Life-Saving Precision: Image-Guided Interventions Transforming Outcomes in Living-Donor Liver Transplant Complications

Abstract

Living-donor liver transplantation (LDLT) is a preferred treatment modality for patients with end-stage liver disease. However, the incidence of postoperative complications, particularly involving the biliary and vascular systems, remains significant. These complications often necessitate urgent interventional management to prevent graft loss. Although surgical revision is an option, it carries increased morbidity and mortality risks. This case series explores the utility of minimally invasive, image-guided techniques for managing complex post-LDLT complications. We present four cases involving distinct image-guided interventions, including percutaneous transhepatic biliary drainage (PTBD) with balloon cholangioplasty for biliary strictures, hepatic venoplasty with intravascular stenting for hepatic venous outflow tract obstruction, and transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites secondary to portal hypertension. Procedural techniques, immediate outcomes, and follow-up results were assessed. All interventions were technically successful, with immediate clinical and biochemical improvement observed in each patient. Follow-up imaging confirmed patency and resolution of the vascular or biliary complications. This series underscores the efficacy of image-guided interventions as a safer alternative to surgical re-exploration in complex post-transplant cases. Image-guided interventions, including PTBD, venoplasty, and TIPS, offer robust management solutions for biliary and vascular complications in LDLT recipients, highlighting the role of interventional radiology in post-transplant care.

Keywords: biliary complications; hepatic venoplasty; image-guided interventions; interventional radiology; living-donor liver transplantation (ldlt); minimally invasive procedures; percutaneous transhepatic biliary drainage (ptbd); postoperative management; transjugular intrahepatic portosystemic shunt (tips); vascular complications.

Figure 1. List of post-LDLT complications

IVC: Inferior vena cava; LDLT: Living-donor liver transplantation Figure credits: Author Bribin Bright

Figure 2. Various minimally invasive treatment options in post-LDLT vascular complications

IVC: Inferior vena cava; LDLT: Living-donor liver transplantation; HVPG: Hepatic venous-portal gradient; HTN: Hypertension Figure credits: Author Bribin Bright

Figure 3. Options in biliary complications

Figure 4. 3D MRCP showing biliary anastomotic stricture with hepatic hilar collection

MRCP: Magnetic resonance cholangiopancreatography

Figure 5. Cholangiogram showing two strictures involving segment 2 and 3 ducts , which were accessed percutaneously using a Chiba needle (Cook Medical, Bloomington, USA) and crossed successfully with a Terumo wire (Terumo Interventional Systems, USA)

Figure 6. Percutaneous intervention - serial balloon dilation for strictures in segment 2 and 3 ducts

Figure 7. Follow-up cholangiogram showing patent biliary anastomosis with good flow across the reconstructed biliary anastomotic site

Figure 8. (a) Retrohepatic IVC narrowing on USG; (b) Turbulent flow on Doppler sonography; (c) Reversal of flow in the right and middle hepatic veins on Doppler sonography

IVC: Inferior vena cava; USG: Ultrasound

Figure 9. Delayed phase post-contrast coronal CT section showing narrowing of the hepatic and retrohepatic IVC segment with occlusion of the hepatic veins

CT: Computed tomography; IVC: Inferior vena cava

Figure 10. Cavogram showing tight stenosis in the hepatic IVC segment with venous collaterals and focal occlusions in the hepatic vein

IVC: Inferior vena cava

Figure 11. IVC stenosis balloon angioplasty and hepatic vein stenting

IVC: Inferior vena cava

Figure 12. TIPS procedure

(a) Shunt track was created across the right hepatic vein and right branch of the portal vein using the Rösch-Uchida set (Cook Medical, Bloomington, USA). (b) The parenchymal tract was dilated, and a 10 mm x 10 cm stent (Niti-S, Taewoong Medical, Gimpo-si, South Korea) was successfully placed. (c) Post-stenting portogram showing good flow through the shunt. TIPS: Transjugular intrahepatic portosystemic shunt

Figure 13. Axial and coronal post-contrast CT images showing portal vein anastomotic stenosis

CT: Computed tomography

Figure 14. Percutaneous approach portogram showing narrowing of the right portal vein

Figure 15. Angiographic image of portal vein stenting (a,b) and good flow across the stent post-stenting (c)

Figure 16. Post-stenting follow-up ultrasound Doppler image showing good flow in portal vein across the stent

Figure 17. Overview of percutaneous transhepatic approach for biliary complications

Percutaneous biliary techniques are effective treatment options with good outcomes in LDLT patients with biliary complications and failed ERCP. Percutaneous techniques have a definite complementary role to ERCP. ERCP: Endoscopic retrograde cholangiopancreatography; LDLT: Living-donor liver transplantation; USG: Ultrasound; CT: Computed tomography; HIDA: Hepatobiliary iminodiacetic acid; MRCP: Magnetic resonance cholangiopancreatography; PTBD: Percutaneous transhepatic biliary drainage Figure is adapted from Kulkarni et al. [2], with permission obtained for its use.

Figure 18. Approach to restenosis

In restenosis, SEMS provide durable long-term patency and reduce the need for repeated interventions. SEMS: Self-expandable metallic stents; PTBD: Percutaneous transhepatic biliary drainage Figure credits: Author Bribin Bright

Figure 19. Key strategies for prevention of hepatic encephalopathy following TIPS

TIPS: Transjugular intrahepatic portosystemic shunt; MELD: Model for End-Stage Liver Disease; HE: Hepatic encephalopathy Figure credits: Author Bribin Bright