Liver transplant is an important treatment option for end-stage liver disease, and living related donation is an option to shorten or eliminate the waiting period for the patients, especially when shortage of organs is of concern. It is crucial to provide optimal safety for the donors and to thoroughly examine them preope-ratively in order to decrease perioperative and postoperative complications. Here, we report the case of a living donor who had undergone a left liver lobectomy and on postoperative day 2 presented with a radiologically severe pulmonary embolism, despite the absence of any risk factor for venous thromboembolism or pulmonary embolism. The patient was treated with tissue plasminogen activator and heparin infusions and was discharged 1 week later.
Key words : End-stage liver disease, Liver transplantation, Living donor transplant, Lobectomy, Thromboembolism
Liver transplant is a treatment modality for end-stage liver disease. Deceased donors or, when suitable, living donors are the source for allografts to replace diseased livers. Donor evaluation is important and should be performed carefully in order to predict any possible intraoperative and postoperative complications.
Donor safety is crucial in adult-to-adult liver transplant.1 According to our review of the literature, the risk for venous thromboembolism in living liver donors was found to be 1.8% to 2%, and there are many studies that have shown successful liver transplants without any thrombosis.1-3 The risk for thrombosis in these patients was mainly related to preoperative risk factors such as obesity, smoking, oral contraceptive usage, previously unknown predisposing coagulation disorder, or absence of prophylaxis treatment for deep vein thrombosis.
Here, we report a living liver donor without any risk factor for thrombosis who was diagnosed with severe pulmonary embolism despite having received medical prophylaxis before surgery.
Here, we present a 31-year old female donor who was admitted for living related liver transplant to her daughter (age, 2 years and 3 months) to treat the child’s biliary atresia. The donor was healthy and had no previous history of any disease. She had a history of smoking but had maintained abstinence for the previous 6 years. All of her laboratory test results were within reference ranges, and her chest radiograph was unremarkable. She underwent a left lobectomy, without any complication. During hospitalization, due to her immobilization, she was given a prophylactic dosage of low-molecular-weight heparin.
On postoperative day 2, she exhibited sudden dyspnea, tachycardia, and a decrease in oxygen saturation level to 83%. Her blood pressure was normal, and she had no history of syncope. Echocardiography showed a pulmonary arterial pressure of 35 to 40 mm Hg and tricuspid annular plane systolic excursion of 26 mm. Computed tomography angiography showed bilateral acute massive thrombus in pulmonary artery segments (Figure 1). Due to a radiologically massive thrombus, the patient was given an infusion of tissue plasminogen activator, 50 mg/h, which was followed by heparin infusion. Her clinical status was stable, but hemoglobin levels were low (7.8 g/dL), which was treated with erythrocyte. Abdominal tomography showed a hematoma in the right rectus muscle. Heparin infusion was switched to subcutaneous enoxaparin treatment, and close follow-up with serial abdomen ultrasonography showed a resorp-tion of the hematoma.
On postoperative day 7, she had no need for supplementary oxygen, and the control thorax computed tomography showed a partial resorption of the thrombus in pulmonary arteries. The results from the Doppler ultrasonography of lower extremities were negative for deep vein thrombosis, and the thrombophilia screening result was unremarkable. The patient was discharged with bemiparin (1 dose of 7500 IU/0.3 mL) and an adjusted dosage of warfarin as oral anticoagulant and was asked to return as an outpatient for the follow-up check of prothrombin time (international normalized ratio). For social reasons, she chose to continue the follow-up at a different center (in the city where she was living). There, she was evaluated 5 months after cessation of pulmonary embolism treatment, with no respiratory concern until early in 2022, which was the most recent date of her admission to our hospital.
Postoperative pulmonary embolism can cause death; therefore, an early diagnosis with prompt inter-vention is critical for patient survival. Living donors who are healthy people and volunteer to undergo hepatectomy/lobectomy should be assessed for the risk of surgical and postoperative complications.
Pulmonary embolism has been reported rarely in living donors after surgery; however, despite this rarity, the possible severity (death) warrants appropriate attention to facilitate early diagnosis and prompt treatment. According to our review of the literature, there are 4 case reports that describe the details of pulmonary embolism in living donors after liver transplant. (Table 1).4-7 According to these case reports, no risk factors for pulmonary embolism were detected in any of these donors during the preoperative evaluation. The age of donors varied from 33 to 57 years, and all were male donors. Two of the donors underwent right hepatectomy/lobectomy, whereas the other 2 donors underwent a left hepatectomy/lobectomy. The common feature for 3 of these cases was the absence of a pharmacological deep vein thrombosis prophylaxis, whereas 1 case revealed a previously unknown condition of elevated von Willebrand factor activity that was diagnosed after the pulmonary embolism occurred.
Regarding the preoperative evaluation of living liver donors, there is presently no established guideline for the risk assessment of deep vein thrombosis or pulmonary embolism. Such risk is mainly calculated in a manner similar to standard methods for other preoperative patients, that is, assessment of known history of thrombosis and evaluation for risk factors such as obesity, smoking, oral contraceptive usage, previously unknown predisposing coagulation disorder, or absence of prophylaxis treatment for deep vein thrombosis. On the other hand, pharmacological prophylaxis is associated with a risk of bleeding in the postoperative period; therefore, it is not recommended for mobile patients or patients without any risk factor.
In contrast with the previous published cases, our patient was a female donor, and she was administered the prophylaxis due to a limited mobilization as an inpatient and, interestingly, was diagnosed with a pulmonary embolism. Prompt diagnosis and treatment is crucial for the survival of patients who develop pulmonary embolism; therefore, infusions of heparin and tissue plasminogen activator were administered in a manner similar to the details reported in the literature, even though a high risk for bleeding was present. In fact, bleeding complication occurred in both our case and the case reported by Durand and colleagues.5
Among the published studies on the possible postoperative complications in living liver donors, some have reported higher rates of complications for right lobe donor versus left lateral segment donors or left lobe donors.8,9 These studies have also reported a frequency of pulmonary embolism of 0.2%, usually in right lobe donors.9 Our patient (1) underwent a left lobectomy, (2) did not have any risk factor, and (3) received prophylaxis for thrombosis, and yet a pulmonary embolism developed without deep vein thrombosis. We suggest that further research is warranted for these cases, and a list of criteria should be established for prevention of these postoperative complications of living liver donors.
We recommend prompt and aggressive intervention according to both clinical and radiological findings; such interventions can be safe and could lead to a reductions in mortality due to pulmonary embolism in postoperative patients.
Volume : 21
Issue : 10
Pages : 851 - 853
DOI : 10.6002/ect.2023.0098
From the 1Department of Chest Diseases and the 2Department of General Surgery, Baskent University, Faculty of Medicine, Ankara, Turkey
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Dorina Esendagli, Baskent University School of Medicine, Department of Chest Diseases, Yukari Bahcelievler, Maresal Fevzi Cakmak Cd. No:45, 06490 Cankaya/Ankara, Turkey
Figure 1. Computed Tomography Angiography Showing Bilateral Acute Massive Thrombus in Pulmonary Artery Segments
Table 1. Common Characteristics of Reported Living Liver Donors With Pulmonary Embolism