2009 John Wiley & Sons A/S.

Clin Transplant 2010: 24: 550556 DOI: 10.1111/j.1399-0012.2009.01123.x

Risk factors for portal vein complications in

pediatric living donor liver transplantation
Shibasaki S, Taniguchi M, Shimamura T, Suzuki T, Yamashita K, Susumu Shibasakia, Masahiko
Wakayama K, Hirokata G, Ohta M, Kamiyama T, Matsushita M, Taniguchia, Tsuyoshi
Furukawa H, Todo S. Risk factors for portal vein complications in Shimamurab, Tomomi Suzukic,
pediatric living donor liver transplantation. Kenichiro Yamashitad, Kenji
Clin Transplant 2010: 24: 550556. 2009 John Wiley & Sons A/S. Wakayamaa, Gentaro Hirokataa,
Minoru Ohtab, Toshiya
Abstract: Background: Portal vein (PV) complications in pediatric living
Kamiyamaa, Michiaki Matsushitaa,
donor liver transplantation (LDLT) are often asymptomatic in the early
stages after transplantation and can be serious enough to lead to graft Hiroyuki Furukawac and Satoru
failure. There have been few reports on risk factors for PV complications in Todoa
a
LDLT. The aim of this study is to investigate the inuence of hepatic inow Department of General Surgery, bDivision of
upon PV complications and to predict patients at risk for these complica- Organ Transplantation, cDepartment of Organ
tions. Transplantation and Regeneration and
d
Material/method: From 1997 to 2008, 46 pediatric patients underwent Department of Molecular Surgery, Graduate
LDLT at our center. Portal venous and hepatic arterial ows and PV School of Medicine, Hokkaido University,
diameter were analyzed. Sapporo, Japan
Results: PV complications were identied in seven patients (15.2%) and
occurred at a younger age and lower weight. As a result of appropriate
treatment, none of the patients suered graft failure. Analysis of the 46 Key words: liver transplantation living donor
patients and 27 patients under two yr of age indentied smaller PV diameter pediatric portal vein complications
in recipient and larger discrepancy of PV diameter as risk factors. Portal
Corresponding author: Masahiko Taniguchi, MD,
venous ow tended to be low, in contrast to hepatic arterial ow, which
Department of General Surgery, Graduate
tended to be high.
School of Medicine, Hokkaido University, N-15,
Conclusion: PV size strongly inuences PV complications. Other factors
W-7, Kita-ku, Sapporo 060-8638, Japan.
such as younger age, low portal venous ow, and high hepatic arterial ow
Tel.: +81 11 706 7062; fax: +81 11 706 7064;
may be risk factors for PV complications.
e-mail: tonny@isis.ocn.ne.jp

Accepted for publication 25 August 2009

Pediatric liver transplantation is one of the most
eective modalities for treatment of pediatric end-
stage liver diseases. Since living donor liver
transplantation (LDLT) was rst performed by
Raia in 1988 in Brazil (1), pediatric LDLT has been
accepted as an alternative to orthotopic liver
transplantation (OLT) because of the shortage of
donor grafts. In actuality, outcomes for pediatric
end-stage liver diseases have improved dramati-
cally: the patient survival rates in pediatric LDLT
at ve and 10 yr have reached 8298% (25) and
7782% (3, 4), and the graft survival rates at 5 and
10 yr have reached 8189% (4, 5) and 75% (4).
Recently, reports of portal vein (PV) complica-
tions in pediatric LDLT have increased, occurring
at an incidence of 827% (510) when compared to
1.83% in adult recipients (11, 12). PV complica-
tions are often asymptomatic; in fact, 64% of such
asymptomatic cases were detected by abdominal
ultrasound screening (13). In a few cases with few
symptoms, these complications can become extre-
mely serious, as indicated by reports of a mortality
rate of 5.230% and a graft loss rate of 7.935%
(6, 8, 13, 14). Thus, careful follow-up leading to
earlier discovery and earlier treatment is crucial to
preventing graft loss.
However, there are few reports on risk factors
for PV complications in pediatric LDLT. A more
rigorous follow-up can be performed by clarifying
risk factors for these complications. The aim of this
study is to investigate what inuences the occur-
rence of PV complications and to predict patients
with a high risk of such complications in pediatric
LDLT.

