Bifurcated T-stent reconstruction is safe and effective treatment for HVOO in orthotopic liver transplant patients

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dillon brown university of washington
Dillon Brown

A study has found that bifurcated T-stent reconstruction offers a safe and effective treatment option for hepatic venous outflow obstruction (HVOO) with anastomotic stenoses in orthotopic liver transplantation (OLT) recipients.

The findings of this study were presented at the 2021 meeting of the Society of Interventional Radiology (SIR; 20–26 March, online), and indicated that this interlocking stent construct may also offer advantages in treating complex stenosis involving the hepatocaval junction—while minimising the risk of stent migration or the jailing of hepatic venous (HV) outflow by an inferior vena cava (IVC) stent.

Clinical success, as demonstrated by an improvement in the presenting symptoms of HVOO, was seen in six (75%) of the eight OLT patients included in the study, while the remaining two (25%) patients required repeat intervention, which was performed within two months due to a lack of clinical response in both cases.

The study was presented by Dillon Brown, a medical student at the University of Washington School of Medicine (Seattle, USA), who said: “The bifurcated hepatocaval stent model employed in our study could mean lower rates of complications such as stent migration and hepatic vein jailing for OLT patients experiencing hepatic venous outflow insufficiency. It could also allow the operator to treat more severe anastomotic stenosis, and treat both IVC and HV stenosis simultaneously.”

The study involved a total of eight OLT patients with symptomatic HVOO (six males; mean age: 57.6±7.6 years; range: 48–69 years), all of whom underwent combined IVC and HV bifurcated T-stent placement between 2004 and 2019. Indications observed in these patients included seven refractory ascites (87.5%), four liver function abnormalities (50%), and one hepatic hydrothorax (12.5%) in the setting of hepatocaval anastomotic stenoses, diagnosed using either Doppler ultrasound or computed tomography.

According to Brown, success, adverse events, and stent patency were all assessed, with technical success being defined as intended bifurcated hepatocaval stent placement and clinical success being defined by improvements in presenting symptoms.

All of the patients included in the study underwent technically successful bifurcated hepatocaval stent reconstruction with supra/intrahepatic IVC stent (Wallstent, Wallflex [Boston Scientific] or Gianturco Z-stent [Cook Medical]) placement followed by HV stent (Venovo [BD], Smart [Cordis], or Wallstent [Boston Scientific]) placement through the interstices of the IVC stent. The mean number of stents placed in each patient was 2.3 ± 0.5 (range: 2–3), with a mean IVC stent diameter of 22.6±4.7mm (range: 14–30mm) and a mean HV stent diameter of 12.4±2.2mm (range: 10–16mm).

While no IVC stent migrations occurred over the course of the study, one HV stent migration occurred 18 days after placement, requiring retrieval from within the IVC stent and replacement. One patient also died 66 days after intervention due to graft rejection, according to Brown.

In six of the eight patients included in the study, Brown stated clinical success was achieved at a mean time of 41±28.4 days (range: 7–91 days). For the remaining two patients, repeat intervention was performed within two months due to a lack of clinical response—including angioplasty (n=2) and additional IVC stent placement (n=1) for in-stent stenoses.

All of the stents demonstrated patency at the last follow-up appointment (mean: 2,126 days; range: 32–4,846 days), leading the researchers to conclude that bifurcated T-stent reconstruction offers a safe and effective therapy for HVOO with anastomotic stenoses in OLT.

“The next steps in researching the bifurcated hepatocaval stent construct will be to increase the size of our study by increasing the number of patients who receive this treatment, and also comparing the patient outcomes of patients receiving the bifurcated stents with conventional single-stent therapies,” Brown said.


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