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• W2969608800 abstract "Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible. Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible. Adequate portal inflow is necessary to ensure graft and patient survival after liver transplantation (LT);[1]Lerut J. Tzakis A.G. Bron K. Gordon R.D. Iwatsuki S. Esquivel C.O. et al.Complications of venous reconstruction in human orthotopic liver transplantation.Ann Surg. 1987; 205: 404-414Crossref PubMed Google Scholar thus, coexisting portal vein thrombosis (PVT) was long considered an absolute contraindication for LT due to the high mortality associated with the procedure.[2]Van Thiel D.H. Schade R.R. Starzl T.E. Iwatsuki S. Shaw Jr, B.W. Gavaler J.S. et al.Liver transplantation in adults.Hepatology. 1982; 2: 637-640Crossref PubMed Google Scholar The first successful LT in a patient with PVT was reported in 1985,[3]Shaw Jr, B.W. Iwatsuki S. Bron K. Starzl T.E. Portal vein grafts in hepatic transplantation.Surg Gynecol Obstet. 1985; 161: 66-68PubMed Google Scholar where the portal vein trunk was resected en bloc with the thrombus, and porto-portal anastomosis was performed with an interposed cadaveric vein jump graft. Though initial studies reported worse post-LT outcomes in patients with PVT compared to those without PVT, most studies published after the year 2000 have reported similar 1-year survival in both groups.4Ghabril M. Agarwal S. Lacerda M. Chalasani N. Kwo P. Tector A.J. Portal Vein Thrombosis Is a Risk Factor for Poor Early Outcomes After Liver Transplantation: Analysis of Risk Factors and Outcomes for Portal Vein Thrombosis in Waitlisted Patients.Transplantation. 2016; 100: 126-133Crossref PubMed Scopus (46) Google Scholar, 5Nery F. Chevret S. Condat B. de Raucourt E. Boudaoud L. Rautou P.E. et al.Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis: results of a longitudinal study.Hepatology. 2015; 61: 660-667Crossref PubMed Scopus (165) Google Scholar However, the vast majority of these studies did not detail post-LT results according to the extent/grade of PVT, which may influence the post-LT outcome to a large extent.4Ghabril M. Agarwal S. Lacerda M. Chalasani N. Kwo P. Tector A.J. Portal Vein Thrombosis Is a Risk Factor for Poor Early Outcomes After Liver Transplantation: Analysis of Risk Factors and Outcomes for Portal Vein Thrombosis in Waitlisted Patients.Transplantation. 2016; 100: 126-133Crossref PubMed Scopus (46) Google Scholar, 6Francoz C. Valla D. Durand F. Portal vein thrombosis, cirrhosis, and liver transplantation.J Hepatol. 2012; 57: 203-212Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 7Gao P.J. Gao J. Li Z. Hu Z.P. Leng X.S. Zhu J.Y. Liver transplantation in adults with portal vein thrombosis: Data from the China Liver Transplant Registry.Clin Res Hepatol Gastroenterol. 2016; 40: 327-332Crossref PubMed Scopus (7) Google Scholar In a recent meta-analysis, Zanetto et al.[8]Zanetto A. Rodriguez-Kastro K.I. Germani G. Ferrarese A. Cillo U. Burra P. et al.Mortality in liver transplant recipients with portal vein thrombosis - an updated meta-analysis.Transpl Int. 2018; 31: 1318-1329Crossref PubMed Scopus (9) Google Scholar found that postoperative mortality was higher (27%) in patients with grade 4 (Yerdel) PVT in the 10 studies that reported on mortality by grade of PVT. One-year mortality was also higher in patients with complete (42%) compared to partial (22%) PVT in 3 studies. Meanwhile, previous studies have shown that even in higher grades of PVT, if it is possible to achieve a porto-portal anastomosis, there is no major impact on post-LT survival.9Ravaioli M. Zanello M. Grazi G.L. Ercolani G. Cescon M. Del Gaudio M. et al.Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna.Ann Surg. 2011; 253: 378-384Crossref PubMed Scopus (52) Google Scholar, 10Chen H. Turon F. Hernández-Gea V. Fuster J. Garcia-Criado A. Barrufet M. et al.Nontumoral portal vein thrombosis in patients awaiting liver transplantation.Liver Transpl. 2016; 22: 352-365Crossref PubMed Scopus (56) Google Scholar With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based (site and extent), to also incorporating functional parameters (presence of symptomatic portal hypertension [PHT] or a portal cavernoma), which may aid in decision-making with regards to the medical management of these patients (role of transjugular intrahepatic portosystemic shunt [TIPS], variceal ligation, embolisation of spontaneous portosystemic shunts etc.).11European Association for the Study of the Liver EASL Clinical Practice Guidelines: Vascular diseases of the liver.J Hepatol. 2016; 64: 179-202Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar, 12Sarin S.K. Philips C.A. Kamath P.S. Choudhury A. Maruyama H. Nery F.G. et al.Toward a comprehensive new classification of portal vein thrombosis in patients with cirrhosis.Gastroenterology. 2016; 151 (e573): 574-577Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar None of the 9 currently proposed classifications12Sarin S.K. Philips C.A. Kamath P.S. Choudhury A. Maruyama H. Nery F.G. et al.Toward a comprehensive new classification of portal vein thrombosis in patients with cirrhosis.Gastroenterology. 2016; 151 (e573): 574-577Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 13Stieber A.C. Zetti G. Todo S. Tzakis A.G. Fung J.J. Marino I. et al.The spectrum of portal vein thrombosis in liver transplantation.Ann Surg. 1991; 213: 199-206Crossref PubMed Google Scholar, 14Nonami T. Yokoyama I. Iwatsuki S. Starzl T.E. The incidence of portal vein thrombosis at liver transplantation.Hepatology. 1992; 16: 1195-1198Crossref PubMed Google Scholar, 15Gayowski T.J. Marino I.R. Doyle H.R. Echeverri L. Mieles L. Todo S. et al.A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation.J Surg Res. 1996; 60: 333-338Abstract Full Text PDF PubMed Scopus (0) Google Scholar, 16Yerdel M.A. Gunson B. Mirza D. Karayalçin K. Olliff S. Buckels J. et al.Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome.Transplantation. 2000; 69: 1873-1881Crossref PubMed Google Scholar, 17Jamieson N.V. Changing perspectives in portal vein thrombosis and liver transplantation.Transplantation. 2000; 69: 1772-1774Crossref PubMed Google Scholar, 18Charco R. Fuster J. Fondevila C. Ferrer J. Mans E. García-Valdecasas J.C. Portal vein thrombosis in liver transplantation.Transplant Proc. 2005; 37: 3904-3905Crossref PubMed Scopus (0) Google Scholar, 19Bauer J. Johnson S. Durham J. Ludkowski M. Trotter J. Bak T. et al.The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis.Liver Transpl. 2006; 12: 1544-1551Crossref PubMed Scopus (58) Google Scholar, 20Ma J. Yan Z. Luo J. Liu Q. Wang J. Qiu S. Rational classification of portal vein thrombosis and its clinical significance.PLoS ONE. 2014; 9e112501Crossref PubMed Scopus (7) Google Scholar are directed towards decision-making, regarding the choice of inflow to the graft during LT. Though the functional classification proposed by Sarin et al.[12]Sarin S.K. Philips C.A. Kamath P.S. Choudhury A. Maruyama H. Nery F.G. et al.Toward a comprehensive new classification of portal vein thrombosis in patients with cirrhosis.Gastroenterology. 