Successful Use of the Inferior Mesenteric Vein for Renal Transplantation

For renal transplantation, the standard venous drainage of the allograft is via the iliac vein. In unusual circumstances, such as thrombosis or agenesis of the iliac veins and the inferior vena cava, portal venous drainage may be a suitable option. We report a case in which the inferior mesenteric vein was used for venous drainage of a cadaveric renal allograft.     

A rare case of complex vascular reconstruction in liver transplantation.

Abnormalities of recipient or donor vascular structures are associated with reconstructive difficulties in liver transplantation. A patient with thrombosis of the right hepatic vein and associated stricture of the inferior vena cava (IVC), portal vein thrombosis and multiple aberrant arteries underwent orthotopic liver transplantation. The donor's suprahepatic IVC was anastomosed to the recipient's intrathoracic IVC. The portal vein flow was restored by venous graft interposition, while the arterial flow was ensured by interposing an iliac arterial graft anastomosed to the infrarenal aorta. In conclusion, graft function remains excellent more than 5 years postoperatively.     

Successful Urgent Transplantation of an Adult Kidney into a Child with Inferior Vena Cava Thrombosis

Poor venous drainage options following inferior vena cava (IVC) thrombosis have been considered to complicate or preclude renal transplantation of adult kidneys into pediatric patients. We describe urgent renal transplantation in a 5-year-old (15.3 kg) male with IVC thrombosis using an adult living donor. Preoperative magnetic resonance venography revealed a patent infrahepatic/suprarenal vena cava and portal system. In surgery, the right liver lobe was mobilized sufficiently to anastomose the graft renal vein to the native IVC at the confluence of the native left renal vein and proximal vena cava. Graft function has remained excellent with serum creatinine of 0.5 mg/dL at 36 months. IVC thrombosis need not preclude successful transplantation of adult-sized kidneys into children.     

Reconstruction of the vena cava and of its primary tributaries: a preliminary report

Encouraged by results from our research laboratory and from recent clinical reports, we performed reconstructions of the vena cava and/or its major tributaries on 16 patients (11 males and five females). Ages ranged from 8 to 81 years (median, 38 years). Eight patients had superior vena cava syndrome (benign, six; malignant, two). Two other patients had membranous occlusion of the inferior vena cava; four had iliocaval venous thrombosis; one had excision of the iliac veins for pelvic neurilemmoma; and one had inferior vena cava injury during orthotopic liver transplantation. The superior vena cava was reconstructed with spiral saphenous vein grafts in five patients and with expanded polytetrafluoroethylene in three. One spiral saphenous vein graft and one expanded polytetrafluoroethylene graft required revision; seven of the eight grafts were patent at follow-up, but one bifurcated spiral saphenous vein graft occluded at 3 months. The inferior vena cava and its tributaries were reconstructed with expanded polytetrafluoroethylene in five patients, spiral saphenous vein graft in two, and Dacron in one. At follow-up four of the expanded polytetrafluoroethylene grafts were patent. In contrast, one of the spiral saphenous vein grafts was occluded, and results of imaging studies of the other were inconclusive. Three of the five expanded polytetrafluoroethylene grafts had a concomitant temporary arteriovenous fistula at the groin; two had documented patency at follow-up. At the present time, spiral saphenous vein graft is our first choice for superior vena cava replacement. However, expanded polytetrafluoroethylene grafts are good alternatives and in the abdomen appear to perform better than spiral saphenous vein graft. These clinical results encourage us to perform further caval grafting in selected patients.     

Surgical Treatment of Portal Vein Thrombosis With the Use of Cadaveric Venous Patch After Donor Hepatectomy: A Case Report

Live donors should be the priority of transplant professionals to prevent surgery-related morbidity and mortality during living-donor liver transplantation. Portal vein thrombosis after donor hepatectomy is an important complication which can be prevented by careful preoperative as well as perioperative evaluation. If portal vein thrombus occurs after donor hepatectomy, anticoagulation and surgical thrombectomy and even portal vein reconstruction should be kept in mind. Cadaveric venous patches can be used for the reconstruction of narrowed and angulated portal veins. Here we report the surgical treatment of a donor with a cadaveric venous patch who developed portal vein thrombosis after donor hepatectomy.     

