- Email: [email protected]
Artificial Vascular Graft for Inferior Vena Cava Reconstruction in Living Donor Liver Transplantation: A Case Report
Artificial Vascular Graft for Inferior Vena Cava Reconstruction in Living Donor Liver Transplantation: A Case Report L.-B. Jeng, P.-C. Li, M.-D. Yang, C.-C. Lee, C.-L. Chang, and R. S.-C. Wu ABSTRACT Artificial grafts are not recommended because of the high incidence of thrombogenic effects. However, in some situations, such as emergency or when no vascular bank is available, an artificial graft must be used. We present a case in which a polytetrafluoroethyline graft was used as a conduit to reconstruct the retrohepatic vena cava severed during living donor liver transplantation (LDLT). A 48-year-old woman had end-stage primary biliary cirrhosis for 5 years received a right lobe liver graft from her son. The retrohepatic vena cava was divided and ligated in several sequences. The upper end of the severed retrohepatic vena cava retracted into the liver parenchyma. The lower end of the severed vena cava was distended, with multiple stitches. A 16-mm artificial graft was used as a conduit to replace the inferin vena cava for outflow reconstruction. The patient tolerated the complicated procedure well. No anticoagulant was used throughout the entire course. The patient has been well with excellent liver function after follow-up for more than 5 years. Magnetic resonance imaging and Doppler ultrasonographic studies showed good patency of the cava with no evidence of thrombosis. We suggest use of an artificial graft in living donor liver transplantation, in particular in urgent situations when autologous or allogeneic vessels are not available.
A
UTOLOGOUS OR ALLOGENEIC vascular grafts have been used for vessel reconstruction in liver transplantation.1–5 Artificial grafts are not recommended because of the high incidence of thrombogenic effects.6 However, in some situations, such as an emergency or when no vascular bank is available, an artificial graft must be used. We present a case in which a polytetrafluoroethyline (PTFE) graft (Gore-Tex; W. L. Gore and Associates, Flagstaff, Arizona) was used as a conduit to reconstruct a severed retrohepatic vena cava during living donor liver transplantation (LDLT). CASE REPORT A 48-year-old woman who had end-stage primary biliary cirrhosis for years received a right lobe liver graft from her son. Mobilization of the diseased liver was performed by the recipient team. No retrohepatic vena cava could be identified. After meticulous dissection, it was found that the retrohepatic vena cava had been divided and ligated in several sequences. The upper end of the severed retrohepatic vena cava was retracted into the liver parenchyma close to the draining orifice of the hepatic veins. The lower end of the severed vena cava was distended because it had been closed with multiple stitches and ligatures. The recipient liver was excised after the suprahepatic cava was cross-clamped. The stumps of the middle and left hepatic veins (MHV and LHV, respectively) were oversewn with 4-0 polypropyline.
The right hepatic veins (RHV) was left open. The edge of the severed retrohepatic cava was zigzag shaped and about 1 cm distal to the inferior margin of the clamp. The right lobe of donor liver was harvested as soon as possible. Implantation procedures started with the hepatic vein anastomosis. The donor RHV was anastomosed to the recipient RHV end-to-end. The portal vein anastomosis was performed next. Then the graft was revascularized with a clamp applied to the edge of the severed cava. Immediately, the liver graft appeared to be congested and gradually became stony hard. No outflow was evident. A clamp was applied to the cava above the RHV anastomosis site. The graft was removed and reperfused with University of Wisconsin solution and placed in a basin. The edge of the severed cava was trimmed. A 16-mm PTFE graft was anastomosed to the trimmed end. Then the RHV of the liver graft was sewn to an opening created at the PTFE graft close to the anastomosis. When the liver graft was revascularized after completion of the portal vein anastomosis, no graft congestion was noted. The other end of the From the Departments of Surgery (L.-B.J., P.-C.L., M.-D.Y., C.-C.L., C.-L.C.), and Anesthesiology Pain Service and Critical Care Medicine (R.S.-C.W.), China Medical University and China Medical University Hospital, Taichung, Taiwan, China. Address reprint requests to Dr Long-Bin Jeng, Department of Surgery, China Medical University and China Medical University Hospital, No. 2, Yu-Der Road, 404 Taichung, Taiwan, China. E-mail: [email protected]
© 2008 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/08/$–see front matter doi:10.1016/j.transproceed.2008.07.024
Transplantation Proceedings, 40, 2527–2528 (2008)
2527
2528
JENG, LI, YANG, ET AL
DISCUSSION
