Outflow reconstruction for right liver allograft with multiple hepatic veins: “V‐plasty” of hepatic veins to form a common outflow channel versus 2 or more hepatic vein–to–inferior vena cava anastomoses in limited retrohepatic space

Abstract

Outflow reconstruction in living donor liver transplantation (LDLT) is certainly difficult in limited retrohepatic space with using right liver grafts with venous anomalies. Venoplasty of the inferior right hepatic veins (IRHVs) and middle hepatic vein (MHV) reconstruction using synthetic grafts to form a common outflow channel or a second venocaval anastomosis are available options. We aim to compare outcomes of LDLT recipients who underwent outflow reconstruction with a "V-Plasty" technique and outcomes of patients who underwent a second venocaval anastomosis. Out of 325 recipients who underwent LDLT from March 2011 to September 2014, 45 received right liver allografts that were devoid of MHV with multiple draining IRHVs (2 or more). Group A (n 5 16) comprised the recipients with outflow reconstruction with a V-Plasty, and group B (n 5 29) included the recipients with a second venocaval anastomosis. Group A recipients (male:female, 10:6; median age, 50.5 years) had a mean Model for End-Stage Liver Disease score of 14.7, whereas for group B recipients (male:female, 20:9; median age, 52.0 years) it was 17.2. The mean IRHV diameter for group A and B grafts was 8.3 mm each. Mean warm ischemia time for group A was significantly lower (25.2 minutes) as compared to group B recipients (34.6 minutes) with P < 0.001. The 2-month patency rates of vascular grafts were 100% for group A recipients with no evidence of thrombosis. In conclusion, the V-Plasty technique of MHV and IRHV reconstruction to form a common outflow is a new concept that proves to be a safe and feasible alternative for second venocaval anastomosis.

Assessing the Safety of Expanded Polytetrafluoroethylene Synthetic Grafts in Living Donor Liver Transplantation: Graft Migration Into Hollow Viscous Organs – Diagnosis and Treatment Options

“…The ePTFE synthetic grafts are commonly used interpositional conduits during the backtable venoplasty procedure of such liver allografts, with excellent short- and long-term graft outcomes [2,3,8]. Thrombosis of the graft and possible risk of infections, although rare, are the possible complications of ePTFE use in LDLT recipients.…”

“…ePTFE graft migration into the surrounding hollow viscous organs causing perforation has been described recently, and tends to narrow the safety margin for the use of the ePTFE synthetic grafts [5–7]. However, such complications are fortunately rare and the safety and feasibility of ePTFE use in LDLT has been proven by several studies [2,3,8,10]. …”

“…Third, surgical intervention was necessary to remove the infected graft, which was proven to be an adequate treatment without need for formal hepatectomy. As mentioned in our previous studies [3,8], the intrahepatic venous collateral channels are expected to develop within 2 months after liver transplantation, and the patency of the ePTFE graft does not serve the same purpose after two months post-transplantation. Hence, its removal after this period has no effect on liver allograft venous outflow.…”

“…Description of the backtable venoplasty technique of our institution is beyond the scope of this article and was described earlier in detail [3,8]. Figure 1 shows various backtable venoplasty procedures used to reconstruct the MHV and/or IRHV tributaries.…”

Reconstruction of the Portal Vein with Expanded Polytetrafluoroethylene Jump Graft in Living Donor Liver Transplantation Recipients with Complete Portal Vein Thrombosis: A Feasible and Safe Alternative

“…We do not have cryopreserved vascular grafts at our centre, and due to the underlying surgical complexity of harvesting donor or recipient autologous veins during LDLT, we prefer ePTFE vascular conduits for venous reconstruction. In our earlier studies, we have reported the safety and feasibility of ePTFE synthetic grafts for venous reconstruction for vessels such as inferior vena cava and middle hepatic venous tributaries of the right liver allograft without any thrombotic complications (10)(11)(12). By far, the role of the ePTFE graft for portal vein reconstruction remains scarce (3).…”