Ann Liver Transplant.  2021 Nov;1(2):153-159. 10.52604/alt.21.0025.

Technical refinement of inferior vena cava replacement using a synthetic vascular graft in living donor liver transplantation

• Moon DB
• Hwang S
• Ahn CS
• Ha TY
• Song GW
• Jung DH
• Park GC
• Yoon YI
• Lee SG

• KMID: 2560866
• DOI: http://doi.org/10.52604/alt.21.0025

Abstract

The native inferior vena cava (IVC) can be resected during living donor liver transplantation (LDLT) in Budd-Chiari syndrome or advanced hepatocellular carcinoma (HCC). The present study aimed to present the technical details of IVC replacement with synthetic vascular graft interposition. Following laparotomy, the recipient liver was mobilized to expose the IVC. Piggyback or classical total hepatectomy including IVC was performed. In patients with Budd-Chiari syndrome, atrio-caval anastomosis with a vascular graft is necessary, in which clamp slippage should be completely prevented. No-touch en bloc isolation of the native liver is necessary for patients with advanced HCC. The wall of a large-caliber vascular graft is pleated to prevent luminal collapse, suggesting the need for tension to stretch it. The length of a vascular graft should be adjusted meticulously. An adequately interposed vascular graft appears to be rather short under IVC cross-clamping, but elongated and expanded after restoration of the IVC flow. A single right or left liver graft, or even dual-graft can be implanted to the interposed IVC vascular graft. An elliptical excision of the graft wall is mandatory for graft hepatic vein implantation, because an incision at the graft does not expand. In conclusion, IVC replacement with interposition of a synthetic vascular graft expands the indications for LDLT, particularly in patients with Budd-Chiari syndrome and advanced HCC, similar to those of deceased donor liver transplantation.

Keyword

Living donor liver transplantation; Budd-Chiari syndrome; Graft outflow vein obstruction; Hepatocellular carcinoma; Synthetic graft

Figure

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  Figure 1 Intraoperative photographs of inferior vena cava (IVC) replacement in a patient with Budd-Chiari syndrome. (A) The native suprahepatic IVC is divided and closed after total hepatectomy. (B) Pericardiotomy is performed to expose the atrium. (C) The inferior right-lateral surface of the atrium is clamped with a Satinsky clamp. (D) A 30-mm-long incision is made for anastomosis. (E) A synthetic vascular graft is anastomosed with the atrial opening. (F) A test for hemostasis at the atrio-caval anastomosis is performed. (G) The proximal portion of the vascular graft is clamped after release of the atrial clamping. (H) The outflow vein orifice of a left liver graft is anastomosed with the opening at the vascular graft after elliptical excision of the graft wall. (I, J) The suprahepatic and infrahepatic caval anastomoses are visible.

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  Figure 2 Intraoperative photographs of inferior vena cava (IVC) replacement in a patient with advanced hepatocellular carcinoma. (A) A large-sized vascular graft is anastomosed with the suprahepatic IVC. (B, C) The stump of the infrahepatic IVC is reinforced with an autologous greater saphenous vein patch. (D, E) The vascular graft is stretched caudally to avoid kinking from redundancy, followed by infrahepatic caval anastomosis. (F) The configuration of the interposition graft is visualized after temporary IVC cross-clamping. (G) The graft right hepatic vein is anastomosed to the vascular conduit after creating an elliptical excision in the graft wall. (H) The graft middle hepatic vein conduit is anastomosed to the vascular conduit after making an elliptical excision of the graft wall.

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  Figure 3 Intraoperative photographs of inferior vena cava (IVC) replacement in a patient with Budd-Chiari syndrome. (A, B) The length of a vascular conduit is be adjusted after atrio-caval anastomosis. (C, D) The interposed vascular graft appears to be rather short under IVC cross-clamping, but elongates and expands after the release of the IVC cross-clamping. A modified right liver graft with a middle hepatic vein conduit using a cryopreserved aorta is implanted to the interposed vascular graft.

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  Figure 4 Intraoperative photographs of inferior vena cava (IVC) replacement in a patient with advanced hepatocellular carcinoma. (A) The suprahepatic IVC stump is widened after unification of the hepatic vein trunk openings. (B) A size-matched vascular graft is anastomosed with the suprahepatic IVC stump. (C) A telescoping anastomosis is performed with the infrahepatic IVC stump. (D) A modified right liver graft with all-in-one outflow vein venoplasty is implanted to the interposed vascular graft.

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  Figure 5 Intraoperative photographs of inferior vena cava replacement in a patient with advanced hepatocellular carcinoma. (A) A saphenous vein patch is attached to create an opening at the interposed vascular graft. (B) A middle hepatic vein conduit of a modified right liver graft is anastomosed with this opening.

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  Figure 6 Intraoperative photographs of inferior vena cava replacement in a patient with advanced hepatocellular carcinoma. (A) The right hepatic vein opening conjoined with a middle hepatic vein conduit is anastomosed with a large-caliber vascular graft. (B) An inferior right hepatic vein opening (arrow) is also anastomosed with the vascular graft. (C, D) This modified right liver graft with all-in-one outflow vein reconstruction is implanted through two caval anastomoses.

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