Liver transplantation (LT) is a serious hemostatic challenge in patients with portal vein thrombosis (PVT). Advances in monitoring systems have improved surgery in this setting. We report the successful application of a point-of-care (POC) rotational viscoelastic thromboelastometry-guided (TEM) testing system (ROTEM) which allowed management of coagulation during LT in a 64-year-old cirrhotic patient with a model for end-stage liver disease (MELD) score of 16. Perioperatively, the patient showed complete PVT, hepatomegaly, splenomegaly, recanalization of the umbilical vein, and portosystemic shunt. Macroscopic liver and spleen adherences with collateral circulation were evident. Coagulation factors and fibrinolysis were assessed preoperatively and at graft reperfusion to evaluate the need of hemostatic therapy. Based on ROTEM findings, the patient received 16？g of human fibrinogen concentrate, half preoperatively (with prothrombin complex concentrate 2000？IU, tranexamic acid 1？g, and platelets 2？IU), and two doses of 4？g before and after graft reperfusion; we achieved normalization of all monitored parameters. No ischemia-reperfusion syndrome was present. Postoperatively portal vein flux at Color-Doppler ultrasonography was normal. After a 3-day ICU stay, the patient was moved to the Department of Surgery and discharged on day 14. The postoperative course was uneventful and did not require any further haemostatic therapy. 1. Introduction Chronic liver disease affects hemostasis via three predominant mechanisms: reduced synthesis of coagulation factors and inhibitors, thrombocytopenia and/or thrombocytopathy, and altered fibrinolysis. Liver transplantation (LT) is a serious haemostatic challenge faced by patients with chronic liver disease [1], as the risk of coagulopathic bleeding adds to surgical bleeding. In liver cirrhosis, portal hypertension may induce the formation of collateral vessels that drain portal blood directly into the general circulation, bypassing the liver and causing congestion of the portal area [2]. This situation may dramatically increase surgical bleeding during LT. Portal vein thrombosis (PVT) may decrease the portal flow worsening portal hypertension [3], a condition which shows an incidence of 2–26% in patients with end-stage liver disease which are candidates to LT [4] and who demonstrate exacerbate bleeding during hepatectomy. LT is always a complex surgical procedure; its complexity increases even more in patients with PVT [5] and in the past PVT used to be considered an absolute contraindication for surgery [6]. However,
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