Postreperfusion Syndrome Presenting as Posttransplant Portal Hypertension due to Prolonged Elevation of Pulmonary Vascular Resistance and the Role of Nitroglycerin in Diagnosis and Treatment: A Case Report of Budd-Chiari Syndrome

Takahiro Kawaji,¹ Hiroaki Toyama,¹ Norifumi Yoshida,¹ Shoichiro Moteki,¹ Ayaka Sasaki,¹ Kengo Sasaki,² Atsushi Fujio,² Kazuaki Tokodai,² Shigehito Miyagi² and Masanori Yamauchi¹

¹Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
²Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan

Postreperfusion syndrome is one of the responsible mechanisms of portal hypertension in patients undergoing liver transplantation. And post-transplant portal hypertension causes graft dysfunction. Postreperfusion syndrome is characterized by a decrease in arterial pressure and cardiac output, and an increase in central venous pressure, pulmonary artery pressure, and pulmonary vascular resistance that occurs after the release of the portal vein clamp. Although early recovery from postreperfusion syndrome is desired, there is a little medication therapy such as the administration of calcium chloride, sodium bicarbonate, and beta-agonist for postreperfusion syndrome. We present a case of postreperfusion syndrome manifested as post-transplant portal hypertension and reversed after nitroglycerin administration. A 49-year-old Asian woman was scheduled for liver transplantation because of Budd-Chiari syndrome. After portal vein reperfusion, she experienced severe postreperfusion syndrome. Administration of ephedrine and calcium restored arterial pressure; however, pulmonary artery pressure, pulmonary vascular resistance, and central venous pressure elevations were sustained, causing right ventricular overload. This condition did not improve after hepatic artery reperfusion, and caused post-transplant portal hypertension. After nitroglycerin administration, pulmonary vascular resistance and central venous pressure decreased, mean arterial pressure increased, right heart contractility recovered, and portal hypertension disappeared. Hemodynamic improvement by nitroglycerin administration helped in diagnosing postreperfusion syndrome and avoiding unnecessary splenectomy. If portal vein pressure increases after liver transplantation, the change in hemodynamic parameters by nitroglycerin administration should be assessed, which will lead to accurate diagnosis and appropriate treatment. Furthermore, postreperfusion syndrome should be listed as a differential diagnosis of post-transplant portal hypertension.

Keywords —— liver transplantation; nitroglycerin; postreperfusion syndrome; posttransplant portal hypertension; pulmonary vascular resistance

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Tohoku J. Exp. Med 2023, 259, 121-126.

Correspondence: Hiroaki Toyama, M.D., Ph.D., Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan.

e-mail: h-toyama@umin.ac.jp