Name: New Thrombectomy Technique for Total Portal Vein Thrombosis in Liver Transplantation (Video) | JoVE Journal
Uploaded: 2025-06-27T14:30:00.000+00:00
Duration: 8 min 45 s
Description: Learn a new thrombectomy technique for portal vein thrombosis in liver transplantation using circular incision and vessel loop stabilization. This method enables complete thrombus removal without fragmentation, improving surgical outcomes.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

The authors have no acknowledgments.

The patients provided written informed consent for the operation and the use of medical data for scientific purposes. This research was performed in compliance with the Declaration of Helsinki and was approved by the local Institution&#39;s Human Research Ethics Committee and the Institutional Review Board. For the protocol presentation and explanation, we present two case reports of Grade II PVT that were managed with a novel thrombectomy technique.
1. Preoperative procedure
<ol>
	<li>Prohibit the patient from eating and drinking 8 h before the surgery.</li>
	<li>Use tracheal intubation under general anesthesia. Place a central venous catheter, a Swan-Ganz catheter, and an intra-arterial pressure catheter.</li>
	<li>Sterilize the skin with a 2% Clorhexidine-based scrub. Place sterile towels on the inter-nipple connection, symphysis pubis, right midaxillary, and left midclavicular lines.</li>
</ol>
2. Surgery
<ol>
	<li>Realize an inverted Makuuchi incision and liberate the liver from all the ligaments. Start the dissection of the hepatic hilum and ligation of the hepatic artery and common bile duct, isolate the portal vein in the hepatic pedicle, and individualize the right and left hepatic veins.</li>
	<li>Continue isolating the portal vein, ligating all the collaterals caudally as possible until the left gastric vein or even the retro-pancreatic portion of the vein is reached.</li>
	<li>Once the portal vein is isolated, apply a German clamp or ligate the right and left portal veins, stabilizing the thrombus within the vein to allow a more controlled and easier thrombectomy (Figure 3A). 
	NOTE: The traditional technique involves cutting the vein alongside the thrombus.</li>
	<li>Pass a vessel loop twice as a tourniquet as caudally as possible for better hemostatic control and to avoid excessive bleeding during the thrombectomy.</li>
	<li>With vascular control of the vein established, perform incision in a circular fashion in the portal vein without rupturing the thrombus (Figure 3B). It is important to perform this step with gentle movements.</li>
	<li>Once the thrombus is completely separated from the vein at the incision site, proceed with the thrombectomy by caudally everting the portal vein wall with anatomical forceps (Figure 3C).</li>
	<li>In areas where the thrombus is firmly attached to the vein, make small incisions in the adhesions or use a small periosteal dissector to separate the thrombus from the vein wall.</li>
	<li>After completely liberating the thrombus from the portal vein, carefully remove it, securing the vessel loop gently to prevent bleeding from the portal flow (Figure 3D). 
	NOTE: Using this technique, the thrombus remains attached to the native liver (Figure 4).</li>
	<li>Perform thrombectomy
	<ol>
		<li>Apply a portal clamp above the vessel loop, which is subsequently removed. The portal flow is tested, and the transplantation procedure continues with total hepatectomy using the piggyback technique.</li>
		<li>Perform the implantation of the new liver with end-to-end anastomosis of the portal vein, hepatic artery, and common bile duct.</li>
		<li>Place a Jackson-Pratt drain in the hepatic hilum. Close the incisions with polypropylene suture 0 for aponeurosis, polyglactin suture 2-0 for deep cellular tissue, and nylon suture 3-0 for the skin.</li>
	</ol>
	</li>
</ol>
3. Post-operative procedure
<ol>
	<li>Remove the nasogastric tube the day after the operation. Start a liquid enteric diet and expand to a normal diet in 3 days.</li>
	<li>On postoperative day 1, begin with Tacrolimus and a high dose of Prednisone. Also, perform Doppler Ultrasound of the transplanted liver to identify the portal and arterial flow. Remove the orotracheal tube, if permitted.</li>
	<li>On postoperative day 3, remove all the catheters and change to peripheral access.</li>
	<li>On postoperative day 4, discharge the patient from the ICU.</li>
	<li>Perform a blood routine examination, tacrolimus dosage, and blood biochemistry examination daily, to assess postoperative control of the transplanted liver.</li>
	<li>On postoperative day 10, discharge the patient from the hospital.</li>
</ol>

