Segmental venous replacement

Smith, David Eugene; Hammon, John W.; Anane-Sefah, John; Richardson, Robert S.; Trimble, Cleve

doi:10.1016/s0022-5223(19)41540-7

Cited by 61 publications

(1 citation statement)

References 23 publications

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“…Obviously, it carries the risk of thrombosis that is associated with the use of a prosthetic graft in a low-pressure system. 7 This risk may have been minimized in our patient because of the high pressure gradient between the IVC and the right atrium. Augmentation of flow in the cavoatrial shunt during inspiration may have been another contributing factor.…”

Section: Discussionmentioning

confidence: 92%

Cavoatrial shunt: A graft salvage procedure for suprahepatic caval anastomosis obstruction after liver transplantation

et al. 1998

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A liver transplant recipient developed the BuddChiari syndrome because of an obstruction of the suprahepatic inferior vena cava anastomosis. Percutaneous balloon dilatation angioplasty was not feasible. On exploration, dense retrohepatic fibrotic reaction was observed. The patient underwent successful retrohepatic cavoatrial shunt placement by means of a 16-mm, ring-enforced polytetrafluoroethylene graft. We conclude that this shunt should be considered an additional graft salvage procedure for this complication. Copyright 1998 by the American Association for the Study of Liver Diseases S evere stenosis or obstruction of the suprahepatic inferior vena cava (IVC) anastomosis is a rare but serious vascular complication after orthotopic liver transplantation (OLT). 1,2 It usually causes significant obstruction to venous drainage from the allograft liver, resulting in the Budd-Chiari syndrome. 3 The majority of untreated patients die of graft failure. 2 Balloon dilatation angioplasty, with or without the implantation of an intraluminal stent, is the treatment of choice for this complication. 3,4 Surgical repair of the anastomosis has been the subsequent therapeutic option before resorting to retransplantation. The cavoatrial shunt can be considered an alternative graft salvage procedure, and its successful use is described in this report. Case ReportA 45-year-old woman underwent OLT because of hepatitis B cirrhosis. Recipient hepatectomy was somewhat difficult to perform because of dense adhesion of the liver to the right diaphragm, induced by a coexisting right-lobe echinococcal cyst. Routine postoperative Doppler ultrasonography revealed patent vascular anastomoses.Three months post-OLT, the patient developed the Budd-Chiari syndrome. Liver biopsy showed severe centrilobular congestion, with hemorrhage. Inferior venocavogram showed total obstruction of the suprahepatic IVC anastomosis, with reflux of contrast material into the hepatic and left renal veins (Fig. 1). A pressure gradient of 20 cm H 2 O between the IVC and the right atrium was measured. Balloon dilatation angioplasty was attempted, but repeated attempts at crossing the anastomosis were unsuccessful. Laparotomy through a right thoracoabdominal approach was performed.The line of incision began at the anterior axillary line over the ninth rib and was performed obliquely and radially across the costal margin to a midline point that was 2 to 3 cm above the umbilicus. The diaphragm was split in a line toward the supradiaphragmatic segment of the IVC. The inferior pulmonary ligament was divided, and the lung was retracted upward. A markedly engorged liver and a large quantity of ascitic fluid were present. The right hepatic lobe was mobilized and displaced to the left. This permitted access to the retrohepatic IVC. Dense fibrotic reaction compressing the suprahepatic caval anastomosis was found. Direct revision of the anastomosis was judged dangerous because it might induce uncontrollable bleeding or graft ischemia. Therefore, a cavoatrial bypass was perform...

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Section: Discussionmentioning

confidence: 92%