Cryopreserved iliac artery is indispensable interposition graft material for middle hepatic vein reconstruction of right liver grafts

Abstract

Cryopreserved iliac vein grafts (IVGs) have often been used for reconstruction of middle hepatic vein (MHV) branches in right liver grafts, but their storage pool has often been exhausted in our institution due to the low incidence of deceased donor organ procurement. To overcome this shortage of IVG, we started to use cryopreserved iliac artery graft (IAG). During September and October 2004, we carried out 41 cases of adult living donor liver transplantation, including 29 right lobe grafts with MHV reconstruction. Interposition vessel grafts were autologous vein (n ‫؍‬ 6), IVG (n ‫؍‬ 13), and IAG (n ‫؍‬ 10). IAG was used in 3 (21%) of 13 cases during the first month. For the next month, it was more frequently used (7 [44%] of 16) because handling of cryopreserved IAG was not difficult and its outcome was favorable. On follow-up with computed tomography for 3 months, outflow disturbance occurred in 1 (17%) of 6 autologous vein cases, in 2 (15%) of 13 IVG cases, and in 1 (10%) of 10 IAG cases. Twomonth patency rate of IAG was not lower than that of IVG. In conclusion, we feel that cryopreserved IAG can be used as an interposition vessel graft for MHV reconstruction of right liver graft when cryopreserved IVG is not available. (Liver Transpl 2005;11:644-649.) H epatic venous congestion (HVC) from deprivation of middle hepatic vein (MHV) outflow in the right lobe (RL) graft can be prevented by interposition of a vein graft between the major tributaries of MHV and recipient inferior vena cava. 1 In addition to the recipient's autologous vein grafts, such as greater saphenous vein (GSV), left portal vein, and paraumbilical vein, homologous vein grafts such as cryopreserved iliac vein graft (IVG) also have been used for this purpose. 2,3 Recently, cryopreserved IVG became the most preferred vessel graft for MHV reconstruction in our institution, because it did not require time-consuming dissection of recipient tissues and it was usually large and long enough to use for any variant type of MHV branch. However, this IVG preference often exhausted the cryopreserved IVG pool in our situation, because the number of living donor liver transplantations (LDLTs) requiring MHV reconstruction exceeded the low incidence of deceased donor organ procurement. On the other hand, a number of iliac artery grafts (IAGs) always were left in storage because they were never previously used. Although there was no reference to IAG use as a vein graft substitute to our knowledge at that time, we tried to use the cryopreserved IAG in order to overcome the disproportionate shortage of vein grafts. Only after application of several RL grafts did we feel that it was possible to replace IVG with IAG without any serious problem. We herein describe our early experience of MHV reconstruction using IAG for RL grafts. Patients and Methods Recipients and Living DonorsDuring the months of September and October 2004, we have performed 41 cases of adult-to-adult LDLT using 29 RL grafts, 2 left lobe grafts, and 9 dual grafts. As there was one dual LDLT case...

Living-Donor Liver Transplant Using the Right Hepatic Lobe Without the Right Hepatic Vein: Solving the Drainage Problem

“…Wide ostium drainage models have been developed to accept the graft's compression. 2,11 Hwang and associates, [12][13][14] who advocated that SVHs should be greater than 5 mm to be integrated into the drainage system, reported in their latest study that they integrated SVHs ≥ 4 mm into the drainage system. Most the integration models aimed at developing a wide ostium anastomosis tolerating compression are made of allogenic grafts or artificial graft materials.…”

“…Homologous grafts should be preserved by cryopreservation, and no proliferation in cultures should form from the graft material before using the graft. 1,6,12 The recipient left portal vein, the paraumbilical vein, and the vena saphena magna may be used as an autologous vessel Saphenous vein and iliac artery graft was used for creating the common-large opening models. graft.…”

Middle hepatic vein to middle hepatic vein anastomosis in right lobe living donor liver transplantation

“…Although some centers advocate venoplasty of the right hepatic vein (RHV) and the middle hepatic vein (MHV) into a common venous channel, which is then anastomosed directly to a newly created opening on the anterior wall of the inferior vena cava (IVC), 2 others use a variety of extension grafts on the veins draining segments V and VIII, which are then anastomosed to the IVC. 3,4 We use the MHV stump or a length of the MHV from the recipient's liver and perform a direct anastomosis with the MHV of the graft without the use of any extension. We report this technique for anterior sector venous outflow reconstruction, which we have successfully employed at our institution for 78 right lobe LDLT procedures.…”

One-step venous reconstruction for a right lobe graft with multiple venous orifices in living donor liver transplantation

“…Various reconstruction techniques have been reported using autologous vein grafts such as the greater saphenous vein, 2 the left portal vein (PV), 3 or the paraumbilical vein. 4 Moreover, some techniques have been reported using cryopreserved veins 5 or arteries 6 ; however, the availability of such vascular grafts is extremely limited.…”

“…The Model for End-Stage Liver Disease score was 9. Imaging studies revealed severe liver cirrhosis with 3 hypervascular nodules (maximum size, 2.3 cm) in segments 8,6, and 7 of the liver, which were compatible with hepatocellular carcinomas. An LDLT was indicated because of the expected poor prognosis with conventional therapeutic modality.…”