2016; 151 (e573): 574-577Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar has incorporated thrombus and patient characteristics, it does not allude to the pre-transplant approach towards ensuring portal vein patency for eventual porto-portal anastomoses in these patients.Key pointPrevalence of non-malignant PVT in cirrhotic patients ranges from 5% to 26% at the time of LT. Prevalence of non-malignant PVT in cirrhotic patients ranges from 5% to 26% at the time of LT. This study is a scoping review of the English-language literature on the currently available classifications of PVT (their usefulness and limitations in defining surgical strategy during LT), and methods described for portal inflow to the graft during LT in the case of diffuse PVT (with their associated outcomes). Since the body of evidence on this topic is complex, and suffers from heterogeneity, a precise systematic review is not possible. Also, the surgical options, and an algorithmic approach to surgical management during LT in cases of “complex PVT”, as defined here, have not been comprehensively reviewed before. This review tries to consolidate the current evidence available on the management of diffuse PVT in the liver transplant setting, as well as mapping out the results achieved to date. We have also tried to clarify the concept of physiological vs. non-physiological inflow reconstruction, and proposed a new algorithm for the surgical strategy during transplant, which could provide portal inflow to the graft together with control of prehepatic PHT whenever feasible. Nine classification systems have been proposed to grade non-tumoral PVT12Sarin S.K. Philips C.A. Kamath P.S. Choudhury A. Maruyama H. Nery F.G. et al.Toward a comprehensive new classification of portal vein thrombosis in patients with cirrhosis.Gastroenterology. 2016; 151 (e573): 574-577Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 13Stieber A.C. Zetti G. Todo S. Tzakis A.G. Fung J.J. Marino I. et al.The spectrum of portal vein thrombosis in liver transplantation.Ann Surg. 1991; 213: 199-206Crossref PubMed Google Scholar, 14Nonami T. Yokoyama I. Iwatsuki S. Starzl T.E. The incidence of portal vein thrombosis at liver transplantation.Hepatology. 1992; 16: 1195-1198Crossref PubMed Google Scholar, 15Gayowski T.J. Marino I.R. Doyle H.R. Echeverri L. Mieles L. Todo S. et al.A high incidence of native portal vein thrombosis in veterans undergoing liver transplantation.J Surg Res. 1996; 60: 333-338Abstract Full Text PDF PubMed Scopus (0) Google Scholar, 16Yerdel M.A. Gunson B. Mirza D. Karayalçin K. Olliff S. Buckels J. et al.Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome.Transplantation. 2000; 69: 1873-1881Crossref PubMed Google Scholar, 17Jamieson N.V. Changing perspectives in portal vein thrombosis and liver transplantation.Transplantation. 2000; 69: 1772-1774Crossref PubMed Google Scholar, 18Charco R. Fuster J. Fondevila C. Ferrer J. Mans E. García-Valdecasas J.C. Portal vein thrombosis in liver transplantation.Transplant Proc. 2005; 37: 3904-3905Crossref PubMed Scopus (0) Google Scholar, 19Bauer J. Johnson S. Durham J. Ludkowski M. Trotter J. Bak T. et al.The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis.Liver Transpl. 2006; 12: 1544-1551Crossref PubMed Scopus (58) Google Scholar, 20Ma J. Yan Z. Luo J. Liu Q. Wang J. Qiu S. Rational classification of portal vein thrombosis and its clinical significance.PLoS ONE. 2014; 9e112501Crossref PubMed Scopus (7) Google Scholar (Table S1). All but one[12]Sarin S.K. Philips C.A. Kamath P.S. Choudhury A. Maruyama H. Nery F.G. et al.Toward a comprehensive new classification of portal vein thrombosis in patients with cirrhosis.Gastroenterology. 2016; 151 (e573): 574-577Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar include 4 grades, and there is no one grade common to all classification systems. Some include grades pertaining to thrombosis of intrahepatic portal vein branches without portal trunk thrombosis. These grades have limited value, if any, in the setting of LT, because the native liver, together with the thrombosed portal vein branches, will be removed in its entirety during LT. So far, the Yerdel,[16]Yerdel M.A. Gunson B. Mirza D. Karayalçin K. Olliff S. Buckels J. et al.Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome.Transplantation. 