TRANSPLANT TO NORMALCY: A CASE OF LIVER TRANSPLANT IN
ACUTE ON CHRONIC PORTOMESENTRIC THROMBOSIS IN A
PATIENT WITH UNDERLYING CIRRHOSIS OF LIVER
INTRODUCTION
Chronic liver disease (CLD) is a continuous process of hepatic fibrosis, liver architecture changes, and
formation of regeneration nodule in response to chronic liver injury that leads to portal hypertension and
end stage liver disease.1 Portal Vein Thrombosis (PVT) is commonly seen in cirrhotic patient. PVT is
develops due to low velocity in portal vein flow and hypercoaguable state induced due to cirrhosis or
prothrombotic predisposition. PVT can be either acute or chronic. Acute PVT usually presents with
abdominal pain and intestinal ischemia, whereas, chronic PVT is associated with signs of decompensation
(ascites, varices formation, jaundice) and formation of venous collaterals as a result of neoangiogensis to
2,3
bypass the occlusion of the portal vein.
Table 1: Classification of portal vein thrombosis (PVT) proposed by Yerdel et al.4
CASE DESCRIPTION
HOPI: 61 year old female with a history of chronic liver disease with portal hypertension and Type II
Diabetes mellitus presented with complaints of abdominal distension and swelling of both limbs.
Past medical history: Decompensated cirrhosis of liver with portal hypertension, Type II Diabetes
mellitus.
Social History: Lives in Sri Lanka, Worked in a Garment Factory.
Course of event:
After thorough evaluation, need for liver transplantation was explained to her and work up was initiated
as per protocol. On evaluation, Computed Tomography (CT) Abdomen and pelvis showed an acute on
chronic portal vein thrombosis extending into the superior mesenteric vein. Liver Transplant work up was
withheld. She was started on low molecular weight heparin (LMWH) and Transhepatic intrajugualr
portosystemic shunt (TIPSS) after portal vein thrombolysis was done on 16/02/2021.
On follow up, rethrombosis of portal vein was noticed and a repeat portal vein thrombolysis was done on
17/02/2021. Liver Transplant work up resumed following this.
Durirg Cardiological evaluation, Coronary Artery Angiogram (CAG), she was found to have
double vessel coronary artery disease of left anterior descending (LAD) artery and right coronary
artery (RCA), for which percutaneous transluminal coronary angioplasty (PTCA) was done along
with stenting to LAD on 07/03/2021. She was on therapeutic dose of anticoagulation. After
obtaining clearance from the multiple disciplinary team consisting of cardiologist, pulmonologist,
psychiatrist, hepatologist, gynaecologist, surgeons, physiotherapist, dietician, dentist,
endocrinologist and anaesthesiologist, she was placed on Deceased Donor Liver Transplant waiting
list.
Following availability of suitable Deceased Donor organ, she was counselled and consented for Liver
transplant on 21/06/2021. The procedure was uneventful with good graft function and was shifted to
Transplant Intensive Care Unit. Daily ultrasound liver Doppler was done between post-operation day
(POD) 0 to POD 5. Her graft function was good throughout her hospital stay. On POD 2, she got
breathless with drop in saturation level requiring non-invasive ventilation support. Chest- X-ray showed
evidence of pulmonary oedema and pleural effusion for which she was diuresed and pleural effusion was
tapped. By POD 4, her saturation levels improved. She also developed loose stools which was controlled
with altered diet and medication. She was discharged on POD 16 with good graft function and good
haemodynamical status. She is currently of routine follow-up in out-patient department basis with normal
graft function.
Jayanth Reddy, Anurag Agarwal
Portal Vein Thrombosis Grading System
A B C patient with cirrhosis showed that anticoagulation group had better recanalization than untreated
Fig A, B, C: CT abdomen with contrast showing chronic liver disease, splenomegaly, acute on chronic
portal vein thrombosis extending into superior mesenteric vein with multiple collaterals and ascites.
D E E
Fig D,E: CT abdomen with contrast showing chronic liver disease, cholelithiasis, patent TIPSS,
patent main portal vein, patent splenoportal confluence
Fig 1: Ultrasound abdomen post-liver transplant showing normal liver echotexture and normal
hepatic, portal vein and normal hepatic artery with normal inferior vena cava.
DISCUSSION
PVTs are commonly seen in liver cirrhotic patient and are associated with a wide spectrum of
etiologies like myeloproliferative disease, Paroxysmal nocturnal hemoglobinuria,
Antiphospholipid syndrome, Factor V Leiden, Factor II gene mutation, Inherited antithrombin
deficiency, Inherited protein C deficiency, Inherited protein S deficiency, Hyperhomocysteinemia.2,3
Patients with PVT are classified based on a system first put forward by Yerdel et al (Table 1). In
this case she had grade 3 PVT.4
Systemic anticoagulation is the mainstay for PVT treatment. LMWH is widely used due to easy
administration of the drug subcutaneously twice a day. The recommended dose of enoxaparin is
1mg/kg every 12 hours. A retrospective study done by Hui Chen et al, on anticoagulation in PVT
group with improvement in 68% of patient who were treated with anticoagulation whereas only
25% of patient improved without treatment.5
A prospective study done by Lv et al which focused on Anticoagulation and Transjugular
Intrahepatic Portosystemic Shunt for the Management of Portal Vein Thrombosis in Cirrhosis
showed that TIPSS and anticoagulation were associated with a higher probability of
recanalization.6
Liver transplant (LT) has morphed PVT from an absolute contraindication to a relative
contraindication, depending on the grade of the thrombus. Patients with Yerdel class 1–3 PVT can
undergo LT at centers with experience in complex portal vein (PV) dissection, thrombectomy, and
reconstruction. Class 4 PVT, how- ever, is even more complex and may require heroic techniques
such as cavoportal hemitransposition, PV arterialization or multivisceral transplant (MVT).7
REFERENCES
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