Obstructive Shock from Intraoperative Thromboembolism During Liver Transplant: A Case of Low-Dose tPA Rescue

Marko Nemet, M.D.1, Chris Marcellino, M.D.1

1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN

LEARNING OBJECTIVES

• Recognize thromboembolism-mediated obstructive shock during orthotopic liver transplantation (OLT).
• Understand etiology, diagnostic modalities, and management strategies.

CASE DESCRIPTION

• 70-year-old male with MASLD → deceased donor OLT
• Portal vein reperfusion → severe bradycardia, hypotension, PEA arrest
• Management:
o TEE: Large RA/RV thrombus, severe RV dysfunction
o CPR + epinephrine → ROSC
o Incomplete thrombus catheter aspiration → 1 mg intracardiac tPA via central line
o Thrombus resolved; hemodynamics improved
• Post-tPA:
o MTP, FFP, Cryo, TXA for bleeding
• Outcome: Off pressors & extubated within 48 h

PATHOPHYSIOLOGY AND MANAGEMENT

Prothrombotic State of Liver Disease
• ↑ von Willebrand & VIII factor
• ↓ ADAMTS13, protein C & S
• ↓ plasminogen

Iatrogenic Manipulation
• Surgical injury: tissue thromboplastin release
• Use of haemostatic agents
• Clamping/unclamping
• Veno-venous by-pass
• Microthrombosis around catheters

Donor Liver Implantation
• Ischaemia-reperfusion
• Impaired clearance of activated coagulation factors (deceased donor)

Recognition
• Hemodynamic instability
• Cardiac arrest (PEA)
• Hypoxemia
• Decrease in end-tidal CO₂

Diagnosis
• Transesophageal echo
• Pulmonary artery catheter

CV Support
• Inotropes
• Vasopressors
• IV fluids
• Inhaled nitric oxide
• ECMO

Reperfusion
• Anticoagulation
• Systemic thrombolysis
• Catheter therapies
• Surgical embolectomy

CONCLUSIONS

• Intraoperative pulmonary embolism can cause of obstructive shock during OLT
• Immediate TEE assessment allows for rapid diagnosis
• Low-dose tPA may restore perfusion but carries substantial bleeding risk.
• Anticipate coagulopathy and early, aggressive hemostatic support

REFERENCES

1. Feltracco P, Barbieri S, Cillo U, Zanus G, Senzolo M, Ori C. Perioperative thrombotic complications in liver transplantation. World J Gastroenterol. 2015 Jul 14;21(26):8004-13. doi: 10.3748/wjg.v21.i26.8004. PMID: 26185371; PMCID: PMC4499342.

2. González-Mendoza DE, Fernández-Nogueira F, Uribe M, Chávez-Tapia NC, Nuño-Lámbarri N. Hemostatic alterations in metabolic dysfunction-associated steatotic liver disease (MASLD) and their link to venous thromboembolism (VTE). Thromb Res. 2025 Jul 6;253:109395.

3. Kumar N, Flores AS, Mitchell J, Hussain N, Kumar JE, Wang J, Fitzsimons M, Dalia AA, Essandoh M, Black SM, Schenk AD, Stein E, Turner K, Sawyer TR, Iyer MH. Intracardiac thrombosis and pulmonary thromboembolism during liver transplantation: A systematic review and meta-analysis. Am J Transplant. 2023 Aug;23(8):1227-1240.