Complete Endovascular Stenting of the Inferior Vena Cava Following Its Twisting After Liver Transplantation

In liver transplantation (LT), inferior vena cava (IVC) outflow obstruction has been reported in 3% of cases.1 The main determinants are technical errors, extensive fibrosis, and ab extrinsic compression.2 The clinical presentation ranges from lower limb edema to ascites to even allograft failure. Diagnosis is confirmed by contrast computed tomography (CT) scan and by cavography.1 We present a case of a 60-y-old woman who underwent deceased-donor LT for alcohol-related cirrhosis. Piggyback technique, using all hepatic vein orifices, was adopted. Five months after LT, she developed imprinted lower limb edema and diuretic-responsive mild ascites. A contrast CT scan showed a “twisting” of the IVC at the caudal portion of the piggyback anastomosis because of graft rotation (Figure 1). Cavography showed patent suprahepatic veins without transanastomotic pressure gradient. Thus, an endovascular stent (Sinus-XL 30 × 60 mm, Optimed Medizinische Instrumente GmbH, Ettlingen, Germany) was placed in the IVC. Three weeks later, lower limb edema and ascites persisted. A new cavography demonstrated further twisting of the IVC at the caudal extremity of the stent. Considering the high risk of a retransplant, we decided to place another endovascular stent (Sinus-XL 22 × 100 mm) to extend the existing stent inside the IVC. Postprocedure cavography demonstrated that twisting of the IVC was still present at the extreme caudal site of the second stent. Thus, a third endovascular stent (Sinus-XL 22 × 80 mm) was placed, extending the previous 2 stents, reaching the outlet of the renal veins. Four weeks later, both the limb edema and ascites partially improved. The new cavography showed, during each inspiration, nearly complete collapse of the IVC at the extreme caudal site of the third stent. Four additional stents (12 × 60 mm and 14 × 60 mm in IVC; BARD Luminexx, NJ), extending the third stent into the left and right iliac veins (12 × 40 and 14 × 40 mm), were placed. Two weeks later, a contrast CT scan demonstrated complete resolution of IVC twisting (Figure 2). The full sequence of endovascular procedures is documented in Video 1. Limb edema and ascites disappeared in 2 wk, and after a follow-up of 12 mo, the patient remained asymptomatic with preserved graft function, and IVC remained patent at the Doppler ultrasound performed every 2 mo.FIGURE 1.: Contrast CT scan key images obtained at a clinical presentation of limb edema and mild diuretic responsive ascites. A, The horizontal plane CT scan image, demonstrating stenosis of the IVC closed to the piggyback anastomosis (arrow), with patency of the 3 hepatic veins. The caudal portion of the IVC is dilated. B, The sagittal CT scan image that illustrates in more detail a significant IVC stenosis, starting 4 mm caudally to the piggyback anastomosis (arrow). The lumen of the IVC between the piggyback anastomosis and the right heart atrium is uneven. This suggests the presence of a slowing of the flow inside the IVC that, in the absence of thrombosis, can be compatible with a twisting of the vein. CT, computed tomography; IVC, inferior vena cava.FIGURE 2.: Contrast CT scan key image obtained after the successful placement of the seventh endovascular stent. The image shows the entire inferior vena cava and both iliac veins underwent endovascular stenting, which allowed complete resolution of the vein twist. CT, computed tomography.To our knowledge, this is the first reported case of repeated twisting of the IVC after LT treated with insertion of 7 endovascular stents. When ballooning of the IVC is insufficient to restore the durable patency of the vein,3 IVC stenosis after LT is treated with endovascular techniques.3-5 Likewise, endovascular stents may sometimes migrate distally or become thrombosed.1 In our case, although the first endovascular stent did not migrate, it was insufficient to restore IVC patency. We hypothesized that the increased abdominal pressure exerted by ascites precluded the maintenance of IVC patency. Otherwise, a pericaval fibrosis could be developed following the dissection of the caudate lobe from IVC during hepatectomy. In summary, complete stenting of the IVC and iliac veins was successfully performed, avoiding the need to surgically remake the anastomosis.