2000; 69: 1873-1881Crossref PubMed Google Scholar Jamieson,[17]Jamieson N.V. Changing perspectives in portal vein thrombosis and liver transplantation.Transplantation. 2000; 69: 1772-1774Crossref PubMed Google Scholar and Charco[18]Charco R. Fuster J. Fondevila C. Ferrer J. Mans E. García-Valdecasas J.C. Portal vein thrombosis in liver transplantation.Transplant Proc. 2005; 37: 3904-3905Crossref PubMed Scopus (0) Google Scholar grading systems are best at describing a correlation between the extent of thrombosis and surgical management at the time of LT. In Yerdel’s classification,[16]Yerdel M.A. Gunson B. Mirza D. Karayalçin K. Olliff S. Buckels J. et al.Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome.Transplantation. 2000; 69: 1873-1881Crossref PubMed Google Scholar grade 4 PVT denotes complete splanchnic vein thrombosis, including thrombosis of the portal vein and proximal superior mesenteric vein (SMV) and splenic vein. The surgical decisiveness of this classification is limited because it does not consider the coexistence of large spontaneous or surgical shunts that could be used for portal inflow reconstruction. The Jamieson[17]Jamieson N.V. Changing perspectives in portal vein thrombosis and liver transplantation.Transplantation. 2000; 69: 1772-1774Crossref PubMed Google Scholar and Charco[18]Charco R. Fuster J. Fondevila C. Ferrer J. Mans E. García-Valdecasas J.C. Portal vein thrombosis in liver transplantation.Transplant Proc. 2005; 37: 3904-3905Crossref PubMed Scopus (0) Google Scholar classification systems aim to define the complete or partial nature of thrombosis, denote the extent of thrombosis along the portal system, and account for the existence of large portosystemic collaterals. In both classification systems, grade 3 is defined as diffuse thrombosis of the splanchnic venous system with large accessible collaterals, whereas grade 4 includes extensive thrombosis of the splanchnic venous system with only fine collaterals. To define the surgical strategy for LT, group Yerdel grade 4 and Jamieson and Charco grades 3 and 4 PVT can be grouped together as “complex PVT” because the technical strategy for portal inflow reconstruction would be similar. In the same vein, we propose to classify less severe PVT (Yerdel grade 1-3 PVT) as “non-complex PVT”. These patients have partial or complete thrombosis limited to the portal vein trunk and/or the very distal part of the splenic vein and/or the SMV. Due to technical improvements, this can be resolved during LT using surgical thrombectomy, with standard porto-portal reconstruction, or an interposition vein graft from the SMV to the graft portal vein. Optimal outcomes with these approaches have been reported extensively and will not be discussed here.21Peters M.D. Godfrey C.M. Khalil H. McInerney P. Parker D. Soares C.B. Guidance for conducting systematic scoping reviews.Int J Evid Based Healthc. 2015; 13: 141-146Crossref PubMed Scopus (574) Google Scholar, 22Orlando G. De Luca L. Toti L. Zazza S. Angelico M. Casciani C.U. et al.Liver transplantation in the presence of portal vein thrombosis: report from a single center.Transplant Proc. 2004; 36: 199-202Crossref PubMed Scopus (0) Google Scholar, 23Robles R. Fernandez J.A. Hernández Q. Marín C. Ramírez P. Sánchez-Bueno F. et al.Eversion thromboendovenectomy in organized portal vein thrombosis during liver transplantation.Clin Transplant. 2004; 18: 79-84Crossref PubMed Scopus (0) Google Scholar, 24Miura K. Sugawara Y. Uchida K. Kawabata S. Yoshii D. Isono K. et al.Adult living donor liver transplantation for patients with portal vein thrombosis: a single-center experience.Transplant Direct. 2018; 4e341Crossref PubMed Scopus (1) Google Scholar, 25Koh P.S. Chan S.C. Chok K.S. Sharr W.W. Wong T.C. Sin S.L. et al.The friendly incidental portal vein thrombus in liver transplantation.Liver Transpl. 