Interventional Radiology, Hospital Sírio-Libanês, São Paulo, Brazil.
Pediatric Intensive Care Unit, Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil.
Pediatr Transplant. 2023 Dec;27(8):e14555. doi: 10.1111/petr.14555. Epub 2023 Jun 8.
The management of complex, intra- and extrahepatic portal vein thrombosis (PVT) after liver transplantation (LT) is challenging. Although most of the patients remain asymptomatic or oligosymptomatic in the chronic setting, some of them may develop severe portal hypertension and related complications, notably gastrointestinal (GI) bleeding. In the emergency scenario, clinical and endoscopic treatments as well as intensive support constitute the bases of conservative management, while more definitive treatment options such as surgical shunting and retransplantation are related to high morbidity rates. Transjugular intrahepatic portosystemic shunt (TIPS) was largely considered of limited role due to technical difficulties arising from extensive PVT. Recently, however, new minimally invasive image-guided techniques emerged, allowing portal vein recanalization and TIPS creation simultaneously (TIPS-PVR), even in complex PVT pretransplant patients.
Herein, we describe a novel indication for TIPS-PVR in a post-LT adolescent presenting with life-threatening, refractory GI bleeding.
The patient presented with complete resolution of the hemorrhagic condition after the procedure, with no deterioration of hepatic function or hepatic encephalopathy. Follow-up Doppler ultrasound after TIPS-PVR showed normal hepatopetal venous flow within the stents, and no evidence of complications, including intraperitoneal or peri splenic bleeding.
This report describes the feasibility of TIPS-PVR in the post-LT scenario complicated by extensive PVT. In this case, a complete resolution of the life-threatening GI bleeding was achieved, with no major complications. Other patients with complex chronic PVT might benefit from the use of the described technique, but further studies are required to determine the correct timing and indications of the procedure, eventually before the occurrence of life-threatening complications.
肝移植（LT）后复杂的肝内和肝外门静脉血栓形成（PVT）的管理具有挑战性。虽然大多数患者在慢性期无症状或仅有轻微症状，但其中一些患者可能会发展为严重的门静脉高压和相关并发症，特别是胃肠道（GI）出血。在紧急情况下，临床和内镜治疗以及强化支持构成保守治疗的基础，而更明确的治疗选择，如手术分流和再次移植，与较高的发病率相关。经颈静脉肝内门体分流术（TIPS）由于广泛 PVT 引起的技术困难，被认为作用有限。然而，最近出现了新的微创影像引导技术，允许同时进行门静脉再通和 TIPS 建立（TIPS-PVR），即使是在移植前复杂 PVT 的患者中也是如此。
在此，我们描述了一种新的 TIPS-PVR 适应证，用于治疗 LT 后出现危及生命的难治性 GI 出血的青少年患者。
该患者在手术后出血情况完全缓解，肝功能或肝性脑病没有恶化。TIPS-PVR 后的随访多普勒超声显示支架内肝向静脉血流正常，没有并发症的证据，包括腹腔内或脾周出血。
本报告描述了 TIPS-PVR 在 LT 后广泛 PVT 合并症中的可行性。在这种情况下，危及生命的 GI 出血得到完全缓解，没有出现主要并发症。其他具有复杂慢性 PVT 的患者可能受益于使用所述技术，但需要进一步研究来确定该技术的正确时机和适应证，最终是在发生危及生命的并发症之前。