<ol><li>Pécora, R. A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Portal+vein+thrombosis+in+liver+transplantation%5BTitle%5D)+AND+%22Arq+Bras+Cir+Dig%22%5BJournal%5D)">Portal vein thrombosis in liver transplantation.</a> Arq Bras Cir Dig. 25 (4), 273-278 (2012).</li>
<li>Chawla, Y. K., Bodh, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Portal+vein+thrombosis%5BTitle%5D)+AND+%22J+Clin+Exp+Hepatol%22%5BJournal%5D)">Portal vein thrombosis.</a> J Clin Exp Hepatol. 5 (1), 22-40 (2015).</li>
<li>Bhangui, P., Fernandes, E. S. M., Di Benedetto, F., Joo, D. J., Nadalin, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+management+of+portal+vein+thrombosis+in+liver+transplantation%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Current management of portal vein thrombosis in liver transplantation.</a> Int J Surg. 82S, 122-127 (2020).</li>
<li>Di Benedetto, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Portal+vein+thrombosis+and+liver+transplantation%3A+management%2C+matching%2C+and+outcomes.+A+retrospective+multicenter+cohort+study%5BTitle%5D)+AND+%22Int+J+Surg%22%5BJournal%5D)">Portal vein thrombosis and liver transplantation: management, matching, and outcomes. A retrospective multicenter cohort study.</a> Int J Surg. 110 (5), 2874-2882 (2024).</li>
<li>Nacif, L. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Portal+vein+surgical+treatment+on+non-tumoral+portal+vein+thrombosis+in+liver+transplantation%3A+Systematic+Review+and+Meta-Analysis%5BTitle%5D)+AND+%22Clinics+%28Sao+Paulo%29%22%5BJournal%5D)">Portal vein surgical treatment on non-tumoral portal vein thrombosis in liver transplantation: Systematic Review and Meta-Analysis.</a> Clinics (Sao Paulo). 76, e2184(2021).</li>
<li>Bagheri Lankarani, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Outcome+of+liver+transplant+patients+with+intraoperative-detected+portal+vein+thrombosis%3A+A+retrospective+cohort+study+in+Shiraz%2C+Iran%5BTitle%5D)+AND+%22Exp+Clin+Transplant%22%5BJournal%5D)">Outcome of liver transplant patients with intraoperative-detected portal vein thrombosis: A retrospective cohort study in Shiraz, Iran.</a> Exp Clin Transplant. 19 (4), 324-330 (2021).</li>
<li>Rizzari, M. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+impact+of+portal+vein+thrombosis+on+liver+transplant+outcomes%3A+Does+grade+or+flow+rate+matter%5BTitle%5D)+AND+%22Transplantation%22%5BJournal%5D)">The impact of portal vein thrombosis on liver transplant outcomes: Does grade or flow rate matter.</a> Transplantation. 105 (2), 363-371 (2021).</li>
<li>Fundora, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Alternative+forms+of+portal+vein+revascularization+in+liver+transplant+recipients+with+complex+portal+vein+thrombosis%5BTitle%5D)+AND+%22J+Hepatol%22%5BJournal%5D)">Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis.</a> J Hepatol. 78 (4), 794-804 (2023).</li>
<li>Yeo, J. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Meta-analysis+and+systematic+review%3A+Prevalence%2C+graft+failure%2C+mortality%2C+and+post-operative+thrombosis+in+liver+transplant+recipients+with+pre-operative+portal+vein+thrombosis%5BTitle%5D)+AND+%22Clin+Transplant%22%5BJournal%5D)">Meta-analysis and systematic review: Prevalence, graft failure, mortality, and post-operative thrombosis in liver transplant recipients with pre-operative portal vein thrombosis.</a> Clin Transplant. 36 (2), e14520(2022).</li>
<li>Harding, D. J., Perera, M. T., Chen, F., Olliff, S., Tripathi, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Portal+vein+thrombosis+in+cirrhosis%3A+Controversies+and+latest+developments%5BTitle%5D)+AND+%22World+J+Gastroenterol%22%5BJournal%5D)">Portal vein thrombosis in cirrhosis: Controversies and latest developments.</a> World J Gastroenterol. 21 (22), 6769-6784 (2015).</li>
<li>Martino, R. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+case+of+left+renal+vein+ligation+in+a+patient+with+solitary+left+kidney+undergoing+liver+transplantation+to+control+splenorenal+shunt+and+improve+portal+venous+flow%5BTitle%5D)+AND+%22Am+J+Case+Rep%22%5BJournal%5D)">A case of left renal vein ligation in a patient with solitary left kidney undergoing liver transplantation to control splenorenal shunt and improve portal venous flow.</a> Am J Case Rep. 18, 1086-1089 (2017).</li>
<li>Pinheiro, R. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Successful+liver+allograft+inflow+reconstruction+with+the+right+gastroepiploic+vein%5BTitle%5D)+AND+%22Hepatobiliary+Pancreat+Dis+Int%22%5BJournal%5D)">Successful liver allograft inflow reconstruction with the right gastroepiploic vein.</a> Hepatobiliary Pancreat Dis Int. 15 (1), 106-107 (2016).</li>
</ol>

