Venous Outflow Obstruction, an Uncommon Complication of Orthotopic Liver Transplant

Purpose: Since its inception in 1963, orthotopic liver transplant has been the treatment of choice for end-stage liver disease with approximately 8000 liver transplants performed each year in the United States. The most common complications of liver transplant include graft rejection, vascular thrombosis and stenosis, biliary disorders, neoplasm, and fluid collections. Vascular complications are the second most common cause of transplant failure, with the incidence of venous outflow obstruction estimated to be less than 2%. Symptoms include lower extremity edema, ascites, abdominal pain, and renal and hepatic dysfunction. This case highlights the approach to therapy of inferior vena cava (IVC) stenosis after orthotopic liver transplant.

Materials and Methods: The patient is a 58-year-old man with history of end-stage liver disease secondary to hepatitis C cirrhosis. Six weeks after orthotopic liver transplant, routine laboratory monitoring noted elevated liver function test (LFT) results. Abdominal ultrasound and magnetic resonance cholangiopancreatography showed patent hepatic vasculature. Immunosuppression therapy was adjusted, but the patient’s LFT results remained elevated. Ultrasound-guided liver biopsy showed acute cellular rejection. Despite treatment with thymoglobulin and high-dose steroids, his LFTs remained elevated, and he developed an AKI and lower extremity edema. Given these findings, interventional radiology was consulted to evaluate for IVC stenosis.

Results: An inferior venocavogram revealed 60% stenosis of the IVC at the hepatic venous anastomosis. Pressure measurements at the level of the right atrium and IVC noted a 7–mm Hg gradient across the stenosis. Fluoroscopic-guided serial venoplasty was performed using 14- and 16-mm angioplasty balloons. Postvenoplasty venogram noted a 3–mm Hg gradient and no residual stenosis. On follow-up, the patient’s LFTs and lower extremity swelling improved.

Conclusions: IVC stenosis is treatable with balloon angioplasty, but because of its high failure rate, balloon angioplasty with stenting is recommended to prevent recurrence. However, therapy with stenting is not always suitable given the risk of stent migration, hepatic venous outflow obstruction, intrastent stenosis, and increased difficulty of retransplantation. In our case, balloon angioplasty without stenting has alleviated our patients symptoms. However, close follow-up will be needed to ensure timely intervention if his IVC stenosis recurs.