Imaging and Intervention in the Management of Vascular Complications Following Liver Transplantation

Abstract

Liver transplantation is the treatment of choice in majority of the patients with end stage liver disease. Vascular complication following liver transplantation is seen in around 7-13% of the patients and is associated with graft dysfunction and high morbidity and mortality. Early diagnosis and prompt treatment are crucial in management of these patients. Advances in interventional radiology have significantly improved the management of vascular complications using minimally invasive percutaneous approach. Endovascular management is preferred in patients with late hepatic artery thrombosis, or stenosis, whereas retransplantation, surgical revision, or endovascular management can be considered in patients with early hepatic artery thrombosis or stenosis. Hepatic artery pseudoaneurysm, arterioportal fistula, and splenic artery steal syndrome are often treated by endovascular means. Endovascular management is also preferred in patients with symptomatic portal vein stenosis, early portal vein thrombosis, and symptomatic late portal vein thrombosis, whereas surgical revision or retransplantation is preferred in patients with perioperative portal vein thrombosis occurring within 3 days of transplantation. Venoplasty with or without stent placement can be considered in patients with hepatic venous outflow tract or inferior vena cava obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) may be required in transplant recipients who develop cirrhosis, often, secondary to disease recurrence, or chronic rejection. Indications for TIPS remain same in the transplant patients; however, major difference is altered vascular anatomy, for which adjunct techniques may be required to create TIPS.

Keywords: TIPS; imaging; interventional radiology; liver transplantation; vascular complications.

Graphical abstract

Figure 1

A 44-year-old male patient, presenting with graft dysfunction at postoperative day 8 of liver transplantation. Contrast enhanced CT (a), and digital subtraction angiogram (DSA) (b) showed hepatic artery thrombosis (HAT) (black arrow). Catheter directed thrombolysis (CDT) was done for HAT (c). DSA at 24 h of thrombolysis (d) showed hepatic artery stenosis (HAS) at the anastomotic site, for which balloon angioplasty was done (e, white arrowhead). Postangioplasty DSA (f) showed residual HAT (black arrowhead). CDT was continued for 12 h, following which DSA was done which showed resolution of HAT, and improved hepatic artery flow (h, blue open arrowhead). However, arterial extravasation was noted along the hepatic cut surface (g, black open arrowhead), for which selective coil embolization was done (h, white open arrowhead).

Figure 2

A 34-month-old male child presenting with variceal bleeding, 3 months following liver transplantation. Contrast enhanced CT abdomen (a), and DSA (b, c) showed chronic thrombosis of portal vein graft (white arrow). Percutaneous transhepatic access was achieved, and balloon angioplasty was done for portal vein thrombosis (d, black arrowhead). DSA following angioplasty (e) showed residual portal vein thrombosis (black arrow). Stenting was done across the portal vein graft (f, white arrowhead), and final angiogram showed good flow across the stent.

Figure 3

A 33-month-old male child presenting with liver function abnormality, a year after liver transplantation. Contrast enhanced CT (a), and DSA (b, c) showed portal vein stenosis (PVS) (white arrow) at the site of anastomosis. Balloon angioplasty was done for PVS (d, e, black arrow). Postprocedure angiogram showed good flow across the anastomotic site (f, white arrowhead).

Figure 4

A 46-year-old female patients presenting with variceal bleeding, 8 months following liver transplantation. Contrast enhanced CT abdomen (a), and venogram (b) showed portal vein stenosis at the site of anastomosis (white arrow). Primary stenting was done (c, black arrow), following which good flow was noted with in the portal vein across the anastomosis (d, back arrowhead).

Figure 5

A 52-year-old male patient presenting with graft dysfunction, 20 days following liver transplantation. Contrast enhanced CT images showed portal vein thrombosis (a, white arrow), and large splenorenal shunt (b, white arrowhead) diverting the portal blood flow to the left renal vein and IVC. Portal venogram (c) showed thrombosed main portal vein (white arrow). Portal venogram after a bolus of catheter directed thrombolysis (d) showed recanalization of portal vein with small residual thrombus load (black arrow), and persistent large splenorenal shunt diverting the portal blood flow. Balloon maceration of thrombus was done (e, black arrowhead). In view of large shunt size, and persistent hepatofugal flow, decision to occlude the shunt was taken to reduce the risk of recurrent portal vein thrombosis. Selective catheterization of the splenorenal shunt was done, and venogram (f) showed opacification of tortuous collaterals draining into left renal vein through splenorenal shunt (white arrowhead). Coil embolization of the splenorenal shunt was done (g, blue arrow). Postembolization portal venogram (h) showed completely recanalized portal vein with antegrade hepatopetal flow (black arrow).

Figure 6

A 40-year-old male patients presenting with refilling ascites at 18 months following liver transplantation. Venogram (a) showed tight stenosis at suprahepatic segment (white arrow) with trans-stenotic pressure gradient of 11 mmHg. Balloon angioplasty was done using 20 mm balloon catheter (b, black arrowhead). Postprocedure venogram (c) revealed improved flow through the IVC (black arrow), with reduction in trans-stenotic gradient to 3 mmHg.

Figure 7

A 38-year-old male patient, presenting with refilling ascites, 1 year following liver transplantation. Venogram (a) revealed tight stenosis at the hepatic vein ostium (white arrow). Primary stenting was done across the stenosis (b, white arrowhead). Postprocedure venogram revealed good flow through the stent (c, black arrow).

Figure 8

A 37-year-old male patient, presenting with liver function abnormality on 17th postoperative day of liver transplantation. Celiac artery angiogram (a) showed non-visualization of hepatic artery (white arrow), and prominent gastroduodenal and splenic artery (white arrowheads). Selective hepatic artery angiogram (b) revealed small caliber hepatic artery with non-visualization of intrahepatic branches (black arrow). Coil embolization of GDA, and splenic artery was done (blue arrowhead). Postembolization angiogram (c) showed improved flow through hepatic artery with opacification of intrahepatic branches (black arrowhead). Postprocedure improvement in liver function test was noted.

Figure 9

Algorithm for management of vascular complications following liver transplantation. Abbreviations: HAT, Hepatic artery thrombosis; HAS, Hepatic artery stenosis; HAP, Hepatic artery pseudoaneurysm; HAR, Hepatic artery rupture; PVT, Portal vein thrombosis; PVS, Portal vein stenosis; PSS, Portal steal syndrome; SSS, Splenic steal syndrome.

Figure 10

A 53-year-old male transplant recipient with chronic liver disease and refractory ascites. Contrast enhanced CT (a, b) showed ascites, splenomegaly, and partial thrombosis of main portal vein, and thrombosis of right and left portal vein (white arrow). Transjugular intrahepatic portosystemic shunt (TIPS) (c) was done in view of refractory ascites. Resolution of ascites was noted following TIPS.