic events and compares antithrombotic therapies in children post-liver transplant, with comparison to our institution's experience. Of the twenty-three articles with sufficient detail to compare antithrombotic regimens, the overall incidence of thrombosis ranged from 2.4% to 17.3%. Incidence of HAT ranged from 0% to 28.1%, of HVT from 0% to 4.7%, of PVT from 1.5% to 11.2%, and of IVC thrombosis from 0% to 2.8%. Re-transplantation due to thrombosis ranged from 0% to 4.8%. Prophylactic antithrombotic therapies varied between studies, and bleeding complications were infrequently reported. Since 2010, 96 children underwent 100 liver transplants at our institution with thrombosis incidence comparable to international literature (HAT 6%, PVT 5%, IVC 1%, and HVT 0%). Re-transplantation due to thrombosis occurred in 2% and major bleeding occurred in 10%. The prophylactic antithrombotic therapies used post-liver transplantation in children remain varied. Low rates of thrombosis have been reported with antiplatelet use both with and without anticoagulation. Standard definitions and consistent reporting of bleeding complications are required, in addition to thrombosis rates, so that true risk-benefit assessment of reported regimes can be understood.
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Affiliation(s)
- Elise Flynn
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Joanna Y Huang
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia.,Hematology Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Winita Hardikar
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Lauren Herd
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Alexandra Hodgson
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Paul Monagle
- Department of Clinical Hematology, Royal Children's Hospital, Parkville, Victoria, Australia.,Hematology Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia
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De Pietri L, Montalti R, Nicolini D, Troisi RI, Moccheggiani F, Vivarelli M. Perioperative thromboprophylaxis in liver transplant patients. World J Gastroenterol 2018; 24:2931-2948. [PMID: 30038462 PMCID: PMC6054944 DOI: 10.3748/wjg.v24.i27.2931] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation (LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications (intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors (portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis’’ can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors (venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.
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Affiliation(s)
- Lesley De Pietri
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, Reggio Emilia 42123, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Roberto Ivan Troisi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent 185 3K3 9000, Belgium
- Department of Clinical Medicine, Federico II University Naples, Naples 80138, Italy
| | - Federico Moccheggiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
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Stine JG, Northup PG. Coagulopathy Before and After Liver Transplantation: From the Hepatic to the Systemic Circulatory Systems. Clin Liver Dis 2017; 21:253-274. [PMID: 28364812 DOI: 10.1016/j.cld.2016.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The hemostatic environment in patients with cirrhosis is a delicate balance between prohemostatic and antihemostatic factors. There is a lack of effective laboratory measures of the hemostatic system in patients with cirrhosis. Many are predisposed to pulmonary embolus, deep vein thrombosis, and portal vein thrombosis in the pretransplantation setting. This pretransplantation hypercoagulable milieu seems to extend for at least several months post-transplantation. Patients with nonalcoholic fatty liver disease, inherited thrombophilia, portal hypertension in the absence of cirrhosis, and hepatocellular carcinoma often require individualized approach to anticoagulation. Early reports suggest a potential role for low-molecular-weight heparins and direct-acting anticoagulants.
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Affiliation(s)
- Jonathan G Stine
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, 1215 JPA and Lee Street, Charlottesville, VA 22908, USA
| | - Patrick G Northup
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, 1215 JPA and Lee Street, Charlottesville, VA 22908, USA.
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13
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Dowell JD, Castle JC, Spinner J, Black S. Role of inferior vena cava filters in transplant patients. Clin Transplant 2016; 31. [PMID: 27801505 DOI: 10.1111/ctr.12865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE This study evaluates the selection, use, and risks of permanent and retrievable inferior vena cava filters (IVCFs) in patients who have undergone organ transplantation. MATERIALS AND METHODS Single-center retrospective review of 35 patients who had an IVCF placed following organ transplantation. Patient demographics, IVCF indication, and eligibility for retrieval were reviewed. Computed tomography (CT) studies showing the filter (n=22) were evaluated independently for IVCF adverse effects. RESULTS Thirty-two (91%) of 35 patients had retrievable IVCFs placed while three (9%) patients received permanent IVCFs. Filter retrieval was indicated in three of the 32 patients receiving retrievable filters and was performed in two cases. Patients were ineligible for retrieval due to short life expectancy, complications/contraindications to anticoagulation, extended filter dwell time, lost to follow-up, and undetermined therapeutic value of anticoagulation. CONCLUSION Current practices of filter placement usually dictate placing a retrievable IVCF in transplant patients. However, transplant patients are unlikely to be eligible for filter retrieval especially in situations of advanced age and comorbidities. Given the low incidence of eligibility for retrieval in this patient population, these results suggest preferential placement of permanent filters may reduce the potential morbidity due to filter-related complications, such as strut perforation, in transplant patients.