550
 Risk factors for PVC in pediatric LDLT

thereafter every three months. If any abnormal

Materials and methods
signs were found, specic tests such as angiography
Patients were performed. All decisions on diagnosis and
treatment were made according to our algorithm for
Subjects were individuals involved in 46 pediatric
PV complications (Fig. 1).
(under 18 yr of age) LDLTs at this center from
September 1997 to March 2008. All grafts were
harvested from healthy adult living donors who Surgical technique
were fully informed and who donated voluntarily.
When the graft was implanted, the donor hepatic vein
The donors were 41 parents (14 fathers and 27
was anastomosed to a new diamond-shaped orice on
mothers), three grandparents (one grandfather and
the front of the inferior vena cava, below the conu-
two grandmothers), one sister, and one aunt. The
ence of the recipients middle hepatic vein and left
harvested grafts were 29 lateral lobes, seven left
hepatic vein. Next, PV anastomosis was performed
lobes, and 10 left lobes with the middle hepatic vein
using continuous Prolene 6-0 suture with making
and one right lobe. The mean ratio of the graft
growth factor. The hepatic vein was then unclamped
volume to standard liver volume was
and portal reperfusion began. After reperfusion,
74.1 27.9% (mean SD range, 36.1133.7).
hepatic artery anastomosis and bile duct reconstruc-
Patients by sex broke down into 19 males and 27
tion, using a Roux-en-Y loop, were performed.
females with an age of 4.29 4.93 yr
There were four methods of PV reconstruction.
(mean SD range, 0.317) and body weight of
End-to-end anastomosis, anastomosis of the graft
16.4 13.5 kg (mean SD range, 4.154). The
PV and the trunk of the recipients PV, was
indications for liver transplant are shown in
performed in 35 cases. Branch patch anastomosis,
Table 1. Biliary atresia was the most frequent
anastomosis of the graft PV to the bifurcation of
indication for liver transplant and was noted in 31
the right and left branches of the recipients PV,
cases (67.4%).
was performed in one case. Conuence anastomo-
Early complications were dened as the onset of
sis, anastomosis of the graft PV to the conuence
PV complications within the rst one month after
of the recipients superior mesenteric vein and
LDLT, and late complications were dened as onset
splenic vein, was performed in ve cases. Inter-
after that point. The mean duration from sur-
posed harvested vein graft anastomosis, anasto-
gery to the onset of late complications was
mosis using a graft harvested from the donor, was
10.4 8.3 months. Pre-operative recipient and
performed in ve cases; in two cases, the external
donor PV diameter were measured by pre-operative
jugular vein was used; in two, the gonadal vein was
abdominal contrast-enhanced computed tomogra-
used; and in one, the inferior mesenteric vein was
phy (CT). Intraoperative ow of the hepatic artery
used. Prophylactic anticoagulant therapy was not
(HA) and PV was measured with an ultrasonic
routinely administered.
transit ow meter. Routine post-operative protocols
for CT and abdominal ultrasonography (US) were
performed as follows: CT, two wk and one to three, Statistics
and six months after transplantation and thereafter
Patients with and without PV complications were
every three months; US, twice daily until one wk
compared using the MannWhitney U test. In
after transplantation, once daily until two wk after
addition, patients were limited to those under
transplantation, then, as in the case of CT, one to
two yr of age, and the same comparison was made.
three, and six months after transplantation, and
Factors with a signicant dierence were compared
Table 1. Indications for liver transplantation
using Fishers exact test with the smallest p-value
serving as the cuto point. Statistical signicance
Cholestatic conditions (n=37) was denoted by p < 0.05.
Biliary atresia 31
Progressive familiar intrahepatic cholestasis 2
Hepatic failure of unknown origin 4 Results
Metabolic disease (n=7)
Wilsons disease 2 PV complications were identied in seven patients
Glycogen storage disease 1 (15.9%). Early PV thrombosis occurred in one,
Ornithine transcarbamylase deficiency 2 early PV stenosis in one, late stenosis in four, and
Metylmaronic acidemia 1 late occlusion in one. Of the seven cases, ve were
Hyperoxaluria 1
diagnosed by routine CT or US, while two were
Neoplasm (n=2)
Hepatoblastoma 2 discovered because of an increase in ascites. Of the
seven patients, four had a decreased platelet count.

