Introduction
Intra-Cardiac Thrombosis (ICT) is a rare but high mortality complication of Orthotopic Liver Transplantation (OLT) (Peiris P, Pai SL, Aniskevich S, et al, 2015). We present a case of using Transesophageal Echocardiography (TEE) guidance for an intra-operative CDT and thrombectomy in the setting of an OLT complicated by an ICT.
Case
Our patient is a 59-year-old female with history of End Stage Liver Disease (ESLD) due to alcoholic cirrhosis. She was admitted after a routine paracentesis complicated by a rectus sheath hematoma treated with multiple blood products including K-Centra (prothrombin complex concentrate with Factors II, VII, IX, X, Protein C and S), Tranexamic acid (TXA) and ultimately embolization. Patient remained coagulopathic but improved over the course of 10 days.
On the day of transplantation, patient’s Model of End Stage Liver Disease (MELD) score was 41. Her comorbidities included atrial fibrillation with rapid ventricular response treated with diltiazem, thrombocytopenia (49,000), International Normalized Ratio (INR) of 2.1.
In the operating room a pre-induction arterial line and invasive monitors was placed and general anesthesia was induced uneventfully with fentanyl, propofol, and rocuronium. A TEE was then performed which showed normal bi-ventricular function and no evidence of an ICT.
The pre-anhepatic phase was notable for surgical bleeding addressed with platelet and cryoprecipitate administration. The preferred surgical approach at our institution is the “piggyback method” without veno-veno bypass (VVB). During the anhepatic phase after vena caval anastomoses, a TEE exam in the 4-chamber and bi-caval views revealed a new massive expanding ICT measuring 3x3 cm extending from the superior vena cava (SVC) to the Tricuspid Valve (TV). Given the stage of the transplantation, a decision was made to administer 10000 units of heparin and continued with the portal vein anastomosis, hepatic reperfusion, then followed by an attempt at thrombolysis and thrombectomy. At this time, the Interventional Radiology team was consulted for potential ICT extraction.
An end-to-side donor vein graft was sewn on to the IVC just below the liver for thrombolytic access. Utilizing a combination of fluoroscopic and TEE guidance, a 12-French directional sheath was used for an aspiration thrombectomy with moderate effect. Furthermore, CDT was undertaken with alteplase (recombinant tissue plasminogen activator) 4 mg mixed with sterile water was slowly infuse to dissolve the large thrombus. TEE evidence of marked decreased in ICT size in the SVC and right atrium (RA). The case however proceeded with significant hemorrhage during the reperfusion/neohepatic phase, requiring a total of 45 Packed Red Blood Cells, 21 Fresh Frozen Plasma, 10 Platelets, 7 Cryoprecipitate, and Protamine.
Conclusion
This case report features the first multi-disciplinary therapeutic administration of TEE-guided IVC-accessed thrombus extraction and catheter-directed thrombolytic therapy during OLT. TEE may serve the anesthesiologist well in diagnosis, intervention, and post-intervention assessment as well. TEE-proficient anesthesiologists provide an invaluable skillset in the management of critically ill patients. Furthermore, a novel multi-disciplinary approach was utilized to address a massive ICT/PE with CDT, while minimizing systemic anticoagulation exposure and decreasing the risk of severe coagulopathy commonplace in liver transplantations.
