Correspondence

Arterialization of the Portal Vein in a Patient with a Dearterialized Liver Graft and Massive Necrosis

N Engl J Med 2001; 345:1352-1353November 1, 2001

Article

To the Editor:

Hepatic-artery thrombosis early after liver transplantation is associated with a very high rate of graft loss and death.1 If urgent revascularization fails2 or if massive hepatic necrosis has already developed, prompt retransplantation is the only hope for the patient's survival.1 However, retransplantation is not always possible. We report on a patient whose dearterialized liver graft with massive necrosis was rescued by arterialization of the portal vein.

A 40-year-old man underwent liver transplantation for cirrhosis related to hepatitis B and C viruses in March 2001. Pneumonia and bacteremia with Klebsiella pneumoniae developed. Seven days after surgery, the patient had a complete hepatic-artery thrombosis. At laparotomy, the liver was macroscopically necrotic, and a graft biopsy showed that 80 percent of the hepatocytes were necrotic. Because of the extensive thrombosis and because the patient was too sick for immediate retransplantation, his hepatic artery was anastomosed, end to side, to the portal vein in order to increase the oxygen supply to the liver parenchyma and promote tissue regeneration.3

After arterialization of the portal vein, the patient's condition rapidly improved. Ten days after the second surgery, liver biopsy showed that 30 percent of the hepatocytes were necrotic.

Twenty-five days after arterialization, the total bilirubin level was 9.8 mg per deciliter; the results of other liver-function tests were normal. There was no clinical evidence of portal hypertension. A computed tomographic scan showed no liver abscesses or biliary leaks (Figure 1Figure 1Computed Tomographic Scan of the Liver Graft Obtained 24 Days after Arterialization of the Portal Vein.). A liver biopsy, performed 24 days after arterialization, showed that 10 percent of the hepatocytes were necrotic, with minimal cholestasis.

After two months, an ischemic biliary stricture developed, probably because of the absence of the hepatic artery for blood supply.4 The total bilirubin level reached 23 mg per deciliter; percutaneous transhepatic biliary drainage was required. A liver biopsy showed moderate cholangitis and cholestasis. The patient received another liver transplant in July 2001. Unfortunately, he subsequently died of multiple-organ failure and pneumonia related to Aspergillus flavus infection.

In life-threatening situations, when other options are not feasible, arterialization of the portal vein can be used to rescue a dearterialized liver graft with massive hepatic necrosis, thus providing a bridge to elective retransplantation.

Antonino Cavallari, M.D.
Bruno Nardo, M.D., Ph.D.
Paolo Caraceni, M.D.
University of Bologna, 40138 Bologna, Italy
cavallari@orsola-malpighi.med.unibo.it

4 References

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   Shimizu Y, Miyazaki M, Shimizu H, et al. Beneficial effects of arterialization of the portal vein on extended hepatectomy. Br J Surg 2000;87:784-789
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   Terblanche J, Allison HF, Northover JM. An ischemic basis for biliary strictures. Surgery 1983;94:52-57
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Citing Articles (5)

Citing Articles

1. 1

   B. Nardo, S. Vaccarisi, V. Pellegrino, M. Cannistrà, E. Barcellona, G. Cavallari. (2011) Extracorporeal Portal Vein Arterialization in Man After Extended Hepatectomy to Prevent Acute Liver Failure: A Case Report. Transplantation Proceedings 43:4, 1193-1195
   CrossRef

2. 2

   Alastair L. Young, K. Rajendra Prasad, Robert Adair, Mohammed Abu Hilal, J. Ashley Guthrie, J. Peter A. Lodge. (2008) Portal Vein Arterialization as a Salvage Procedure During Left Hepatic Trisectionectomy for Hilar Cholangiocarcinoma. Journal of the American College of Surgeons 207:5, e1-e6
   CrossRef

3. 3

   Bruno Nardo, Paolo Caraceni, Lorenza Puviani, Anna Maria Pertosa, Marco Domenicali, Milena Pariali, Graziella Angiolini, Pasquale Chieco, Franco Trevisani, Mauro Bernardi, Antonino Cavallari. (2006) Successful Treatment of CCl4-Induced Acute Liver Failure With Portal Vein Arterialization in the Rat. Journal of Surgical Research 135:2, 394-401
   CrossRef

4. 4

   Bruno Nardo, Roberto Montalti, Lorenza Puviani, Gerardo Martinelli, Antonino Cavallari, Paolo Caraceni, Cristina Rossi. (2005) Portal Vein Arterialization in a Patient with Acute Liver Failure. Transplantation 79:7, 851-852
   CrossRef

5. 5

   Thomas Seufferlein, Bernhard O Boehm. (2002) The impact of pharmacogenomics on gastrointestinal cancer therapy. Pharmacogenomics 3:5, 625-633
   CrossRef