Multivisceral transplant as an option to transplant cirrhotic patients with severe portal vein thrombosis

Abstract

Non-tumoral portal vein thrombosis (PVT) is a critical complication in the patient with advanced cirrhosis awaiting liver transplantation (LT). With the evolution of liver transplant (LT) technique, PVT has morphed from an absolute contraindication to a relative contraindication, depending on the grade of the thrombus. The Yerdel classification is one system of grading PVT severity. Patients with Yerdel class 1–3 PVT can undergo LT at centers with experience in complex portal vein (PV) dissection, thrombectomy, and reconstruction. Class 4 PVT, however, is even more complex and may require heroic techniques such as cavoportal hemitransposition, PV arterialization or multivisceral transplant (MVT). Some centers use a MVT back-up approach for patients with Yerdel class 4 PVT. In these patients, all organs with PV outflow are procured simultaneously as a cluster graft from a deceased donor (liver, pancreas, intestine±stomach). If physiologic PV inflow is established intraoperatively, the recipient undergoes LT. Otherwise the MVT graft is transplanted. MVT establishes physiologic PV flow, but transplantation of the intestine confers significant lifelong risks including rejection, graft-versus host disease and post-transplant lymphoma. Yerdel class 1–4 PVT patients undergoing successful LT have 5-year survival similar to non-PVT patients, while patients requiring full MVT experience somewhat higher mortality because of the complexity of the surgery and medical management. • Non-tumoral portal vein thrombosis (PVT) is an important complication of liver cirrhosis and must be managed beginning from the time of diagnosis and intraoperatively at the time of liver transplantation. • PVT classification aids in developing management algorithms. • Each patient listed for liver transplant with known PVT must have a surgical plan to address the potential for inadequate portal vein flow to support the liver graft. • Multiple surgical techniques are available to overcome complex Yerdel class 4 PVT. • Centers with expertise in multivisceral transplantation (MVT) may employ a back-up MVT algorithm for use in patients in whom robust physiologic portal vein flow cannot be established intraoperatively at transplant.

Topics & Concepts