Hemodynamic profile and tissular oxygenation in orthotopic liver transplantation: Influence of hepatic artery or portal vein revascularization of the graft

Abstract

We performed a prospective, randomized study of adult patients undergoing orthotopic liver transplantation, comparing hemodynamic and tissular oxygenation during reperfusion of the graft. In 30 patients, revascularization was started through the hepatic artery (i.e., initial arterial revascularization) and 10 minutes later the portal vein was unclamped; in 30 others, revascularization was started through the portal vein (i.e., initial portal revascularization) and 10 minutes later the hepatic artery was unclamped. The primary endpoints of the study were mean systemic arterial pressure and the gastric-end-tidal carbon dioxide partial pressure (PCO(2)) difference. The secondary endpoints were other hemodynamic and metabolic data. The pattern of the hemodynamic parameters and tissue oxygenation values during the dissection and anhepatic stages were similar in both groups At the first unclamping, initial portal revascularization produced higher values of mean pulmonary pressure (25 +/- 7 mm of Hg vs. 17 +/- 4 mm of Hg; P < 0.05) and wedge and central venous pressures. At the second unclamping, initial portal revascularization produced higher values of cardiac output and mean arterial pressure (87 +/- 15 mm of Hg vs. 79 +/- 15 mm of Hg; P < 0.05) and pulmonary blood pressure. Postreperfusion syndrome was present in 13 patients (42.5%) in the arterial group and in 11 patients (36%) in the portal group. During revascularization, the values of gastric and arterial pH decreased in both groups and recovered at the end of the procedure, but were more accentuated in the initial arterial revascularization group. In conclusion, we found that initial arterial revascularization of the graft increases pulmonary pressure less markedly, so it may be indicated for those patients with poor pulmonary and cardiac reserve. Nevertheless, for the remaining patients, initial portal revascularization offers more favorable hemodynamic and metabolic behavior, less inotropic drug use, and earlier normalization of lactate and pH values.

Reperfusion of liver graft during transplantation: techniques used in transplant centres within Eurotransplant and meta-analysis of the literature

“…In total, 11 studies could be included. Initial artery reperfusion versus initial portal reperfusion Six studies were included in this comparison: three randomized [1,23,4], two prospective nonrandomized [25,26] and one retrospective study [27]. Meta-analysis of the four included studies did not reveal evidence in favour of a specific reperfusion technique.…”

“…The prolongation of warm ischaemia time and the anhepatic phase with SIMR may impair the graft function [3]. In the systematic review of Gurusamy et al [11], only five randomized controlled trial were included [1,10,23,24,28]. The comparisons performed included IAR vs. IPR, SIMR vs. IPR and RETR vs. SIMR.…”

“…The reason for following this sequence is to ensure that the recipient liver receives blood in the shortest possible time, as portal vein anastomosis is easier, technically, than hepatic artery anastomosis [1]. In addition, endotoxin translocation is reduced, because of intestinal outflow obstruction [2].…”

Anesthesia in Liver Transplantation

“…This reperfusion of the graft is associated with elevations of potassium and hydrogen ion concentrations, increase in preload and decrease in systemic vascular resistance with a decrease in blood pressure. Aggarwal described 'postreperfusion syndrome' (PRS) in 1987, and defined it as at least 30% decrease in mean systemic blood pressure for more than 1 min during the first 5 min following reperfusion and by initial reperfusion of the hepatic artery (Aggarwal et al, 1987;Moreno et al, 2006). Despite the restoration of blood volume, electrolyte and acid base balance, hypotension and bradycardia are also common.…”

“…These changes related to reperfusion may be decreased by using the piggy back technique contributing to a side-bite of IVC allowing the venous return to continue (Findlay, 2002;Gurusamy et al, 2011). Initial arterial reperfusion may be preferable only in patients with poor cardiac reserve (Moreno et al, 2006). Hypothermia is a marker for the presence of graft outflow into the central circulation.…”