Portal vein arterialization following a radical left extended hepatectomy for Klatskin tumor: A case report

Portal vein arterialization (PVA) has been attracting attention for its role as a salvage inflow technique in various clinical applications. Initially performed in shunt surgery for portal hypertension, with the aim of preventing a decreased hepatic inflow, it is largely used in case of hepatic artery thrombosis in the transplantation domain or in the enlarged radical operations in case of hilar cancer invading the hepatic artery. A 62-year-old man underwent a left extended hepatectomy with hepatic bile duct resection and right Roux-en-Y hepaticojejunostomy for hilar cholangiocarcinoma. Computed tomography scan on postoperative day (POD) 5 revealed right hepatic artery pseudo-aneurysm, which was confirmed by an angiography. Stent placement was infeasible. Coiling of the pseudoaneurysm was associated with a risk of complete occlusion inducing critical liver failure. Since his general conditions were deteriorated, the patient underwent an emergency laparotomy. Hepatic artery reconstruction was impossible. Thus, a PVA was performed by anastomosing the ileocecal artery and vein. The intraoperative ultrasound showed satisfactory patency of the PVA with good portal flow in the absence of arterial flow. Doppler ultrasound on POD 15 showed that the cross-sectional area and blood flow of the portal vein were increased. The patient was discharged on POD 54 in good general condition. Hepatic artery disruption represents potentially lethal complications of hepatic, biliary, and pancreatic surgery. PVA may be a feasible therapeutic strategy to guarantee arterial inflow to the remnant liver. Although PVA is a salvage surgical procedure, increased portal flow should be controlled to avoid portal hypertension and liver fibrosis.