2015; 21: 944-952Crossref PubMed Scopus (7) Google Scholar, 26Levi Sandri G.B. Lai Q. Berloco P.B. Rossi M. Portal vein thrombosis before liver transplant does not alter postoperative patient or graft survival.Exp Clin Transplant. 2014; 12: 238-240PubMed Google ScholarKey point“Complex PVT” has been defined in the proposed novel classification as grade 4 (Yerdel), and Grades 3 and 4 (Jamieson and Charco’s classifications). “Complex PVT” has been defined in the proposed novel classification as grade 4 (Yerdel), and Grades 3 and 4 (Jamieson and Charco’s classifications). Published studies (1998–2017, over 2 decades) reporting on the initial diagnosis of PVT, prevalence, and grade of PVT at the time of LT (single centre series only) were reviewed. A total of 28 studies reported on a total of 19,325 cirrhotic patients (Table S2).16Yerdel M.A. Gunson B. Mirza D. Karayalçin K. Olliff S. Buckels J. et al.Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome.Transplantation. 2000; 69: 1873-1881Crossref PubMed Google Scholar, 27Manzanet G. Sanjuán F. Orbis P. López R. Moya A. Juan M. et al.Liver transplantation in patients with portal vein thrombosis.Liver Transpl. 2001; 7: 125-131Crossref PubMed Scopus (142) Google Scholar, 28Molmenti E.P. Roodhouse T.W. Molmenti H. Jaiswal K. Jung G. Marubashi S. et al.Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation.Ann Surg. 2002; 235: 292-296Crossref PubMed Scopus (109) Google Scholar, 29Gimeno F.A. Calvo J. Loinaz C. Meneu J.C. Pérez B. Gomez R. et al.Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis.Transplant Proc. 2005; 37: 3899-3903Crossref PubMed Scopus (0) Google Scholar, 30Bertelli R. Nardo B. Montalti R. Beltempo P. Puviani L. Cavallari A. Liver transplantation in recipients with portal vein thrombosis: experience of a single transplant center.Transplant Proc. 2005; 37: 1119-1121Crossref PubMed Scopus (34) Google Scholar, 31Gómez-Gutierrez M. Quintela J. Marini M. Gala B. Suarez F. Cao I. et al.Portal vein thrombosis in patients undergoing orthotopic liver transplantation: intraoperative endovascular radiological procedures.Transplant Proc. 2005; 37: 3906-3908Crossref PubMed Scopus (0) Google Scholar, 32Egawa H. Tanaka K. Kasahara M. Takada Y. Oike F. Ogawa K. et al.Single center experience of 39 patients with preoperative portal vein thrombosis among 404 adult living donor liver transplantations.Liver Transpl. 2006; 12: 1512-1518Crossref PubMed Scopus (61) Google Scholar, 33Lendoire J. Raffin G. Cejas N. Duek F. Barros Schelotto P. Trigo P. et al.Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome.HPB (Oxford). 2007; 9: 352-356Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 34Lladó L. Fabregat J. Castellote J. Ramos E. Torras J. Jorba R. et al.Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality.Clin Transplant. 2007; 21: 716-721PubMed Google Scholar, 35Arcadipane A. Nadalin S. Gruttadauria S. Panarello G. Burgio G. Vizzini G. et al.The recipient with portal thrombosis and/or previous surgery.Transplant Proc. 2008; 40: 1183-1186Crossref PubMed Scopus (0) Google Scholar, 36Cho J.Y. Suh K.S. Shin W.Y. Lee H.W. Yi N.J. Lee K.U. Thrombosis confined to the portal vein is not a contraindication for living donor liver transplantation.World J Surg. 2008; 32: 1731-1737Crossref PubMed Scopus (0) Google Scholar, 37Tao Y.F. Teng F. Wang Z.X. Guo W.Y. Shi X.M. Wang G.H. et al.Liver transplant recipients with portal vein thrombosis: a single center retrospective study.Hepatobiliary Pancreat Dis Int. 2009; 8: 34-39PubMed Google Scholar, 38Pan C. Shi Y. Zhang J.J. Deng Y.L. Zheng H. Zhu Z.J. et al.Single-center experience of 253 portal vein thrombosis patients undergoing liver transplantation in China.Transplant Proc. 2009; 41: 3761-3765Crossref PubMed Scopus (43) Google Scholar, 39Doenecke A. Tsui T.Y. Zuelke C. Scherer M.N. Schnitzbauer A.A. Schlitt H.J. et al.Pre-existent portal vein thrombosis in liver transplantation: influence of pre-operative disease severity.Clin Transplant. 