551
Shibasaki et al.

Fig. 1. Algorithm for follow-up and treatment of PV stenosis (A) and occlusion (B). PV patency in the early period following
transplantation is usually evaluated by routine US and CE-CT. Additional CE-CT is performed if an abnormality such as decreased
or lack of PV ow is detected by US. If PV stenosis or occlusion is suspected, angiography is performed to diagnose PV compli-
cations. Late-phase PV patency is followed by routine US and CE-CT. If suspicions arise, angiography is performed to make a
decision. With regard to treatment, there are some dierences between the early and late periods following transplantation. Re-
anastomosis is considered in acute stenotic cases that occur within seven d after living donor liver transplantation. In contrast, PTA is
the rst-line therapy for late-stage stenosis. Despite the controversy over long-term patency, stent replacement is considered in cases
that are refractory to repeat balloon dilation. Because early-stage PV occlusion is almost always caused by thrombosis and leads to
acute graft failure, an emergency procedure such as thrombectomy or reconstruction is necessary to prevent graft loss. On the other
hand, because late-stage PV occlusion occurs gradually and is likely to develop collaterals, anticoagulant therapy is the rst choice,
and retransplantation is considered in cases with PV hypertension. US, abdominal ultrasonography; CE-CT, contrast-enhanced
abdominal computed tomography; PTA, percutaneous transhepatic angioplasty; POD, post-operative day.

552
 Risk factors for PVC in pediatric LDLT

The levels of transaminase were close to normal
levels in all seven patients.
Results for risk factors are shown in Table 2. PV
complications occurred at a younger age and lower
weight. With regard to other factors, pre-operative
PV diameter in recipient and pre-operative ratio of
donorrecipient PV diameter were strongly related
to the occurrence of PV complications. Low portal
venous ow and high hepatic arterial ow after
reperfusion also caused a high occurrence of PV
complications. In other words, the ratio of portal
venous ow to hepatic arterial ow in patients with
PV complications was signicantly smaller than in
patients without PV complications. Analysis lim-
ited to patients under two yr of age revealed that a
smaller PV size and a higher ratio of donor
recipient PV diameter cause a high occurrence of
complications. In terms of the cuto point, signif-
icant dierences were found with a pre-operative
PV diameter in recipient 4 mm (p < 0.001),
pre-operative ratio of donorrecipient PV diameter
2.3 (p < 0.001), portal venous ow after reper-
fusion 150 mL/min/100 g (p = 0.046), and he-
patic arterial ow after reperfusion 50 mL/min/
100 g (p = 0.046). With regard to multivariate
analysis, there were no signicant dierences
because of the small sample size. In terms of the
type of anastomosis, conuence and interposed
graft anastomosis had a high occurrence of PV
complications (Table 3). In one of the cases where
an interposed graft was used, the native PV was so
hypoplastic that anastomosis required four at-
tempts; the paternal external jugular vein was
ultimately used in this case. In another complicated
case, the maternal gonadal vein was used.
In one case of early PV thrombosis, re-anasto-
mosis of the PV was performed using the external
jugular vein from the father as an interposition
graft. In one case of late occlusion, occlusion was
complete but the PV developed collaterals, so only
anticoagulant therapy was performed. All ve
cases of stenosis, both early and late, were
improved by repeated transhepatic balloon dila-
tion. The patients in these seven cases are all
currently alive (Table 4).
Discussion
This study has demonstrated that PV complica-
tions in pediatric LDLT occurred more often with
a smaller PV size, even in younger age recipients.
A small PV diameter is thought to relate to great
discrepancy in PV diameter between donor and
recipient and low portal venous ow, which may
represent potential risk factors for PV complica-
tions.
There have been several reports on being young
and having a lower body weight as risk factors for

Table 2. Univariate analysis of risk factors for portal vein (PV) complications

Non-complications
Complications Non-complications group under two -yr-old,
group, (n = 7) group, (n = 39) p-Value (n = 24) p-Value

