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INTRODUCTION

Although the surgical technique of liver transplantation (LT) has emerged from an experimental therapy to a more standardized and relatively safe procedure, great differences exist in the complexity of the operation among different patients. Venous abnormalities are a relatively frequent finding. These abnormalities include acute and chronic portal vein thrombosis (PVT). The incidence of PVT in patients undergoing orthotopic liver transplantation (OLT) ranges from 2.1% to 26% in a large reported series. During LT, it may be difficult to reconstitute adequate portal venous inflow to the graft in these patients. In the 1980s, PVT was considered an absolute contraindication to OLT. In 2000, Yerdel et al. proposed a grading system for PVT (Table 73-1, Fig. 73-1). Grade 1 involves less than 50% of the portal vein (PV) lumen with or without minimal extension into the superior mesenteric vein (SMV) (Fig. 73-2). With grade 2, more than 50% occlusion of the PV is present, including total occlusion, with or without minimal extension into the SMV (Fig. 73-3). Grade 3 involves complete thrombosis of both the PV and the SMV trunk (distal SMV patent) (Fig. 73-4). Grade 4 involves complete thrombosis of both the PV and SMV (Fig. 73-5). Several surgical techniques have been described to deal with portal or mesenteric vein thrombosis.1–3

FIGURE 73-1

Portal vein thrombosis grading system.

FIGURE 73-2

Contrast-enhanced computed tomography showing a portal vein thrombosis grade 1

FIGURE 73-3

Contrast-enhanced computed tomography showing a portal vein thrombosis grade 2 with total occlusion of the PV

FIGURE 73-4

Contrast-enhanced computed tomography showing a portal vein thrombosis grade 3 involving the SMV trunk

FIGURE 73-5

Contrast-enhanced computed tomography showing a portal vein thrombosis grade 4 involving distally the SMV territory.

TABLE 73-1Portal Vein Thrombosis Grading System

Preoperative knowledge of PV disease is imperative and greatly facilitates the operative strategy. Most of these patients undergo a color flow Doppler ultrasonography to assess vascular patency or the presence of partial or ...

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