Transdiaphragmatic Exposure for Direct Atrial-Caval Anastomosis in Liver Transplantation for Budd-Chiari Syndrome

Burtch, Gordon D.; Merion, Robert M.

doi:10.1097/00007890-198907000-00042

Cited by 10 publications

(4 citation statements)

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“…Graft hepatectomy may be hemorrhagic because of intense neovascularization, especially after artery thrombosis. Intrapericardial control of the vena cava 19 and en bloc clamping of both infrahepatic vena cava and hepatic pedicle are techniques that can be used to help minimize blood loss or the occurrence of an air embolism. Portal and arterial reconstruction may require the interposition of donor iliac vessels.…”

Section: Discussionmentioning

confidence: 99%

Rationale and technical constraints of a tertiary liver transplantation

et al. 1997

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Because of the current shortage of donor organs, the routine performance of tertiary liver transplantation (LT) may be questioned. In this study, the indications of tertiary LT are discussed, paying particular attention to intraoperative technique. Of 501 LTs performed from 1986 to 1995, eight (1.6%) were tertiary LTs. Three patients underwent an emergent third LT because of associated hepatic artery and portal vein thromboses (n ‫؍‬ 2) or hyperacute rejection (n ‫؍‬ 1). Five patients had an elective third LT for ischemic cholangitis (n ‫؍‬ 4) or chronic rejection (n ‫؍‬ 1). The 3 patients who underwent retransplantation emergently died early from multiple-organ failure. Because of previous surgery and subsequent technical difficulties, the third LT in the remaining 5 patients required unroutine surgical procedures including the following: intrapericardial control of the suprahepatic vena cava (n ‫؍‬ 1), ''en bloc'' clamping of both the infrahepatic vena cava and the hepatic pedicle (n ‫؍‬ 1), arterial reconstruction onto the aorta via an aortoiliac conduit (n ‫؍‬ 5), and aortic resection with aortoaortic prosthetic reconstruction (n ‫؍‬ 1). Of these 5 patients, 4 required reoperation because of bowel perforation (n ‫؍‬ 5) or intraperitoneal bleeding (n ‫؍‬ 1). The 5 patients (62%) who were regrafted electively are alive and well after a median follow-up of 45 months. A third LT can be reasonably offered to selected young recipients if performed electively. Tertiary LT may require unroutine surgical procedures and may lead to severe morbidity.

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Section: Discussionmentioning

confidence: 99%

Rationale and technical constraints of a tertiary liver transplantation

et al. 1997

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“…Intrapericardial control of the suprahepatic inferior vena cava (SIVC) is a rather uncommon procedure that is occasionally required during isolation of the native liver before its removal during transplantation. [1][2][3] Other indications for intrapericardial control of the SIVC include prior liver resection, trauma, or the need for enhanced exposure (sometimes necessary to impede hemorrhaging). [4][5][6] Control of the SIVC above the diaphragm can be achieved through the chest (eg, through a sternotomy or thoracotomy), through the abdomen (eg, transdiaphragmatically), or through a combination of the two (eg, through a thoracoabdominal incision).…”

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confidence: 99%

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confidence: 99%

Cardiac tamponade following liver transplantation after intrapericardial control of the suprahepatic vena cava

Xu¹,

Hong²,

Busuttil³

2015

Liver Transpl

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Transabdominal intrapericardial control of the suprahepatic inferior vena cava (SIVC) is a rather uncommon procedure occasionally required in conjunction with complicated liver transplantation (LT) and hepatobiliary surgery. Experience with this technique is limited. Here we report 6 cases of LT in which transabdominal intrapericardial control of the SIVC was necessary. After institutional review board approval was obtained, a single-center, retrospective review was conducted from January 1991 to December 2013 to identify adult cases (age > 18 years) of LT in which transabdominal intrapericardial isolation of the SIVC was necessary. Among 4102 adult LT cases in the study period, 6 such cases were identified. To gain access to the pericardial space, a 6-to 9-cm vertical incision was made above the SIVC. After reperfusion, the diaphragmatic incision was partially closed and selectively drained. Pericardial tamponade developed in 1 patient, and it necessitated emergent reoperation and widespread drainage. In conclusion, transabdominal intrapericardial isolation of the SIVC is easily achieved without the need for a separate thoracic incision. However, to be effective, the pericardial incision should be only partially closed, and the pericardial sac should be drained liberally. Such patients should be carefully monitored for signs and symptoms of pericardial tamponade, the development of which should prompt an immediate return to the operating room for emergent decompression and widespread drainage.