The authors don't have any conflict of interest.

Portal vein thrombosis is a significant and important complication in patients requiring liver transplantation7. For cases with a thrombus that occludes the total lumen of the vein, it is often challenging to perform thrombectomy, especially in cases of chronic thrombosis with fibrotic changes in the vessel and thrombus partially or totally adhered to the vessel wall6,8. Additionally, complications of traditional thrombectomy techniques in...

The portal vein is a crucial structure in the body, transporting approximately 75% of the blood to the liver from the gastrointestinal tract and spleen1. In patients with advanced liver diseases, portal vein thrombosis may develop, consisting of the formation of clots within the vein, obstructing the blood flow2. Portal vein thrombosis (PVT) is a complex complication that poses a significant challenge during liver transplantation3. To ensure optimal graft and patient survival, it is essential to maintain good portal inflow1,3.
Portal Vein Thrombosis can be classified as acute or chronic and categorized based on the extent of vein involvement4. Among the numerous PVT categorizations, the Yerdel Classification is often used to guide surgical approaches in liver transplantation (Table 1)4. It consists of four categories: restricted to the main portal vein trunk and affecting less than 50% of its lumen; Grade 1 with more than 50% of occluded lumen, including complete obstruction of the main portal vein trunk; complete obstruction of the portal vein and proximal portion of the superior mesenteric vein; entire venous splanchnic system thrombosis with development of large or small collaterals3,4.
Intraoperatively, Yerdel Grade I/II or early PVT can be managed with a simple thrombectomy (cutting of the vein and the thrombus together with eversion of the vein wall and removal of the thrombus with the aid of a needle holder), or even a thromboendovenectomy (resection of the affected part of the vein with the thrombus)1,5. However, complications with these two techniques (traditional thrombectomy and thromboendovenectomy) include thrombus fragmentation, incomplete removal, or vein injury in anatomically challenging positions, such as the retro-pancreatic portion of the portal vein5.
Yerdel Grade III PVT may require other techniques such as a jump graft from the superior mesenteric vein or splenic vein2. It is important to remember that varices often have thin walls, making them difficult to handle during anastomosis2,6. For a jump graft from the superior mesenteric vein, first we must pass the venous graft obtained from the cadaver donor through the transverse mesocolon and place it anatomically straight in the direction of the portal vein to avoid compression or kinking6. After that, the superior mesenteric vein is isolated for better vascular control. After clamping the vein, an end-to-side anastomosis of the superior mesenteric vein and venous graft is performed5. The surgery is then completed with an end-to-end anastomosis of the venous graft and portal vein of the liver graft6.
Grade IV presents a significant challenge, depending on the presence of portosystemic shunts, enlarged left gastric vein, or pericholedochal varices3,6. The best options include a reno-portal anastomosis if a large splenorenal shunt is present or a direct anastomosis between the graft and an enlarged collateral vein4. In cases where an adequate portal inflow cannot be obtained with these measures, a multivisceral transplant may be the best option6.
