Ann Hepatobiliary Pancreat Surg.  2021 May;25(2):299-306. 10.14701/ahbps.2021.25.2.299.

Third retransplantation using a whole liver graft for late graft failure from hepatic vein stent stenosis in a pediatric patient who underwent split liver retransplantation

• Namgoong JM
• Hwang S
• Yoon YI
• Cho YP
• Kang WH
• Kwon YJ
• Kwon H
• Kim SH
• Kim KM
• Oh SH

• KMID: 2516499
• DOI: http://doi.org/10.14701/ahbps.2021.25.2.299

Abstract

We present a case of third retransplantation using a whole liver graft in a 13-year-old girl who suffered graft failure and hepatopulmonary syndrome following split liver retransplantation with endovascular stenting of the hepatic and portal veins as an infant. She was diagnosed with biliary atresia-polysplenia syndrome, and thus underwent living donor liver transplantation from her mother at 9 months of age. The first liver graft failed due to stenosis of the portal vein. She underwent the second liver transplantation with a split left lateral section graft. Endovascular stenting was performed to the portal vein stenosis 2 months and hepatic vein stenosis 9 months after transplantation. During the next 9 years, 11 sessions of balloon angioplasty for hepatic vein stent stenosis were performed. Ten years after the second transplantation, she underwent third transplantation using a whole liver graft recovered from a 12-year-old-girl. The double inferior vena cava technique was used for outflow vein reconstruction. The graft portal vein was anastomosed with the stent-containing portal vein stump because it was not possible to remove the stent and the inner diameter of the portal vein stent was large enough. An aorto-hepatic jump graft was used for arterial reconstruction. The patient recovered slowly and is doing well for 6 months posttransplant. In conclusion, because stenting of the hepatic vein or portal vein can induce graft failure leading to late retransplantation, we emphasize secure vascular reconstruction to prevent endovascular stenting during LT in infants.

Keyword

Hepatic vein stenosis; Portal vein stenosis; Endovascular stenting; Vascular insufficiency; Infant

Figure

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  Fig. 1 Findings of the first liver transplantation. (A) Com-puted tomography taken before the first transplantation shows biliary atresia-polysplenia syn-drome with insertion of percu-taneous transhepatic biliary drain-age (arrow). (B) The explanted native liver taken after the first transplantation is visible. (C) Computed tomography taken 2 weeks after the first transplan-tation shows the small-sized portal vein (arrow). (D) The explanted first liver graft after the second transplantation is visible.

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  Fig. 2 Findings showing portal vein stenosis after the second liver transplantations. (A, B) Computed tomography taken 1 month after transplantation shows portal vein stenosis (arrows). (C, D) Balloon angioplasty and endovascular stenting with a stent of 10 mm×40 mm are per-formed 2 months after transplan-tation.

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  Fig. 3 Findings showing hepatic vein stenosis after the second liver transplantation. (A) Com-puted tomography taken 8 months after transplantation shows mas-sive ascites. (B) Thrombus (ar-row) within the graft hepatic vein is visible. (C, D) Endo-vascular stenting with stents of 8 mm×40 mm and 8 mm×60 mm is performed at 9 months after transplantation.

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  Fig. 4 Findings showing persi-stent hepatic vein stenosis after the second liver transplantation. (A, B) Computed tomography taken 3 years after transplan-tation shows hepatic vein and portal vein stenting. (C, D) The stenotic portions at the hepatic vein stents are dilated through balloon angioplasty.

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  Fig. 5 Findings before the third liver transplantation. (A-C) Com-puted tomography 4 months be-fore the third transplantation shows marked hepatomegaly with development of collaterals. (D) The explanted second liver graft after the third transplantation is visible.

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  Fig. 6 Intraoperative photographs of the third liver transplanta-tion. (A) The dissected portal vein containing a wall stent is visible (arrow). (B) The tran-sected portal vein shows the lumen of the fully expanded stent with smoothly-formed neo-intima (arrow). (C) The graft portal vein is anastomosed with the stent-containing portal vein stump (arrow). (D) The graft hepatic artery is reconstructed using a jump graft with an iliac artery graft (arrow).

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  Fig. 7 Finding of the inferior vena cava reconstruction follow-ing the third liver transplanta-tion. (A, B) Computed tomo-graphy taken 3 days after third transplantation shows the cavo-caval anastomosis (arrows) using a double inferior vena cava tech-nique. (C, D) Computed tomo-graphy taken 1 month after the third transplantation shows the reshaping of the cavocaval an-astomosis (arrows), which is sim-ilar to the natural smooth stream-lined configuration of the double inferior vena cava.

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  Fig. 8 Finding of the portal vein reconstruction following the third liver transplantation. (A) Direct intraoperative porto-gram shows portal vein flow passing well through the wall stent remnant (arrow). (B, C) Computed tomography taken 3 days after the third transplan-tation shows maintenance of portal vein flow through the wall stent remnant (arrows). (D) An aorto-hepatic jump graft is visi-ble on the three-dimensional re-construction image (arrow).

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