Simplifying hepatic venous outflow reconstruction in sequential living donor liver transplantation

Abstract

The native liver of a familial amyloidotic polyneuropathy recipient who undergoes living donor liver transplantation used as a graft for sequential liver transplantation does not include the inferior vena cava. Implantation of this whole liver graft to a second recipient could be simplified by borrowing the experience from right liver living donor liver transplantation. With careful release of the hepatic vein from its surrounding adventitia mainly by sharp dissections, adequate lengths of these veins could be attained without compromising the native inferior vena cava. Following venoplasty of the right and middle/left hepatic vein stumps, the single cuff of the hepatic veins is anastomosed to the inferior vena cava without interpositional venous graft or patch. Satisfactory venous outflow is reliably achieved because this is the most direct outflow tract. Liver Transpl 15: 1514Transpl 15: -1518Transpl 15: , 2009 Sequential liver transplantation using a deceased donor liver graft for familial amyloidotic polyneuropathy (FAP) is well described.1 Classically, the liver explanted from a patient with FAP, or an amyloid hepatic allograft (AHA), is transplanted to a second recipient (AHA recipient). The latter is usually greater than 60 years old, because the AHA will continue to produce variant transthyretin, resulting in neuropathy years later. In deceased donor sequential liver transplantation, the inferior vena cava (IVC) is included in the deceased donor liver graft and also in the AHA. Therefore, graft implantation is by end-to-end IVC anastomosis for both recipients. Total hepatectomy of the patient with FAP is similar to standard deceased donor liver transplantation, except that the suprahepatic and infrahepatic IVC of a just adequate length are included in the AHA for implantation in the AHA recipient. It is important to note that the FAP patient should not be considered at a disadvantage for being a living liver donor in the recipient total hepatectomy. A way to maintain the IVC flow during the anhepatic phase and without venovenous bypass is application of the piggyback technique.2 This has been applied to patients with FAP who had side-toside cava-caval anastomosis and closure of the suprahepatic and infrahepatic cava. 3In the case of living donor sequential liver transplantation, however, the IVC of the FAP patient has to be preserved in all cases and is not included in the AHA explanted from the FAP patient. This AHA, which is a whole graft and devoid of the IVC for implantation to the AHA recipient, also requires unimpeded venous outflow. The procedure, though akin to the piggyback technique, is different because the length of the hepatic veins in the AHA graft is limited. FIRST RECIPIENTThe patient with FAP was 42 years old. Her main symptoms were peripheral, and autonomic polyneuropathy manifested as numbness of the limbs and constipation. She also had weight loss of 7 kg over a 1-year period. Antral biopsy by upper endoscopy revealed Congo redstained amyloid deposits in the muscularis mucosae. E...

Living donor domino liver transplantation using a maple syrup urine disease donor: A case series of three children – The first report from Japan

“…By venoplasty at the back table, the RHV, MHV, and LHV were sutured together to create a single cuff. Few reports have discussed the optimal techniques of outflow reconstruction . In this case series, we employed the technique described by Chan et al , which was venoplasty of the RHV, MHV, and LHV stumps and the single cuff of the HVs anastomosed to the IVC without an interpositional graft or patch.…”

Technical options for outflow reconstruction in domino liver transplantation: A single European center experience

“…Direct end‐to‐end anastomosis between the HV stumps is technically difficult, and venoplasties are usually performed . The use of vascular grafts is also highly recommended, and several venous graft options have been proposed, including the use of a cadaveric Y‐shaped IVC‐iliac or portal vein bifurcation, a longitudinally opened iliac vein, or an autologous portal vein or umbilical vein .…”

“…The need to share the vascular stumps between the graft and the donor might compromise the length of the vessels and render the outflow reconstruction extremely laborious. Direct end‐to‐end anastomosis between the hepatic veins (HVs) of the graft and the recipient have also been associated with technical difficulties, and therefore, septoplasties or bridge venoplasties between the HV stumps in the FAP graft are advisable whenever possible …”