Hepatic Venous Outflow Obstruction after Adult Living Donor Liver Transplantation

Background: Hepatic venous outflow obstruction (HVOO) after adult living donor liver transplantation (LDLT) is potentially lethal. The aim of this study was to evaluate the incidence, risk factors, morphology, treatment strategy, and outcomes of HVOOs after adult LDLT. Methods: Clinical records of 327 adult patients who underwent LDLT between 2000 and 2019 were reviewed and analyzed in a prospectively collected database. Results: Overall, 15/327 recipients (4.6%) developed HVOO, which occurred early (< 3 months) in 10 and late (≥ 3 months) in 5 after LDLT. One recipient underwent immediate surgical revision and 14 underwent interventional radiological (IVR) procedures. Anastomotic stenosis (n = 12) was the most common morphology. Of these, a single session of balloon angioplasty cured 5 recipients and 6 resolved with multiple sessions, but one required stent placement. Intrahepatic stenosis (n = 2) and kinking (n = 1) were refractory to balloon angioplasty and all 3 required stent placement. All 15 patients finally achieved clinical success after treatment. No preoperative variables were predictive of HVOO. 5-year graft survival rate was numerically lower in the late-onset group (40%) compared to early-onset (79%) and no HVOO (77%) groups without statistically significant difference (p = 0.096). Conclusions: IVR is the mainstay of treatment for HVOOs after adult LDLT with a high success rate. Balloon angioplasty cures most anastomotic stenosis. Stent placement is recommended for intrahepatic stenosis and kinking. Late-onset HVOOs potentially have a worse prognosis. A tailored approach according to morphology and time of onset is essential.