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Affiliation(s)
- Joshua D Dowell
- Division of Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Northwest Radiology, St. Vincent Health, Indianapolis, IN, USA
| | - Jordan C Castle
- Division of Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jesse Spinner
- Division of Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sylvester Black
- Division of Transplant Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Chen H, Turon F, Hernández-Gea V, Fuster J, Garcia-Criado A, Barrufet M, Darnell A, Fondevila C, Garcia-Valdecasas JC, Garcia-Pagán JC. Nontumoral portal vein thrombosis in patients awaiting liver transplantation. Liver Transpl 2016; 22:352-65. [PMID: 26684272 DOI: 10.1002/lt.24387] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/06/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis (PVT) occurs in approximately 2%-26% of the patients awaiting liver transplantation (LT) and is no longer an absolute contraindication for LT. Nearly half of PVT cases are accidentally found during the LT procedure. The most important risk factor for PVT development in cirrhosis may be the severity of liver disease and reduced portal blood flow. Whether other inherited or acquired coagulation disorders also play a role is not yet clear. The development of PVT may have no effect on the liver disease progression, especially when it is nonocclusive. PVT may not increase the risk of wait-list mortality, but it is a risk factor for poor early post-LT mortality. Anticoagulation and transjugular intrahepatic portosystemic shunt (TIPS) are 2 major treatment strategies for patients with PVT on the waiting list. The complete recanalization rate after anticoagulation is approximately 40%. The role of TIPS to maintain PV patency for LT as the primary indication has been reported, but the safety and efficacy should be further evaluated. PVT extension and degree may determine the surgical technique to be used during LT. If a "conventional" end-to-end portal anastomotic technique is used, there is not a major impact on post-LT survival. Post-LT PVT can significantly reduce both graft and patient survival after LT and can preclude future options for re-LT.
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Affiliation(s)
- Hui Chen
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Josep Fuster
- HBP Surgery and Liver Transplantation Unit, University of Barcelona, Barcelona, Spain
| | - Angeles Garcia-Criado
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Marta Barrufet
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Anna Darnell
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Constantino Fondevila
- HBP Surgery and Liver Transplantation Unit, University of Barcelona, Barcelona, Spain
| | | | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Feltracco P, Barbieri S, Cillo U, Zanus G, Senzolo M, Ori C. Perioperative thrombotic complications in liver transplantation. World J Gastroenterol 2015; 21:8004-8013. [PMID: 26185371 PMCID: PMC4499342 DOI: 10.3748/wjg.v21.i26.8004] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/30/2015] [Accepted: 06/10/2015] [Indexed: 02/06/2023] Open
Abstract
Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation (OLT), the possible cohesion of an underestimated intrinsic hypercoagulative state during and after the transplant procedure may pose a major threat to both patient and graft survival. Thromboembolism during OLT is characterized not only by a complex aetiology, but also by unpredictable onset and evolution of the disease. The initiation of a procoagulant process may be triggered by various factors, such as inflammation, venous stasis, ischemia-reperfusion injury, vascular clamping, anatomical and technical abnormalities, genetic factors, deficiency of profibrinolytic activity, and platelet activation. The involvement of the arterial system, intracardiac thrombosis, pulmonary emboli, portal vein thrombosis, and deep vein thrombosis, are among the most serious thrombotic events in the perioperative period. The rapid detection of occlusive vascular events is of paramount importance as it heavily influences the prognosis, particularly when these events occur intraoperatively or early after OLT. Regardless of the lack of studies and guidelines on anticoagulant prophylaxis in this setting, many institutions recommend such an approach especially in the subset of patients at high risk. However, the decision of when, how and in what doses to use the various chemical anticoagulants is still a difficult task, since there is no common consensus, even for high-risk cases. The risk of postoperative thromboembolism causing severe hemodynamic events, or even loss of graft function, must be weighed and compared with the risk of an important bleeding. In this article we briefly review the risk factors and the possible predictors of major thrombotic complications occurring in the perioperative period, as well as their incidence and clinical features. Moreover, the indications to pharmacological prophylaxis and the current treatment strategies are also summarized.
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