2010; 24: 48-55Crossref PubMed Scopus (0) Google Scholar, 40Ramos A.P. Reigada C.P. Ataíde E.C. Almeida J.R. Cardoso A.R. Caruy C.A. et al.Portal vein thrombosis and liver transplantation: long term.Transplant Proc. 2010; 42: 498-501Crossref PubMed Scopus (0) Google Scholar, 41Shi Z. Yan L. Zhao J. Li B. Wen T. Xu M. et al.Prevention and treatment of rethrombosis after liver transplantation with an implantable pump of the portal vein.Liver Transpl. 2010; 16: 324-331Crossref PubMed Scopus (0) Google Scholar, 42Sharma R. Kashyap R. Jain A. Safadjou S. Graham M. Dwivedi A.K. et al.Surgical complications following liver transplantation in patients with portal vein thrombosis–a single-center perspective.J Gastrointest Surg. 2010; 14: 520-527Crossref PubMed Scopus (0) Google Scholar, 43Suarez Artacho G. Barrera Pulido L. Alamo Martinez J.M. Serrano Diez-Canedo J. Bernal Bellido C. Marín Gomez L.M. et al.Outcomes of liver transplantation in candidates with portal vein thrombosis.Transplant Proc. 2010; 42: 3156-3158Crossref PubMed Scopus (0) Google Scholar, 9Ravaioli M. Zanello M. Grazi G.L. Ercolani G. Cescon M. Del Gaudio M. et al.Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna.Ann Surg. 2011; 253: 378-384Crossref PubMed Scopus (52) Google Scholar, 44Bhangui P. Lim C. Salloum C. Andreani P. Sebbagh M. Hoti E. et al.Caval inflow to the graft for liver transplantation in patients with diffuse portal vein thrombosis: a 12-year experience.Ann Surg. 2011; 254: 1008-1016Crossref PubMed Scopus (41) Google Scholar, 45Kim J.D. Choi D.L. Han Y.S. An early single-center experience of portal vein thrombosis in living donor liver transplantation: clinical feature, management and outcome.J Korean Surg Soc. 2011; 81: 35-42Crossref PubMed Scopus (7) Google Scholar, 46Moon D.B. Lee S.G. Ahn C.S. Hwang S. Kim K.H. Ha T.Y. et al.Restoration of portal flow using a pericholedochal varix in adult living donor liver transplantation for patients with total portosplenomesenteric thrombosis.Liver Transpl. 2014; 20: 612-615Crossref PubMed Scopus (9) Google Scholar, 47Hibi T. Nishida S. Levi D.M. Selvaggi G. Tekin A. Fan J. et al.When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases.Ann Surg. 2014; 259: 760-766Crossref PubMed Scopus (64) Google Scholar, 48Hernández Conde M. Llop Herrera E. de la Revilla Negro J Pons Renedo F. Fernández Puga N. Martínez Porras J.L. et al.Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation.Rev Esp Enferm Dig. 2016; 108: 716-720Crossref PubMed Scopus (6) Google Scholar, 49Aktas H. Ozer A. Guner O.S. Gurluler E. Emiroglu R. Liver transplantation in patients with complete portal vein thrombosis: renoportal or varicoportal anastomosis using cryopreserved vein grafts.Transplant Proc. 2017; 49: 1820-1823Crossref PubMed Google Scholar The prevalence of non-tumoral PVT at LT was 5% to 26%, and the prevalence of complex PVT, as defined here, would range from 0% (9/27 analysable series) to 2.2%. The prevalence of non-tumoral PVT at LT may be falsely low because, up until the last decade, many LT teams around the world considered it a contraindication for LT, and hence LT in these patients was refused. In a systematic review of PVT in the transplant population, Rodríguez-Castro et al.[50]Rodríguez-Castro K.I. Porte R.J. Nadal E. Germani G. Burra P. Senzolo M. Management of nonneoplastic portal vein thrombosis in the setting of liver transplantation: a systematic review.Transplantation. 