Age (yr) 0.99 0.41 4.9 5.1 0.043 0.94 0.40 0.739
Sex (M/F) 2/5 17/22 6/12
Height (cm) 67.7 5.6 95.3 34.3 0.023 67.8 6.5 0.856
Weight (kg) 7.5 1.4 18.0 14.1 0.011 7.8 2.0 0.449
BMI 16.4 1.2 17.1 2.1 0.383 16.9 2.5 0.809
Biliary atresia 6 25 18
Child-Pugh-Turcott score 7.0 1.5 7.7 2.2 0.189 7.9 1.9 0.173
Operation time (min) 638.0 224.0 808.5 226.2 0.031 690.9 174.2 0.250
Bleeding (mL) 307.1 224.4 1450.0 1946.9 0.004 623.3 600.4 0.074
Cold ischemic time (min) 36.7 19.6 55.4 39.7 0.119 49.4 47.2 0.525
Warm ischemic time (min) 33.3 7.3 42.0 19.7 0.076 43.6 29.0 0.304
PV anasto-time (min) 14.0 3.7 16.2 9.2 0.433 17.8 12.9 0.380
Donors age (yr) 28.4 3.3 35.7 9.9 0.027 31.8 8.8 0.304
The ratio of graft volume to standard liver volume (%) 83.7 12.0 72.4 30.0 0.194 93.6 27.1 0.397
HA (mm) 3.4 0.53 3.7 1.0 0.717 3.3 0.7 0.505
PV diameter (mm) 3.7 0.95 7.4 2.6 0.0002 5.8 1.4 0.027
Donors PV diameter (mm) 9.4 1.6 9.3 1.5 0.766 9.1 1.7 0.525
PV size ratio of donor to recipient 2.7 0.92 1.4 0.49 0.0003 1.6 0.4 0.0022
PV flow (mL/100 g/min) 150.0 73.1 239.0 100.0 0.026 189.8 70.0 0.204
HA flow (mL/100 g/min) 50.7 23.5 30.6 18.4 0.022 34.1 18.5 0.090
PV/HA flow ratio 3.8 2.8 12.7 14.2 0.0078 8.5 6.9 0.069

HA, hepatic artery; PV, portal vein.

553
Shibasaki et al.

Table 3. Methods of portal vein reconstruction
N Complication
End-to-end 35 3 8.6
Bifurcation 1 0
Confluence 5 2
Interposition 5 2
PV complications in pediatric LDLT (1520). At
this facility, patients who were younger or had a
lower body weight had a higher occurrence of PV
complications as well. The reason for this is thought
to be because of the small PV diameter and
discrepancy in the size of the diameter between the
donor and recipient. In the current study, PV
complications occurred more often in cases of a
smaller PV diameter and greater discrepancy in size.
Cheng et al. (15) reported that a pre-operative
PV diameter of <4 mm was associated with a high
risk for intraoperative portal vein occlusion. A
smaller PV diameter would reasonably lead to a
greater size discrepancy between the donor and
recipient PV, so the risk of developing PV compli-
cations is naturally expected to rise as well. That
said, there has only been one case report (21) and
one study (22) on size discrepancy in OLT. A PV is
expected to be smaller in patients that are younger
or have a lower body weight; in the current study,
there were dierences between the group with PV
complications and that without PV complications
even when looking only at patients under two yr of
age. Besides age, biliary atresia is a potential cause
of a smaller PV. Diem et al. (23) reported that
19.5% of biliary atresia cases had PV hypoplasia.
Additionally, Saad et al. (24) performed a patho-
logical study of native PV in resected livers in
LDLT; they reported that only 20% were normal
or had changed little, but up to 43% had severe
brosis. Based on these facts, biliary atresia and a
smaller PV are closely related. In other words,
severe portal inammation and repeated cholangi-
tis in biliary atresia are thought to shrink the
smaller PV and increase the risk of PV complica-
%
tions. In the current study, complications devel-
oped in 19.4% of biliary atresia cases, which is
0 slightly higher than the 16.5% reported by Chardot
40 et al. (22).
40 Portal venous ow is thought to be another risk
factor. With regard to portal venous ow after
reconstruction, Bueno et al. (25) reported that low
portal venous ow contributed to the resultant
thrombosis in OLT, and Cheng et al. (15) reported
that slow portal venous velocity was predictive of
intraoperative portal vein thrombosis. In contrast,
hepatic arterial ow tended to increase in the
current study like it did in the report by Bueno
et al. (25). This is thought to be because the blood
ow supplied to the liver is constant; a reduced
portal venous ow gives rise to a corresponding
increase in hepatic arterial circulation. There is a
report that noted a signicant increase in hepatic
arterial ow after the temporary occlusion of the
portal vein (26). Poor portal venous ow is thought
to be caused by serious liver cirrhosis existing pre-
operatively because of biliary atresia, the eects of
portal inow escaping through collateral path-
ways, and the eects of a hypoplastic PV. We did
not directly prove that the pre-operative PV ow
was poor by measuring it before reperfusion.
However, in hypoplastic PV cases, a stenotic PV
that lasts for years before transplantation conse-
quently leads to a compensatory increase in HA
ow. This condition persists even after transplan-
tation. We consider the compensatory increase to
be a risk factor for post-transplant PV complica-
tions. However, there are doubts over whether late
PV complications are directly aected by portal
venous ow because the ow was not periodically
measured. Whether decreased portal venous ow
persisted as it did post-operatively is unknown.
The current study did suggest that decreased portal
venous ow, when induced an increased hepatic
arterial ow, might itself represent a high risk of

