Spontaneous Expulsion of Polytetrafluoroethylene (PTFE) Graft in a Liver Transplant Recipient

This letter is to report an interesting complication due to the use of a prosthetic graft in live donor liver transplantation (LDLT). A 25-year-old female with hepatocellular carcinoma (HCC) underwent LDLT using a right lobe graft from her 50-year-old mother. The right lobe graft had single inflows from the right portal vein and right hepatic artery. The venous outflow of the graft was dual: the right hepatic vein (RHV) draining the posterior sector comprising segments 6 and 7 and a reconstructed neo-middle hepatic vein draining the anterior sector comprising segments 5 and 8. A polytetrafluoroethylene (PTFE) graft (Figure 1a) was used to reconstruct the neo-middle hepatic vein (MHV). The RHV of the graft was anastomosed to the RHV of the recipient, and the PTFE graft to inferior vena cava (IVC). At 6 weeks, a routine Doppler scan revealed thrombosis in a neo-MHV graft, without any clinical or biochemical changes, and it was conservatively managed. Routine yearly surveillance of computed tomographic (CT) scans up to the third year after transplantation consistently demonstrated thrombosed PTFE graft but no HCC recurrence.

Figure 1.

a: Right hemi-liver graft with MHV reconstruction using PTFE, b: Endoscopic view of PTFE eroding into the stomach, c: CT image with PTFE neo-MHV graft eroding into the stomach, d: CT image shows no PTFE graft.

We were shocked to see that the caval end of the PTFE graft had eroded into the stomach on a routine follow-up CT scan in the fourth year (Figure 1b and 1c). However, as the patient remained asymptomatic, we did not intervene surgically or endoscopically to retrieve the eroded graft. The patient was advised to visit emergently in case of any symptoms. Surprisingly, a repeat CT scan three years after graft erosion revealed that the graft was no longer visible (Figure 1d). Although the patient did not recall the graft material passing out rectally, it is likely that the PTFE graft spontaneously migrated into the stomach and exited without causing any symptoms!

There are three additional reports documenting graft erosion or migration following LDLT^1,2,3 as well as one detailing the migration of a mesenterico-portal PTFE jump graft after a deceased donor liver transplant.⁴ Graft erosion or migration following liver transplants is often caused by acute thrombosis-induced inflammation, leading to gradual erosion into nearby viscera. Patients may not experience symptoms, but it can cause bleeding, infection, or intestinal obstruction. In our case, the absence of bleeding might be attributed to the thrombosis of the graft, effectively cutting it off from the blood supply.

The removal of a PTFE graft from the duodenum, whether endoscopic or surgical, can potentially cause bleeding if the thrombus at the attached end becomes dislodged. Additionally, there is a possibility of enteric leakage from the site where the graft had entered the intestine. Considering these risks, we opted against intervention. This case demonstrates that eroded PTFE graft into the intestine may spontaneously migrate into the intestine and find its way out of the body, resulting in a successful culmination of the entire episode. Nonetheless, frequent imaging should be performed if a “no intervention” approach is adopted to follow the migration pattern of the graft and pre-empt timely intervention to avoid potentially life-threatening complications such as vascular erosion, pseudoaneurysm formation, or bowel perforation.

Credit authorship contribution statement

Sudhindran Surendran, has designed and conceptualized the review, writing revising, and proofreading of the manuscript. Saraswathy Sivaprasadan and Anila KN drafted the manuscript and carried out the artwork.

Conflicts of interest

None.

Acknowledgements

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Funding

None.