Adult LDLT using a right lobe graft has been adopted as a standard procedure in most series.1 The technique of outflow reconstruction remains controversial, though the general concept is to create a wide outflow tract.2 The patency of the recipient inferior vena cava (IVC) is rarely discussed except in the case of Budd-Chiari syndrome3 or total hepatectomy including the IVC because of hepatoblastoma.4 Complete severance of the retrohepatic cava results in no IVC for graft outflow reconstruction. Before LDLT, imaging studies provide detailed information about the vascular and biliary anatomy of both donor and recipient. In patients with Budd-Chiari syndrome or advanced hepatoblastoma, resection of the IVC and preparation IVC reconstruction using a vascular graft are well planned. In situations such as in our case, there was no preparation. We decided not to place a venovenous bypass graft because the recipient’s vital signs maintained stable. We attempted to implant the liver graft first rather than doing a caval reconstruction. Graft congestion developed after revascularization. The graft had to be removed and recooled, which suggests that IVC reconstruction must be performed first when the length of the IVC remnant is not sufficient to provide a wide lumen for RHV outflow reconstruction. Most surgeons prefer to use autologous or allogeneic vascular grafts from living donors, recipients, or a vascular bank. Synthetic grafts are not suggested because of the greater risk of thrombosis.1,5 However, we had to perform an IVC reconstruction to implant the right lobe graft. There was no time to harvest a suitably sized vessel from either the donor or the recipient. In addition, we did not have any cryopreserved vascular graft in the vascular bank. The PTFE graft was the only choice. The outcome of the recipient and long-term patency of the IVC graft proved the potential alternative of a PTFE graft for IVC reconstruction. In conclusion, we suggest use of an artificial vascular graft for IVC reconstruction during LDLT, in particular in an emergent situation when autologous or allogeneic vessels are not available. REFERENCES Fig 1. A, One year after transplantation, computed tomographic scan shows patent graft and hepatic vein. B, Five years after transplantation, magnetic resonance image shows patent graft and hepatic vein, with no thrombus. The arrows indicate the junction between the right hepatic vein of the donor graft and the interposed PTFE IVC graft.
PTFE graft was anastomosed to the lower end of the severed cava. Then the clamp was relieved to restore the systemic circulation. The hepatic artery anastomosis and biliary reconstruction were subsequently completed. The patient tolerated the complicated procedure well. No anticoagulant was used through the entire course. The patient has been well with excellent liver function after a follow-up for more than 5 years. Magnetic resonance imaging and Doppler ultrasonographic studies showed good patency of the cava with no evidence of thrombosis (Fig 1, A and B).
1. Kilic M, Aydin U, Sozbilen M, et al: Comparison between allogenic and autologous vascular conduits in the drainage of anterior sector in right living donor liver transplantation. Transplant Int 20:697, 2007 2. Hashimoto T, Sugawara Y, Tamura S, et al: One orifice vein reconstruction in left liver plus caudate lobe grafts. Transplantation 83:225, 2007 3. Yamada T, Tanaka K, Ogura Y, et al: Surgical techniques and long-term outcomes of living donor liver transplantation for BuddChiari syndrome. Am J Transplant 6:2463, 2006 4. Shimoda M, Marubashi S, Dono K, et al: Utilization of autologous vein graft for replacement of the inferior vena in living-donor liver transplantation for obliterative hepatocavopathy. Transplant Int 20:804, 2007 5. Chardot C, Saint Martin C, Gilles A, et al: Living-related liver transplantation and vena cava reconstruction after total hepatectomy including the vena cava for hepatoblastoma. Transplantation 73:90, 2002 6. Kraiss W, Johansen K: Pharmacologic intervention to prevent graft failure. Surg Clin North Am 75:761, 1995
A
UTOLOGOUS OR ALLOGENEIC vascular grafts have been used for vessel reconstruction in liver transplantation.1–5 Artificial grafts are not recommended because of the high incidence of thrombogenic effects.6 However, in some situations, such as an emergency or when no vascular bank is available, an artificial graft must be used. We present a case in which a polytetrafluoroethyline (PTFE) graft (Gore-Tex; W. L. Gore and Associates, Flagstaff, Arizona) was used as a conduit to reconstruct a severed retrohepatic vena cava during living donor liver transplantation (LDLT). CASE REPORT A 48-year-old woman who had end-stage primary biliary cirrhosis for years received a right lobe liver graft from her son. Mobilization of the diseased liver was performed by the recipient team. No retrohepatic vena cava could be identified. After meticulous dissection, it was found that the retrohepatic vena cava had been divided and ligated in several sequences. The upper end of the severed retrohepatic vena cava was retracted into the liver parenchyma close to the draining orifice of the hepatic veins. The lower end of the severed vena cava was distended because it had been closed with multiple stitches and ligatures. The recipient liver was excised after the suprahepatic cava was cross-clamped. The stumps of the middle and left hepatic veins (MHV and LHV, respectively) were oversewn with 4-0 polypropyline.