Hemodynamic changes with initiation of veno-venous bypass in orthotopic liver transplant patients

Removal of the liver to start the anhepatic stage of liver transplantation requires cross-clamping of the portal vein, inferior vena cava, and hepatic artery. Adverse effects occur from engorged splanchnic beds and decreased venous return. A veno-venous bypass from the inferior vena cava and portal vein to the axillary vein is used in an attempt to ameliorate these changes. The purpose of this study was to evaluate the effect of institution of veno-venous bypass on hemodynamics. Eight randomly selected adult patients undergoing orthotopic liver transplantation had general anesthesia induced with thiamylal and maintained with nitrous oxide and isoflurane. Cardiopulmonary data and arterial and mixed venous blood gases were measured prospectively using radial artery and pulmonary artery catheters. Measurements were taken under four conditions: (1) 10 minutes before bypass; (2) after partial bypass (vena cava to the axillary vein); (3) after partial bypass with portal vein clamping; and (4) after full bypass (vena cava and portal vein to the axillary vein). Statistically significant changes seen were a 22% decrease in cardiac output and a 47% increase in systemic vascular resistance (SVR). Bypass flow was lower than predicted. Venovenous bypass ameliorates, but does not fully prevent, the reduction of cardiac output and rise in SVR seen with initiation of the anhepatic stage. However, bypass does prevent the hypotension experienced during cross-clamping and for these reasons should be used routinely.     

Acute portal vein thrombosis secondary to donor/recipient portal vein diameter mismatch after orthotopic liver transplantation: a case report

The incidence of portal vein thrombosis in end-stage liver disease is estimated as varying between 5% and 21%, whereas in candidates undergoing liver transplantation, this is 3-13%. Portal vein thrombosis occurring after liver transplantation can be managed surgically by thrombectomy, retransplantation, splenorenal shunt, or Wall-stent placement, or nonsurgically by angioplasty, local high-dose infusion of thrombolytic agents, combination of portal thrombolysis, or embolization of a pre-existing spontaneous splenorenal shunt. We report a case of portal vein thrombosis after liver transplantation diagnosed on postoperative day 1 in a 57-year-old patient who received a liver from an 8-year-old donor. The patient was successfully treated surgically with portal vein thrombectomy and systemic anticoagulation. Portal vein thrombosis, in this case, was considered to be secondary to size discrepancy between the donor and the recipient portal veins. Routine use of daily Doppler ultrasound was the key factor in early diagnosis.     

A selective approach to preexisting portal vein thrombosis in patients undergoing liver transplantation.

Splanchnic venous inflow is considered mandatory to ensure graft survival after liver transplantation. Over a 68-month period, we performed 570 liver transplants in 495 patients. Portal vein thrombosis was present in 16 patients. At transplant, the extent of the occlusion included portal vein alone (n = 4), portal including confluence of the splenic and superior mesenteric veins (n = 8), portal, splenic, and distal superior mesenteric veins (n = 2), and the entire portal vein, splenic vein, and superior mesenteric vein (n = 2). The operative approach included thrombectomy alone (n = 5), anastomosis at the confluence of the splenic and superior mesenteric splenic veins (n = 8), and extra-anatomic venous reconstruction (n = 3). The mean operative blood loss was 22 +/- 22 units, and the mean operative time was 9.7 +/- 4.8 hours. The 1-year actuarial survival rate was 81%, with a mean follow-up of 12.5 months. In summary, with a selective approach and the use of innovative forms of splanchnic venous inflow, portal vein thrombosis is no longer a contraindication to liver transplantation.     

Alternatives to the double vena cava method in partial liver transplantation.

Minimizing graft congestion in partial liver transplantation is important, especially when the graft weight is marginal for the recipient metabolic demand. We prefer the double vena cava technique for reconstructing middle hepatic vein tributaries with thick, short hepatic veins because the technique can reduce the warm ischemic time of the graft and make a wide anastomosis. This technique requires a cryopreserved superior or inferior vena cava. We devised an alternative double vena cava method using iliac or femoral vein grafts and applied it to two right liver transplantation patients. There was no postoperative hepatic venous outflow block in either patient. In conclusion, application of this technique, even in the absence of a suitable vena cava, can help to minimize graft congestion.     

Renal venous diversion: an unusual treatment for renal vein thrombosis

Renal venous thrombosis most commonly occurs in the setting of nephrotic syndrome, hypercoagulability, or dehydration. This can usually be treated with systemic anticoagulation, and the diversion is via natural draining tributaries, eg, adrenal, lumbar, or gonadal veins. Occasionally, renal venous thrombosis results from extension of a thrombotic process, such as a large renal cell carcinoma with tumor thrombus extension into the infrahepatic inferior vena cava resulting in thrombosis of the inferior vena cava and contralateral renal vein. Herein, we report a case of left renal vein thrombosis relieved by diversion through the inferior mesenteric vein.     