This new technique ensures less risk for thrombus fragmentation, incomplete removal, or vein injury5. Delicately performing this technique can guarantee an integral removal of the thrombus in selected cases, so we developed this new type of thrombectomy6.
Two cases of Grade II portal vein thrombosis are presented in which a new technique for thrombectomy was utilized.
Case 1: A 64-year-old man presented with a diagnosis of cirrhosis of the liver with hepatocellular carcinoma. As a complication of the liver disease, he presented with liver encephalopathy and ascites. The patient had a history of heavy drinking that led to cirrhosis. Laboratory examinations revealed a MELD-Na (Model of End-Stage Liver Disease-Sodium) Score of 17 and CHILD-PUGH Class C11. Triphasic dynamic contrast-enhanced abdominal computed tomography (CT) scan showed hematic thrombosis of the main trunk and of the right and left branches of the portal vein (Figure 1).
Case 2: A 37-year-old man presented with primary sclerosing cholangitis that led to cirrhosis. As a complication of the liver disease, he presented with acute-on-chronic liver failure, triggered by spontaneous bacterial peritonitis, leading to liver encephalopathy, ascites, and hepatorenal syndrome. Laboratory exams revealed a MELD-Na Score of 36 and CHILD-PUGH Class C11. Triphasic dynamic contrast-enhanced abdominal CT scan revealed chronic hematic thrombosis in the main trunk of the portal vein, extending to its intrahepatic branches, which were partially recanalized (Figure 2).

<table><tbody><tr><td>SILK 2-0 PRECUTTED</td><td>SHALON MEDICAL, USA.</td><td>W3410013</td><td>Synthetic non-absorbable Suture</td></tr><tr><td>PROLENE 5-0</td><td>ETHICON, USA.</td><td>W8556</td><td>Synthetic non-absorbable Suture</td></tr><tr><td>VESSEL LOOP</td><td>ASPEN SURGICAL PRODUCTS, USA.</td><td></td><td>Sterile Silicone</td></tr></tbody></table>

new thrombectomy technique for total portal vein thrombosis in liver transplantation

New Thrombectomy Technique for Total Portal Vein Thrombosis in Liver Transplantation

Portal vein thrombosis is present in approximately 5-16% of patients with end-stage liver disease who undergo liver transplantation. In this report, we describe a new surgical approach that has been established in our center. Two patients with total thrombosis of the main trunk of the portal vein have been treated currently. Briefly, the portal vein was dissected as caudally as needed to reach an area without thrombus and occlude its cranial portion near the liver. Incision of the portal vein was then performed without cutting the thrombus and by everting the portal vein wall, carefully liberating it from the thrombus until it was removed entirely and remained attached to the native liver. With this new thrombectomy technique, we achieved excellent portal flow in both cases, since the thrombus was not fractured and was entirely removed, leading to optimal reperfusion of the liver graft. Both patients underwent control abdominal CT scans days after the liver transplant, in which no residual thrombi and excellent portal flow in the graft were observed. This novel thrombectomy technique seems safe and feasible, although further experience is necessary to evaluate its long-term outcomes.

This new thrombectomy technique allowed a complete removal of the thrombus in both cases, resulting in excellent portal flow. An end-to-end portal-portal anastomosis could be performed, achieving quick and homogeneous reperfusion of the graft (Figure 5 and Figure 6). The total operative time was 600 min in Case 1 and 365 min in Case 2, with a transfusion of 3 units of packed red blood cells in each case. As a protocol of our hospital, we perform...