The right hepatic veins (RHV) was left open. The edge of the severed retrohepatic cava was zigzag shaped and about 1 cm distal to the inferior margin of the clamp. The right lobe of donor liver was harvested as soon as possible. Implantation procedures started with the hepatic vein anastomosis. The donor RHV was anastomosed to the recipient RHV end-to-end. The portal vein anastomosis was performed next. Then the graft was revascularized with a clamp applied to the edge of the severed cava. Immediately, the liver graft appeared to be congested and gradually became stony hard. No outflow was evident. A clamp was applied to the cava above the RHV anastomosis site. The graft was removed and reperfused with University of Wisconsin solution and placed in a basin. The edge of the severed cava was trimmed. A 16-mm PTFE graft was anastomosed to the trimmed end. Then the RHV of the liver graft was sewn to an opening created at the PTFE graft close to the anastomosis. When the liver graft was revascularized after completion of the portal vein anastomosis, no graft congestion was noted. The other end of the From the Departments of Surgery (L.-B.J., P.-C.L., M.-D.Y., C.-C.L., C.-L.C.), and Anesthesiology Pain Service and Critical Care Medicine (R.S.-C.W.), China Medical University and China Medical University Hospital, Taichung, Taiwan, China. Address reprint requests to Dr Long-Bin Jeng, Department of Surgery, China Medical University and China Medical University Hospital, No. 2, Yu-Der Road, 404 Taichung, Taiwan, China. E-mail: [email protected]
© 2008 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/08/$–see front matter doi:10.1016/j.transproceed.2008.07.024
Transplantation Proceedings, 40, 2527–2528 (2008)
2527
2528
JENG, LI, YANG, ET AL
DISCUSSION
Adult LDLT using a right lobe graft has been adopted as a standard procedure in most series.1 The technique of outflow reconstruction remains controversial, though the general concept is to create a wide outflow tract.2 The patency of the recipient inferior vena cava (IVC) is rarely discussed except in the case of Budd-Chiari syndrome3 or total hepatectomy including the IVC because of hepatoblastoma.4 Complete severance of the retrohepatic cava results in no IVC for graft outflow reconstruction. Before LDLT, imaging studies provide detailed information about the vascular and biliary anatomy of both donor and recipient. In patients with Budd-Chiari syndrome or advanced hepatoblastoma, resection of the IVC and preparation IVC reconstruction using a vascular graft are well planned. In situations such as in our case, there was no preparation. We decided not to place a venovenous bypass graft because the recipient’s vital signs maintained stable. We attempted to implant the liver graft first rather than doing a caval reconstruction. Graft congestion developed after revascularization. The graft had to be removed and recooled, which suggests that IVC reconstruction must be performed first when the length of the IVC remnant is not sufficient to provide a wide lumen for RHV outflow reconstruction. Most surgeons prefer to use autologous or allogeneic vascular grafts from living donors, recipients, or a vascular bank. Synthetic grafts are not suggested because of the greater risk of thrombosis.1,5 However, we had to perform an IVC reconstruction to implant the right lobe graft. There was no time to harvest a suitably sized vessel from either the donor or the recipient. In addition, we did not have any cryopreserved vascular graft in the vascular bank. The PTFE graft was the only choice. The outcome of the recipient and long-term patency of the IVC graft proved the potential alternative of a PTFE graft for IVC reconstruction. In conclusion, we suggest use of an artificial vascular graft for IVC reconstruction during LDLT, in particular in an emergent situation when autologous or allogeneic vessels are not available. REFERENCES Fig 1. A, One year after transplantation, computed tomographic scan shows patent graft and hepatic vein. B, Five years after transplantation, magnetic resonance image shows patent graft and hepatic vein, with no thrombus. The arrows indicate the junction between the right hepatic vein of the donor graft and the interposed PTFE IVC graft.
PTFE graft was anastomosed to the lower end of the severed cava. Then the clamp was relieved to restore the systemic circulation. The hepatic artery anastomosis and biliary reconstruction were subsequently completed. The patient tolerated the complicated procedure well. No anticoagulant was used through the entire course. The patient has been well with excellent liver function after a follow-up for more than 5 years. Magnetic resonance imaging and Doppler ultrasonographic studies showed good patency of the cava with no evidence of thrombosis (Fig 1, A and B).
1. Kilic M, Aydin U, Sozbilen M, et al: Comparison between allogenic and autologous vascular conduits in the drainage of anterior sector in right living donor liver transplantation. Transplant Int 20:697, 2007 2. Hashimoto T, Sugawara Y, Tamura S, et al: One orifice vein reconstruction in left liver plus caudate lobe grafts. Transplantation 83:225, 2007 3. Yamada T, Tanaka K, Ogura Y, et al: Surgical techniques and long-term outcomes of living donor liver transplantation for BuddChiari syndrome. Am J Transplant 6:2463, 2006 4. Shimoda M, Marubashi S, Dono K, et al: Utilization of autologous vein graft for replacement of the inferior vena in living-donor liver transplantation for obliterative hepatocavopathy. Transplant Int 20:804, 2007 5. Chardot C, Saint Martin C, Gilles A, et al: Living-related liver transplantation and vena cava reconstruction after total hepatectomy including the vena cava for hepatoblastoma. Transplantation 73:90, 2002 6. Kraiss W, Johansen K: Pharmacologic intervention to prevent graft failure. Surg Clin North Am 75:761, 1995