Left Renal Vein Ligation: A Technique to Mitigate Low Portal Flow from Splenic Vein Siphon during Liver Transplantation

Slater, R.; Jabbour, Nicolas; Abbass, Abou A.; Patil, Vasant; Hundley, Jonathan C.; Kazimi, Marwan; Kim, D.; Yoshida, Atsushi; Abouljoud, Marwan

doi:10.1111/j.1600-6143.2011.03578.x

Cited by 32 publications

(28 citation statements)

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“…The LT procedure's plan included preservation of the native IVC and ligation of the LRV to optimize the portal vein flow during LT and to prevent any blood steal through the SRS siphon. (3) At the time of surgery, the LRV was approached by following the infrahepatic IVC downward. The vein identified as the LRV at its root into the IVC was taped.…”

Section: Case Reportmentioning

confidence: 99%

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Duplicate inferior vena cava in liver transplantation: A note of caution when left renal vein ligation is needed

Osseis¹,

Lim²,

Salloum³

et al. 2016

Liver Transpl

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In the case of a hemodynamically significant splenorenal shunt (SRS; spontaneous [5%-12%] (1) or surgical), ligation of the left renal vein (LRV) at its root into the inferior vena cava (IVC) is indicated during liver transplantation (LT) in the following 2 situations:1. To improve the flow through portoportal anastomosis and prevent portal blood steal through the splenorenal siphon. (2,3) 2. To perform renoportal anastomosis in case of stage IV portal vein thrombosis. (4)(5)(6) In this setting, the presence of a duplicate IVC should be diagnosed up front because inadvertent ligation of the duplicate left IVC misdiagnosed with the LRV might result in extensive thrombosis of the left IVC, iliac, and leg deep veins.We report here, for the first time, a case of a cadaveric LT in a recipient with large SRS where a duplicate left IVC was ligated inadvertently. Case ReportA 55-year-old man with hepatocellular carcinoma and alcoholic cirrhosis was referred to our department for LT. This patient had severe portal hypertension and recurrent episodes of hepatic encephalopathy. Preoperative computed tomography (CT) showed a large patent SRS (Fig. 1A). Upon Doppler ultrasonography (DUS), the portal vein was patent with hepatofugal monophasic flow diverted to the SRS. The LT procedure's plan included preservation of the native IVC and ligation of the LRV to optimize the portal vein flow during LT and to prevent any blood steal through the SRS siphon. (3) At the time of surgery, the LRV was approached by following the infrahepatic IVC downward. The vein identified as the LRV at its root into the IVC was taped. No mobilization of the right colon or Kocher maneuver was required. Following portal reperfusion (cold ischemia time 5 5 hours), the portal flow upon DUS showed drastically improved portal flow upon clamping of the taped vein. This was subsequently ligated. Arterial and biliary reconstructions were then performed as usual. At postoperative day 1, a massive left leg edema was found. DUS revealed thrombosis extending from the left iliac vein to the left femoral vein. CT diagnosed the duplicate IVC (Fig. 1B) and extensive thrombosis of the left IVC from its ligation on the left border of the right IVC to the left femoral vein (Fig. 2). Retrospective analysis of the pretransplant CT demonstrated that the anatomical variation was already visible: the left-sided inferior vena cava (L-IVC) ran parallel to the left side of the abdominal aorta to receive the LRV and then crossed the aorta anteriorly to join the contralateral right-sided inferior vena cava (R-IVC) and to drain into a common suprarenal IVC (Fig. 1B). Curative anticoagulation was initiated. At 9 months, the patient is alive with normal DUS and no sequelae. The left iliac vein and IVC are partially repermeabilized.Abbreviations: CT, computed tomography; DUS, Doppler ultrasonography; IVC, inferior vena cava; L-IVC, left-sided inferior vena cava; LRV, left renal vein; LT, liver transplantation; R-IVC, right-sided inferior vena cava; SRS, splenorenal shunt. Address re...

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Section: Case Reportmentioning

confidence: 99%

“…To improve the flow through portoportal anastomosis and prevent portal blood steal through the splenorenal siphon. (2,3) 2. To perform renoportal anastomosis in case of stage IV portal vein thrombosis.…”

mentioning

confidence: 99%

Duplicate inferior vena cava in liver transplantation: A note of caution when left renal vein ligation is needed

Osseis¹,

Lim²,

Salloum³

et al. 2016

Liver Transpl

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“…3,6 In the present case, LRVL was the best alternative therapy for SRS even though the recipient had only 1 kidney. The safety of the procedure was confirmed by normal renal function and creatinine levels that were expected for the patient's age and follow-up duration.…”

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confidence: 92%

“…This procedure restores the appropriate portal flow to the liver graft by reversing the blood flow from the left renal vein to the portal vein through the SRS. 3 We report a case of LRVL that was performed during liver transplantation (LT) for a female recipient with only a single (left) kidney. The patient was a 61-yearold woman with hepatitis B, hepatic cirrhosis, and portal hypertension.…”