Donor graft outflow venoplasty in living donor liver transplantation.

Hepatic venous outflow reconstruction is a key to successful living donor liver transplantation (LDLT) because its obstruction leads to graft dysfunction and eventual loss. Inclusion or reconstruction of most draining veins is ideal to ensure graft venous drainage and avoids acute congestion in the donor graft. We developed donor graft hepatic venoplasty techniques for multiple hepatic veins that can be used in either right- or left-lobe liver transplantation. In left-lobe grafts, venoplasty consisting of the left hepatic vein and adjacent veins such as the left superior vein, middle hepatic vein, or segment 3 vein is performed to create a single, wide orifice without compromising outflow for anastomosis with the recipient's vena cava. In right lobe graft where a right hepatic vein (RHV) is adjacent with a significantly-sized segment 8 vein, accessory RHV, and/or inferior RHV, venoplasty of the RHV with the accessory RHV, inferior RHV, and/or segment 8 vein is performed to create a single orifice for single outflow reconstruction with the recipient's RHV or vena cava. Of 35 venoplasties, 2 developed hepatic venous stenoses which were promptly managed with percutaneous interventional radiologic procedures. No graft was lost due to hepatic venous stenosis. In conclusion, these techniques avoid interposition grafts, are easily performed at the back table, simplify graft-to-recipient cava anastomosis, and avoid venous outflow narrowing.     

肝癌肝移植术中的无瘤操作技巧

目的 探讨肝癌肝移植术中的无瘤操作技巧。方法 7例肝癌患者实施肝移植。尽早建立静脉转流通道及断离门静脉、下腔静脉。游离肝脏时尽量不触及、压迫肿瘤;B超测量癌肿与下腔静脉、肝静脉、门静脉关系,确定血管是否切除及切除范围。结果 手术后2月,所有患者AFP均降至正常水平,肝脏未发现复发病灶,PET检查未见远处转移。结论 尽早建立静脉转流通道。手术中坚持癌肿切除的一般原则,同时针对肝移植特点,利用B超确定血管是否切除及切除范围,是预防肝癌肝移植术后复发的有效的手段。     

The measurement of hepatic circulation before and after orthotopic liver transplantation in dog--by using transit-time blood flow meter and H2 clearance method

Orthotopic liver transplantation was successfully carried out in 40 mongrel dogs, in which hepatic circulation was investigated before and after grafting. Blood flows in hepatic artery, portal vein and intrahepatic inferior vena cava were measured by using transit-time ultrasonic blood flow meter and regional tissue blood flow was determined by hydrogen gas clearance method. Before transplantation the mean blood flows were 234 +/- 95mg/min in portal vein, 118 +/- 76ml/min in hepatic artery and 291 +/- 103ml/min in inferior vena cava in 40 recipients. The blood flow ratio of portal vein and hepatic artery was 2.9 +/- 2.2. The mean regional blood flow of the liver was 63 +/- 24ml/min/100g. After transplantation, the mean blood flows decreased to 189 +/- 86ml/min in portal vein, 77 +/- 51ml/min in hepatic artery and 179 +/- 111ml/min in inferior vena cava and the regional tissue blood flow was 57 +/- 25ml/min/100g. Hepatic arterial flow decreased by 37 percent after transplantation, however, portal venous flow decreased by 24 percent and the regional blood flow decreased by 9 percent after transplantation of the liver. These data suggested that the microcirculation of the liver was slightly disturbed after liver transplantation in dog, which was in part due to the decreased blood flows of the hepatic artery and portal vein.     

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.     

The establishment of a new en bloc combined liver-small bowel transplantation model in rats

In order to facilitate preclinical research, we established a new combined liver-small bowel transplantation rat model. Male inbred Wistar rats were chosen as donors and recipients. An en bloc liver-small bowel graft was harvested. During the donor operation, the inferior vena cava in the chest was removed to be used as an interpositional venous graft to anastomose to the portal vein. In the recipient operation the portal veins of donor and recipient were quickly anastomosed using a cuff technique instead of the traditional suture method. Rearterialization was achieved by anastomosing the superior mesenteric artery of graft to the right renal artery of the recipient. The recipient small bowel was resected and intestinal continuity restored simultaneously by two end-to-end anastomoses. The postoperative 5-day survival rate was 77.5% (31/40) and 60-day survival rate, 72.5% (29/40). Recipient rats that tolerated the operation remained healthy. Liver and renal function was normal. The liver and intestinal grafts showed normal histological architecture in all rats surviving for 2 months postoperatively. Our results demonstrated that the present model is feasible, allowing preclinical experimental research on combined liver-small bowel transplantation.     

