A percutaneous technique for venovenous bypass in orthotopic cadaver liver transplantation and comparison with the open technique

Abstract

Venovenous bypass minimizes the hemodynamic alterations during the anhepatic phase of liver transplantation. A new technique for the percutaneous placement of the bypass cannulae is described and compared to the cut‐down (“open”) technique. The records of 81 patients who underwent 94 liver transplants between August 1991 and April 1994 were reviewed for indications for transplant, United Network for Organ Sharing status, mean age, body surface area, bypass technique and time, flow rates, cardiac output, mean arterial pressure and central venous pressure during bypass, the development of deep venous thrombophlebitis, and lymphoceles. Femoral flow rates were higher in the open group (2054 ± 74 mL/min), compared with the percutaneous group (1726 ± 74 mL/min) (p = 0.003). Total flow rates in the open (2238 ± 58 mL/min) and percutaneous (2197 ± 67 mL/min) groups were not different. Maximum cardiac outputs (L/min) were higher in the open (10.1 ± 0.6) versus percutaneous group (7.0 ± 0.5) (p < 0.0002). Similarly, minimum cardiac outputs (L/min) were higher in the open (8.9 ± 0.7) versus percutaneous group (5.8 ± 0.5) (p = 0.003). Other hemodynamic parameters (mean arterial pressure, central venous pressure) were not different between groups. Venous thrombosis occurred in 1/50 (2.0%) and 4/34 (11.8%) patients in the open and percutaneous groups, respectively (p = 0.153). Nineteen lymphoceles occurred in 102 (18.6%) at‐risk sites in the open group, whereas no lymphoceles occurred in 66 at‐risk sites in the percutaneous group (p < 0.001). Groin lymphoceles occurred in 7/50 (14%) and 0/34 at‐risk sites in the open and percutaneous groups, respectively (p = 0.039). Axillary lymphoceles occurred in 12/52 (23.1%) and 0/32 at‐risk sites in the open and percutaneous groups, respectively (p = 0.0031). Operative repair of a lymphocele was required in 11/16 (69%) patients. The percutaneous placement of catheters for venovenous bypass has the advantage of comparable flow rates with satisfactory hemodynamics without the lymphatic complications of the cut‐down technique. Copyright © 1996 by the American Association for the Study of Liver Diseases.

Technical considerations in liver transplantation: What a hepatologist needs to know (and every surgeon should practice)

“…They can be avoided by careful dissection and ligation of all lymphatics. Lymphocoeles are usually self‐limiting and self‐healing, but occasionally chronic lymphorrhea can be quite disabling and requiring surgical correction 9–15. Newer approaches to percutaneous cannulation of the femoral vein and internal jugular vein may obviate the wound complications associated with cutdowns, however the risk of hematoma formation or venous perforation exists with these techniques.…”

Complications associated with percutaneous placement of venous return cannula for venovenous bypass in adult orthotopic liver transplantation

“…Traditionally, a venous return cannula was inserted into the axillary vein with surgical cut‐down, which carried a high incidence of complications,4 such as seromas or lymphoceles,5, 6 wound infection, and nerve injuries 7. A percutaneous technique, first introduced in 1994,8 has been shown to reduce complications related to the surgical cut‐down,9, 10 maintain adequate shunt flow and stable hemodynamics,9, 11 and has become an established alternative method for cannula placement in VVB.…”

Venovenous bypass in orthotopic liver transplantation: Time for a rethink?

“…The reported complication rate with standard techniques is about 10%,3 the most common complication being lymphocele formation. The reported incidence of lymphocele formation with this technique ranges from 15.6‐18.6% 51, 52. Brachial plexus injury has been reported in patients with surgical cutdown of axillary veins (2.5%) 53…”