2012; 94: 1145-1153Crossref PubMed Scopus (105) Google Scholar analysed 41 studies published from 1986 to 2012 (25,753 patients) and found a 14.6% incidence of Yerdel grade 4 PVT (104/713 PVT cases), representing 2.8% of all LTs. The presence of large usable portosystemic shunts (spontaneous or surgical) was not analysed in either study. Similarly, 2 reviews based on the Organ Procurement and Transplant Network waitlist and first LT found that the prevalence of PVT at LT was between 6.8% and 8.7%.4Ghabril M. Agarwal S. Lacerda M. Chalasani N. Kwo P. Tector A.J. Portal Vein Thrombosis Is a Risk Factor for Poor Early Outcomes After Liver Transplantation: Analysis of Risk Factors and Outcomes for Portal Vein Thrombosis in Waitlisted Patients.Transplantation. 2016; 100: 126-133Crossref PubMed Scopus (46) Google Scholar, 51Montenovo M. Rahnemai-Azar A. Reyes J. Perkins J. Clinical Impact and Risk Factors of Portal Vein Thrombosis for Patients on Wait List for Liver Transplant.Exp Clin Transplant. 2018; 16: 166-171PubMed Google Scholar The grade of PVT and the presence of shunts were not detailed in either review.Key pointIn complex PVT, portal reconstruction can be considered “physiological” when the splanchnic blood is somehow redirected to the graft, thus resolving the pre-existing PHT. In complex PVT, portal reconstruction can be considered “physiological” when the splanchnic blood is somehow redirected to the graft, thus resolving the pre-existing PHT. In an audit of 174 cases of non-tumoral PVT at LT, Hibi et al.[47]Hibi T. Nishida S. Levi D.M. Selvaggi G. Tekin A. Fan J. et al.When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases.Ann Surg. 2014; 259: 760-766Crossref PubMed Scopus (64) Google Scholar defined portal inflow reconstruction as non-physiological when porto-portal anastomosis could not be performed. According to that definition, inflow achieved by renoportal anastomosis (RPA), cavoportal hemitransposition, or portal vein arterialisation (see below) would all be types of non-physiological portal flow reconstruction. They also defined the terms anatomical and non-anatomical to denote the use of interposed grafts for portal inflow reconstruction. From a functional standpoint, we propose defining reconstruction of portal flow as physiological when the splanchnic venous blood (all or part of it) can be redirected to the liver graft. Hence, in addition to porto-portal anastomoses, reconstruction of physiological portal inflow is also possible by redirecting the blood flow from a large portosystemic shunt (spontaneous or surgical) to the graft, either by anastomosis of the shunt to the graft portal vein, or anastomosis of the tributary of the inferior vena cava (IVC), which drains this shunt, to the graft portal vein. This dichotomy is important because physiological portal flow reconstruction, as defined by us, should solve the problem of pre-existing prehepatic PHT due to PVT, either immediately or in the short/mid-term after LT. This is contrary to non-physiological portal flow reconstruction in which PHT persists, or even worsens following LT. Furthermore, it could be better to clearly specify whether the reconstruction requires an interposed biological or synthetic graft, rather than using the misleading terms anatomical and non-anatomical to denote this.Key pointDiligent management of PHT before, and after LT is key. Diligent management of PHT before, and after LT is key. Subsequently, we can consider that portal inflow reconstruction for non-complex PVT (as defined above) is always physiological. For patients with complex PVT, the available options for portal inflow reconstructions are dichotomised into physiological or non-physiological as follows. The prevalence of large spontaneous portosystemic shunts in patie" @default.
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• W2969608800 date "2019-11-01" @default.
• W2969608800 modified "2023-10-18" @default.
• W2969608800 title "Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation" @default.
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