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confidence: 99%

“…Adequate portal perfusion is essential for a graft's continued viability after LT. 3 Portal flow diversion through a SRS occurs in nearly 19% of patients with cirrhosis and results in hepatofugal flow and compromised hepatic graft reperfusion. 4,5 When it is necessary, a SRS can be surgically treated during LT through direct ligation of the splenorenal collateral veins with or without splenectomy.…”

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Left renal vein ligation during liver transplantation in a recipient with a single kidney

et al. 2013

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TO THE EDITORS:The treatments for a spontaneous splenorenal shunt (SRS) include splenectomy and direct SRS ligation. However, both are major, technically complicated procedures that are associated with significant bleeding risks.1,2 To achieve the same outcome and avoid SRS manipulation in a region with significant collateral circulation, the surgeon may perform left renal vein ligation (LRVL). This procedure restores the appropriate portal flow to the liver graft by reversing the blood flow from the left renal vein to the portal vein through the SRS. 3 We report a case of LRVL that was performed during liver transplantation (LT) for a female recipient with only a single (left) kidney. The patient was a 61-yearold woman with hepatitis B, hepatic cirrhosis, and portal hypertension. She had tense ascites, jaundice (total bilirubin level 5 3.8 mg/dL), and encephalopathy with a Model for End-Stage Liver Disease score of 21 and a Child-Pugh score of 12. Color Doppler ultrasonography indicated a patent portal vein with a hepatofugal, monophasic flow and a diverted flow to the upper mesenteric veins, gastric veins, and splenorenal shunts. During LT, the recipient portal vein flows were low after reperfusion. Dissection and clamping of the left renal vein were followed by a significant increase in the portal vein flow; LRVL was subsequently performed. Postoperative creatinine levels varied between 1.4 and 2.4 mg/dL. There was no damage to renal function attributable to this maneuver, with creatinine levels remaining at 1.4 mg/dL at the 1-year follow-up examination. Post-LT angioresonance indicated left kidney venous drainage through the gonadal vein to the iliac vessels and through the perisplenic veins to the portal vein (Fig. 1). A 2-year follow-up Doppler ultrasound examination showed increased portal vein flow approximately 3 times greater than the normal with a homogeneous echotexture of the hepatic parenchyma.Adequate portal perfusion is essential for a graft's continued viability after LT.3 Portal flow diversion through a SRS occurs in nearly 19% of patients with cirrhosis and results in hepatofugal flow and compromised hepatic graft reperfusion. 4,5 When it is necessary, a SRS can be surgically treated during LT through direct ligation of the splenorenal collateral veins with or without splenectomy. However, these procedures are dangerous because they are associated with a significant bleeding risk and may even result in death. As a simpler alternative to direct SRS ligation, LRVL has been proposed to avoid surgical manipulation in a region comprising innumerable Figure. 1. Post-LT magnetic resonance angiography shows adequate left kidney venous drainage through the gonadal vein to the iliac vessels and through perisplenic veins to the portal vein. Top arrow indicates a SRS and lower arrow a gonadal vein.The study protocol received a priori approval by the institutional review committee.Address reprint requests to

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Analysis of factors associated with portal vein thrombosis in pediatric living donor liver transplant recipients

et al. 2014

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The technique of vascular reconstruction plays a major role in the outcome of living donor liver transplantation (LDLT). An increased use of vascular grafts (VGs) as replacements for sclerotic portal veins has become a standard technique for our group. The aim of this study was to analyze the factors associated with portal vein thrombosis (PVT) in pediatric LDLT. We performed a retrospective analysis of 486 primary pediatric LDLT procedures performed between October 1995 and May 2013. VGs used for portal reconstruction included living donor inferior mesenteric veins, living donor ovarian veins, recipient internal jugular veins, deceased donor iliac arteries, and deceased donor iliac veins. Thirty-four patients (7.0%) developed PVT. The incidence of PVT dropped from 10.1% to 2%; the overall utilization of VGs increased from 3.5% to 37.1%. In a multivariate analysis, only the use of VGs remained an independent risk factor for the occurrence of PVT (hazard ratio 5 7.2, 95% confidence interval 5 2.8-18.7, P < 0.001). There was no difference in survival rates between patients with PVT and patients without PVT. No patient with PVT underwent retransplantation. In conclusion, the use of VGs was independently associated with the development of PVT. Over time, there was a reduction in the incidence of early PVT in this cohort, and there was a trend toward a reduction in total PVT. The occurrence of isolated PVT in this study was not associated with decreased patient or graft survival.

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Left Renal Vein Ligation: A Technique to Mitigate Low Portal Flow from Splenic Vein Siphon during Liver Transplantation

Cited by 32 publications

References 13 publications

Duplicate inferior vena cava in liver transplantation: A note of caution when left renal vein ligation is needed

Duplicate inferior vena cava in liver transplantation: A note of caution when left renal vein ligation is needed

Left renal vein ligation during liver transplantation in a recipient with a single kidney

Analysis of factors associated with portal vein thrombosis in pediatric living donor liver transplant recipients

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