Reply

Potential conflict of interest: Nothing to report. To the Editor: We thank Ikegami et al. for the interesting comments on our study on risk factors of de novo portal vein thrombosis (PVT) in adult‐to‐adult living donor liver transplantation (LDLT)1 and for the detailed description of their approach for managing acute grade 4 total PVT. As described in our article, we agree that in the event of acute PVT without portal venous flow after LDLT, the patient should be taken to the operating room to be treated surgically. In our study, we had 2 patients with acute total PVT (grade 2) for whom the thrombosis was resolved with thrombectomy, Fogarty catheter, and anticoagulation. In contrast, we had only 1 patient with grade 4 total PVT, which developed chronically and was detected 133 days after the LDLT with no signs of acute liver injury. In this latter patient, the treatment was not surgical on the basis of the absence of signs of acute injury (elevated hepatic enzymes, abdominal pain, or ascites). In these type of patients, the chronicity of the event leads to the development of collaterals, which maintain an adequate graft perfusion and liver function. The patient from our study with chronic grade 4 total PVT had a functional organ at almost 6 years of follow‐up after the LDLT. We consider that the experience with LDLT in Kyushu University, Fukuoka, Japan, is very impressive with 475 LDLTs in a period of 12 years. Their procedure included a deep dissection of the splenic, mesenteric, and portal veins at the confluence level and a subsequent splenic venotomy and suction of the thrombus from the portal system followed by the ligation of the splenic vein. This detailed description for the management of acute grade 4 total PVT provides a valuable additional option for the management of these complex patients. In conclusion, we believe that the cases of acute PVT without portal venous flow (grade 2, grade 3 total, and grade 4 total PVT) should definitely be treated surgically, including a possible ligation of the splenic vein in patients with splenectomy to avoid recurrence originating from this vein. In contrast, a medical treatment with anticoagulation (heparin/warfarin) should be considered first in patients with acute partial PVT (grade 1, grade 3 partial, and grade 4 partial PVT) or chronic PVT without signs of acute hepatic injury.

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