Table 4. Prognosis for patients with portal vein (PV) complications. The left side of the follow-up duration indicates the time since diagnosis, while the right side
indicates the time since final treatment was performed (months)

Age Opportunity PV Follow-up Final

Case (months) Type Onset of diagnosis Therapy patency duration (M) outcome

1 14 Stenosis 10 M Late CT PTA 3 Patent 61/41 Alive

2 6 Stenosis 10 M Late CT PTA 2 Patent 64/61 Alive
3 10 Thrombosis 7d Acute US Reoperation Patent 69/69 Alive
4 6 Stenosis 1M Acute Ascitis PTA 5 Patent 41/16 Alive
5 11 Stenosis 2M Late Ascitis PTA 2 Patent 42/41 Alive
6 20 Occlusion 6M Late CT Anticoagulant Occlusion 19/19 Alive
7 15 Stenosis 24 M Late CT PTA 1 Patent 14/14 Alive

M, month; PTA, percutaneous transhepatic angioplasty; CT, computed tomography; US, ultrasonography.

554

complications. Thus, ow at reperfusion may serve
as an indicator for the onset of PV complications.
Crucial responses to these risk factors are
increasing portal venous ow by clamping collat-
eral pathways and devising methods of reconstruc-
tion that reduce the size discrepancy. Someda et al.
(27) reported that ligation of the collateral path-
ways was eective at improving poor portal venous
inow and consequently avoiding intraoperative
portal vein complications. Shirozu et al. (20)
reported another reconstructive technique for
infant recipients weighing <6 kg: they widened
the diameter of the PV by applying a patch to its
anterior surface. They reported good results, i.e.,
no complications in any of the eight patients they
studied, and such techniques may prove useful.
Another clinical problem is PV anastomotic
modalities, especially with conuence and inter-
posed vein graft anastomosis; these modalities
tended to inuence the occurrence of PV
complications in this study, albeit in only a few
cases. Conuence anastomosis is supposed to
stretch the anastomotic site and prevent the vein
from fully opening because of the short PV
distance and tensioned anastomotic site, but the
anastomotic diameter is greater. In contrast, inter-
position anastomosis, which is supposed to prevent
anastomotic tension, has been noted to carry risk
factors for late PV complications; the incidence of
such complications with a vein graft harvested
from a living donor in pediatric LDLT has reached
3341% (4, 7) while that with a cryopreserved graft
has reached 41.7% (6). Surprisingly, Sugawara
et al. (28) reported that, even in adults, the rate of
PV complications was 60.9% with a cryopreserved
vein graft and 30% with a harvested vein graft. The
most important fact is that these two modalities
were used for cases of an extremely narrow PV or
thrombotic occlusion. This is quite reasonable in
light of the current nding that the state of a pre-
operative recipients PV greatly aects the occur-
rence of PV complications. In such situations, we
believe it is better to use interposition grafts for
reconstruction, despite their uncertain eects on
long-term patency. Conduit grafts can prevent
acute PV anastomosis complications by preventing
anastomotic tension and replacing the recipients
hypoplastic PV. Further, considerable attention
needs to be paid to the risk factors for late stenosis
and careful follow-up is essential.
Conclusion
PV complications in pediatric LDLT are dicult to
discern in the early stages after transplantation.
Once they progress, they can lead to graft loss and
Risk factors for PVC in pediatric LDLT
mortality, so during reconstruction, increasing the
portal venous ow and minimizing the discrepancy
in portal vein size are crucial to preventing these
complications. Additionally, high-risk groups such
as those mentioned above should be closely followed
and PV complications should be detected early on.
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