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Preoperative coronal computed tomography scan at 4months prior to liver transplantation. The PV trunk (arrows) was sclerotic and narrowed. A huge mesenteric-caval shunt (*) originating from the inferior mesenteric vein directly drained into the infra-renal IVC. PV, portal vein; SMV, superior mesenteric vein; SpV, splenic vein; IVC, inferior vena cava.
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An enhanced computed tomography (CT) scan at 4 months prior to his DDLT showed a huge mesenteric-caval shunt originating from the inferior mesenteric vein (IMV) and directly draining into the infra-renal IVC (Fig. 1).
Intraoperative findings of the recipient. Ligation (arrow) of the dilated IMV-caval shunt (*).
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In addition to this PV interposition vein graft reconstruction, the dilated IMV collateral was ligated at the level of ligament of Treitz to obtain sufficient portal flow (Fig. 2).
Diagnosis of IVC thrombosis at postoperative day 1. (A) An ultrasound study showed thrombus (T) inside the infra-hepatic IVC. (B) A contrast-enhanced abdominal computed tomography scan showed a thrombus in the IVC that developed from a thrombus in the collateral vessel of the IMV (arrows). IVC, inferior vena cava.
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Immediate graft function was excellent, but a routine Doppler ultrasound study on post-operative day (POD) 1 showed thrombus inside the infra-hepatic IVC (Fig. 3A). A CT scan on POD 1 showed that this thrombus originated from the location of the ligated collateral vessel of the IMV (Fig. 3B).
Gradual resolution of IVC thrombus. The IVC thrombus (arrow heads) was slowly minimized with anticoagulant therapy, although it still remained. Hepatic and renal veins were consistently patent. IVC, inferior vena cava; LRV, left renal vein; POD, post-operative day.
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The size of IVC thrombus was slowly reduced with long-time warfarin administration, but complete dissolve of the thrombus was not achieved so far (Fig. 4).