Renal transplantation with venous drainage through the superior mesenteric vein in cases of thrombosis of the inferior vena cava

Renal transplantation usually is performed by placing the graft in the iliac fossa, anastomosing the renal vein to the iliac vein or, when this is not possible, to the vena cava. When vascular complications occur, particularly on the venous side, the position of the graft may have to be changed. This report describes orthotopic renal grafts and positioning of the organ with anastomosis to the splenic vessels. Venous drainage was established directly into the mesenteric-portal territory, with two cases to the portal vein and one to the inferior mesenteric vein. A new technique for the venous drainage of the renal graft is shown. We have used this model in two cases of infrarenal inferior vena cava thrombosis. The kidney was located in a retroperitoneal position, with venous drainage to the superior mesenteric vein through an orifice in the posterior peritoneum.     

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation?

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.     

Replacement of the vena cava with aortic graft for living donor liver transplantation in budd-Chiari syndrome associated with hydatid cyst surgery: a case report

A 12-year-old girl, operated because of a hydatid cyst of the liver, with Budd-Chiari syndrome was evaluated for postoperative development of ascites and paraumbilical varicose veins. A vena caval stent was placed for the relief of inferior vena caval obstruction. The patient was admitted because of progressive deterioration in ascites and liver functions. Imaging techniques showed degeneration adjacent to the right hepatic vein in liver segments 7 to 8, a partially calcified 5-cm hydatid cyst, and a thrombosis in the inferior vena cava was that addressed with a 10-cm metal stent. A living donor segments 2 to 3 liver transplantation was obtained from the patient's mother. After completion of the donor operation without complications, the vena caval stent was removed following the recipient hepatectomy. Suprarenal flow continued after resection of the fibrotic vena cava and placement of a cadaveric cryopreserved aortic graft for the vena cava, anastomosed between the suprarenal and subdiaphragmatic segments of the vena cava. An end-to-side anastomosis was performed between the left hepatic vein of the donor liver and the aortic graft. There was no complication and the patient was discharged on postoperative day 19. Follow-up Doppler ultrasonography showed the aortic vena caval graft to be open, along with the hepatic/portal vein and hepatic artery. This case demonstrated that operations for liver hydatid cyst surgeries can iatrogenically induce Budd-Chiari syndrome; a cryopreserved aortic graft can be an alternative to ensure the continuity of the vena cava in living donor liver transplantation.     

Balloon Venoplasty for Liver Failure Due to Stenosis of the Left Hepatic Vein After Right Tri-Segmentectomy

A 41-year-old male patient with hepatitis B underwent right tri-segmentectomy and total caudate lobectomy for a huge hepatocellular carcinoma associated with complete occlusion of the inferior vena cava with thrombosis of the infrahepatic inferior vena cava due to tumor compression. Five months later, he was readmitted for ascites and hyperbilirubinemia. Venography revealed stenosis and tortuosity of the left hepatic vein and the inferior vena cava, for which balloon angioplasty of the left hepatic vein and the inferior vena cava was performed using an 8-mm and 10-mm balloon, respectively. The left hepatic venous pressure decreased from 65 mmHg to 25 mmHg after dilatation. The patient made a satisfactory recovery thereafter and remains well with normal liver functions and without ascites. Balloon angioplasty may be useful for liver failure due to hepatic vein stenosis after hepatic resection.     

VENOUS ALLOGRAFTS: A USEFUL ALTERNATIVE TO VENOUS AUTOGRAFTS IN DIGESTIVE SURGERY

Over a 16 month period seven patients underwent surgery using venous allografts either to reconstruct the portal vein, or to construct a mesocaval ‘H’ graft or a shunt between the coronary vein and the subhepatic inferior vena cava. The allografts were harvested during multiorgan procurement from the bifurcation of the inferior vena cava, the common iliac vein and the external iliac vein and kept in a preservation solution at 4°C for a mean time of 6 days (range 1–29) before use. Subsequent thrombosis was clinically evident in only two patients. The use of venous allografts appears to be a useful alternative to other venous replacements.