Omameuda Takahiko, Sanada Yukihiro, Sakuma Yasunaru, Onishi Yasuharu, Wakiya Taiichi, Okada Noriki, Hirata Yuta, Horiuchi Toshio, Takadera Kiichiro, Akimoto Ryosuke, Uehara Tomoya, Sata Naohiro
Division of Gastroenterological, General and Transplant Surgery, Department of Surgery, Jichi Medical University, Tochigi, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.24-0165. Epub 2025 Apr 25.
When a thrombus extends to the suprahepatic inferior vena cava (IVC) in patients with Budd-Chiari syndrome (BCS) requiring liver transplantation (LT), there is a risk of thrombus migration during hepatectomy that can potentially lead to pulmonary embolism. Intraoperative pulmonary embolism can be life-threatening and may necessitate urgent thrombectomy. However, preventive strategies for pulmonary embolism during LT in BCS cases with IVC thrombosis have seldom been discussed in the literature. We report a case involving a 51-year-old woman with BCS complicated by thrombi extending into the suprahepatic IVC who underwent deceased donor LT (DDLT) for acute liver failure (ALF).
A previously healthy 51-year-old woman with ALF secondary to BCS was admitted to our hospital. 19 days back, BCS was diagnosed at another hospital, where computed tomography revealed thrombi in the hepatic veins and IVC. She subsequently developed grade II hepatic encephalopathy and severe liver dysfunction. Conservative treatment was ineffective, and 4 days before the current admission, she experienced grade III hepatic encephalopathy and showed hepatofugal portal flow on ultrasonography. DDLT was performed on day 13 after admission. Median sternotomy was performed to clamp the suprahepatic IVC near the right atrium, mitigating the risk of thrombus migration during hepatectomy and allowing for urgent thrombectomy in case of pulmonary embolism. Additionally, because a large-for-size graft was being used, the median sternotomy enhanced visibility and provided adequate space, facilitating suprahepatic IVC anastomosis. Postoperatively, the patient experienced no complications related to the sternotomy and was discharged 58 days after surgery.
This case report highlights the potential utility of median sternotomy during LT for BCS, particularly for cases with concerns regarding thrombus migration from the suprahepatic IVC, the need for rapid thrombectomy in the event of pulmonary embolism, and anticipated challenges in suprahepatic IVC anastomosis due to large-for-size grafts.
在需要肝移植（LT）的布加综合征（BCS）患者中，当血栓延伸至肝上下腔静脉（IVC）时，肝切除术中存在血栓迁移的风险，这可能会导致肺栓塞。术中肺栓塞可能危及生命，可能需要紧急进行血栓切除术。然而，文献中很少讨论BCS合并IVC血栓形成患者肝移植期间肺栓塞的预防策略。我们报告了一例病例，一名51岁患有BCS且血栓延伸至肝上下腔静脉的女性因急性肝衰竭（ALF）接受了脑死亡供体肝移植（DDLT）。
一名既往健康的51岁女性因BCS继发ALF入住我院。19天前，在另一家医院诊断为BCS，计算机断层扫描显示肝静脉和IVC有血栓形成。随后她出现了II级肝性脑病和严重肝功能不全。保守治疗无效，在本次入院前4天，她出现了III级肝性脑病，超声检查显示肝门血流离肝。入院后第13天进行了DDLT。采用正中胸骨切开术夹闭右心房附近的肝上下腔静脉，降低了肝切除术中血栓迁移的风险，并在发生肺栓塞时能够进行紧急血栓切除术。此外，由于使用的是大尺寸移植物，正中胸骨切开术提高了视野清晰度并提供了足够的空间，便于肝上下腔静脉吻合。术后，患者未出现与胸骨切开术相关的并发症，术后58天出院。
本病例报告强调了正中胸骨切开术在BCS肝移植中的潜在作用，特别是对于担心肝上下腔静脉血栓迁移、肺栓塞时需要快速进行血栓切除术以及因大尺寸移植物而预期肝上下腔静脉吻合存在挑战的病例。
