LETTER FROM THE FRONTILINE / CASE REPORT

Unrecognized spontaneous mesocaval shunt in paedriatic patient with living related donor liver
transplantation: How did we solve it?

Gabriel Gondolesi, M.D. Pablo Barros Schelotto, M.D. Diego Ramisch, M.D Guillermo Pfaffen MD
Pablo Farinelli MD Pablo Romero, M.D Luis Moulin MD Nicols Aguirre MD
Multi-organ transplantation Institute. Hepatology, HPB Surgery and Liver Transplantation Unit.
Hospital Universitario Fundacin Favaloro. Buenos Aires Argentina.
TO THE EDITORS
The development of collateral circulation, which is often extensive, is typical in patients with portal
hypertension due to liver cirrhosis 1. These collaterals may form porto systemic shunts (PSS) that
generate portal flow - steal. This may range from a decreased flow, absence of it, or even reverse
flow. These hemodynamic conditions, in worst-case scenarios, may cause portal thrombosis and
graft loss. After a successful transplant, these big shunts tend to disappear due to the low
resistance to portal flow offered by the graft. Nevertheless, on some occasions, this situation may
be delayed or may not even occur 2. In such circumstances, an appropriate treatment strategy is the
correct identification and its ligation. Mesocaval shunts are infrequent collateral vessels, in the area
of the superior mesenteric vein (SMV) or the inferior mesenteric vein (IMV) and the inferior vena
cava (IVC). Doppler ultrasound is standard in pre-operative evaluation of the portal flow 3. However,
this shunt may go unnoticed in pre-operative evaluation, and may be diagnosed in post-operative,
either with the same method or by angiotomography.

PATIENTS AND METHODS

1-year-old patient, with a history of bile duct congenital atresia, treated with Kasai surgery. The
patient is evaluated for transplantation due to liver disease progression. Ortho- topic liver
transplantation is performed with living related donor, using Piggy Backs technique. The patient
receives segments II-III from her mother. During intra-operative stage, portal hypoplasia is
observed, associated to biliary atresia. For this reason, portal vein reconstruction is performed using
bank iliac venous graft, due to strong discrepancy marked by the portal size between recipient and
graft. Portal, hepatic and arterial blood flows appear normal during reperfusion stage, obtaining an
appropriate hepatic perfusion.

On the first post-operative day, doppler ultrasound reports absence of portal flow and inverted flow
of the superior mesenteric vein. The patient is operated again. Vascular graft is removed through
hypo-flow with associated thrombosis, and it is replaced by a new one. Mesenteric and portal flows
are maintained. On the second post-operative day, the patient evolves negatively: hemodynamic
instability, ascites, edema and elevated liver enzymes. Doppler ultrasound reports again absence of
portal flow, with a maintained arterial flow and inverted flow of the superior mesenteric vein.
Angiotomography is performed and mesocaval shunt previous to the iliac confluent (Fig.1, 2 & 3) is
observed together with an absence of portal flow.
Fig.1 Abdomen Angiotomography. Mesocaval Shunt: arrow, portal confluent: arrow, VMI: mesenteric
inferior vein, VE: splenic vein, VMS: mesenteric superior vein.

Fig.2. Abdomen Angiotomography. Mesocaval shunt: arrow

Fig.3. Abdomen Angiotomography. VE: splenic vein. VRI: left renal vein. Splenic renal
shunt is not observed.

The patient is operated again. Exploratory laparotomy is performed, release of right Toldts fascia,
identification of colic vessels and Mesocaval shunt (Fig.4)

Fig.4 Laparotomy. Mesocaval shunt is observed and tied.

Permeable portal venous graft is observed. The shunt is tied using silk suture. Flow measurement
shows hepatopetal portal flow, with normal direction of mesenteric and splenic flow.

REFERENCES

1. Helena Boixadera , Alejandro Tomasello , Sergi Quiroga Joan Cordoba , Mercedes Perez ,
Antoni Segarra Successful Embolization of a Spontaneous Mesocaval Shunt Using the
Amplatzer Vascular Plug II Cardiovasc Intervent Radiol (2010) 33:10441048

2. Tomasz Chmurowicz, Katarzyna Zasada-Cedro and Maciej Wojcicki. Cavoportal

hemitransposition for unrecognized spontaneous mesocaval shunt after liver
transplantation: a case report. Transplant International
3. . Federico N. Aucejo, Koji Hashimoto, Cristiano Quintini, Dympna Kelly, David Vogt, Charles
Winans, Bijan Eghtesad, Mark Baker, John Fung, and Charles Miller. Triple-Phase

Computed Tomography and Intraoperative Flow Measurements Improve the Management

of Portosystemic Shunts DuringTransplantation Liver Transplantation 14:96-99, 2008