Portal vein thrombosis (PVT) is a frequent complication in patients with portal hypertension resulting from end-stage liver disease. In certain instances, PVT may be a contraindication for liver transplantation. We have developed a novel approach for managing PVT cases involving complete occlusion of the main trunk of the portal vein.

Portal vein thrombosis is present in approximately 5-16% of patients with end-stage liver disease who undergo liver transplantation. In this report, we ...

new-thrombectomy-technique-for-total-portal-vein-thrombosis-liver

Research

JoVE Journal

Medicine

This video describes a surgical procedure to deliver mammary tumor cells to the murine liver via portal vein injection. This model permits the investigation of late stages of liver metastasis.

Portal Vein Injection: A Method to Study Cancer Metastasis to the Liver

Auxiliary liver transplantation provides a temporary support in acute hepatic failure, until regeneration of the failing liver. The heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA) renders sufficient liver function. We developed an analogous technique in the rat, to examine the influence of the portal vein arterialization on the morphology and function of the graft.

Heterotopic Auxiliary Rat Liver Transplantation With Flow-regulated Portal Vein Arterialization in Acute Hepatic Failure

Experimental animal research plays a pivotal role in the development of clinical transplantation practice. The porcine orthotopic liver transplantation model (OLTx) closely resembles human conditions and is frequently used in clinically oriented research. The following protocol contains all information for a reliable porcine OLTx model using an active porto-caval-jugular shunt.

Technique of Porcine Liver Procurement and Orthotopic Transplantation using an Active Porto-Caval Shunt

Inducing rapid liver hypertrophy using Associating Liver Partition and Portal vein ligation for a Staged hepatectomy (ALPPS) has been proposed for resection of borderline resectable liver tumors. This model may elucidate mechanisms involved in rapid hypertrophy and allows testing of drugs that promote or block the acceleration of regeneration.

Rat Model of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure

Here, a protocol involving re-arterialized rat partial liver transplantation is presented. Specifically, 70% liver was resected in vivo by using an updated technique of vessel-oriented hepatectomy. The hepatic artery was reconstructed in an end-to-side manner. The cuff technique was modified to shorten the anastomosis time of the infrahepatic vena cava.

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

We establish a novel surgical technique for an in vivo single liver lobe perfusion model in rat as a prerequisite for further studying in vivo partial liver engineering in the future.

A Novel Surgical Technique As a Foundation for In Vivo Partial Liver Engineering in Rat

Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has been shown to result in remarkable liver regeneration after several weeks post first-stage surgery. Animal models that have undergone ALPPS have been developed to explore potential liver regeneration ability and achieve favorable clinical outcomes.

A Mouse Model of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Procedure Aided by Microscopy

Laparoscopic left lateral sectionectomy guided by the ligamentum teres hepatis and umbilical fissure vein effectively controls intraoperative bleeding even without controlled low central venous pressure and prevents loss of direction during parenchymal dissection.

Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein

We present a laparoscopic technique for anatomic S7+S8d resection with right hepatic vein transection, preserving the inferior right hepatic vein and segment S6. Relying on meticulous anatomical landmarks without intraoperative ultrasound, this approach offers a precise and parenchyma-sparing option for dorsally located right-liver tumors, particularly in settings with limited advanced navigation resources.

Laparoscopic Anatomic S7+S8d Resection Preserving Inferior Right Hepatic Vein and S6 with Right Hepatic Vein Transection

We present an easy-to-establish revision of the classical two-cuff technique for orthotopic liver transplantation in rat.

Orthotopic Liver Transplantation in Rats

Learn a new thrombectomy technique for portal vein thrombosis in liver transplantation using circular incision and vessel loop stabilization. This method enables complete thrombus removal without fragmentation, improving surgical outcomes.

New Thrombectomy Technique for Total Portal Vein Thrombosis in Liver Transplantation

Explore More Videos