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“…Extensive caval thrombolysis and thrombectomy were performed at the time of transplant with excision of the recipient infra‐ and suprahepatic IVC, and placement of an interposition donor infrarenal IVC graft between the donor cava and the recipient RA. In previously reported cases with IVC stricture or thrombosis extending to the RA that were undergoing orthotopic liver transplantation, direct atriocaval anastomosis has been described 9, 10…”

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confidence: 99%

Liver transplantation with caval thrombectomy and cavoatrial shunt in acute Budd-Chiari syndrome

et al. 2007

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A 38-year-old woman was admitted to her local hospital with acute-onset upper abdominal pain and vomiting. Examination revealed mild jaundice, ascites, smooth, tender hepatomegaly, and bilateral lower limb edema. Liver function tests were abnormal, with increased serum bilirubin of 37 mol/L and aspartate transaminase of 515 IU/L. Abdominal ultrasound revealed a diffusely enlarged hypoechoic liver with thrombus in the inferior vena cava (IVC) extending to the hepatic veins, moderate ascites, and a patent portal vein. A procoagulant screen was normal, with the exception of lupus anticoagulant, which was increased at 1.46 (normal range 0.8-1.2). No anticoagulation therapy had been used. Abdominal computed tomographic scan confirmed the presence of luminal caval thrombus extending from the level of the bifurcation superiorly to the right atrium (RA) (Fig. 1). The patient was transferred to our liver intensive care unit for further management of acute Budd-Chiari syndrome.Her clinical condition deteriorated over several days, and she was listed for urgent liver transplantation. Intraoperative findings included moderate ascites, severe portal hypertension, and an enlarged, hard, congested liver. The IVC was thrombosed along its length from the iliac veins to the RA. Access for left axillary vein to portal vein venovenous bypass was prepared early. The femoral veins were not cannulated because of the presence of iliac thrombus. The supradiaphragmatic IVC was severely stenosed, with extensive hard caval thrombus. A midline sternotomy was performed, the RA cross-clamped just below the coronary sinus, and the stenotic IVC excised. The infrahepatic vena cava was thrombectomized with a Foley and a large Fogarty catheter, followed by retrograde infusion of 3 mg of recombinant tissue plasminogen activator. The liver was removed after clamping the infrahepatic vena cava. Because the donor heart had been retrieved leaving a very short suprahepatic cava, donor infrarenal IVC was used as an interpositional graft, with anastomosis to the RA (Fig. 2). The graft was implanted by first suturing the suprahepatic vena cava to the caval interpositional graft. The infrahepatic vena cava was re-bled, and a further thrombectomy performed. Portal, arterial, and biliary anastomoses were completed in standard fashion. Postoperative recovery was complicated by renal failure and sepsis. The patient is currently well 1 year after transplantation and has patent cava and hepatic veins (Fig. 3).Budd-Chiari syndrome is a heterogenous group of disorders characterized by obstruction of hepatic venous outflow.

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Transdiaphragmatic Exposure for Direct Atrial-Caval Anastomosis in Liver Transplantation for Budd-Chiari Syndrome

Cited by 10 publications

References 0 publications

Rationale and technical constraints of a tertiary liver transplantation

Rationale and technical constraints of a tertiary liver transplantation

Cardiac tamponade following liver transplantation after intrapericardial control of the suprahepatic vena cava

Liver transplantation with caval thrombectomy and cavoatrial shunt in acute Budd-Chiari syndrome

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