A Method for Percutaneous Cannulation for Veno-Veno Bypass During Orthotopic Liver Transplantation

Abstract

To the Editor: At our institution, veno-veno (V-V) bypass for orthotopic liver transplantation (OLTX) is routinely used in patients weighing more than 35 kg. V-V bypass is accomplished through cannulas surgically placed into the femoral and portal veins for blood drainage and into the axillary vein for blood return. Recently we have modified the V-V bypass system by percutaneously placing a large-bore catheter (15-21 Fr, depending on size and anatomy of the patient) into the right internal jugular vein, using the Seldinger technique. The cannulas used were originally designed to provide arterial inflow during cardiopulmonary bypass via the femoral artery (Biomedicus arterial catheter; Biomedicus, Eden Prairie, MN). Prior to V-V bypass the catheter was connected to a centrifugal pump (Biomedicus) with 3/8-in. pump tubing. A Luer-lock side port on the cannula also allowed us to use the catheter for rapid infusion of volume before and after initiation of bypass Figure 1. After V-V bypass, blood was drained from the pump tubing through the cannula into the patient, the tubing was clamped with a tubing clamp and cut off close to the cannula, and the end was crimped tightly. In all 30 cases where this cannula was used, it was removed in the intensive care unit 1-4 days postoperatively without hemorrhage or other complications.Figure 1: Diagram of the Biomedicus arterial catheter (1) with a Luer-lock side port (2) connected to intravenous tubing (3) for volume infusion. Pump tubing (3/8 in.) (4) and a 3/8-in. fitted connector (5) provide the attachment to a Biomedicus centrifugal pump (6) for veno-veno bypass. Gott shunt tubing (8) inserted into femoral and portal veins and joined via a Y-connector (7) with 3/8-in. pump tubing completes the bypass circuit.Other techniques for percutaneously placing cannulas for V-V bypass during OLTX have been described [1,2]. We believe that our approach is a safe alternative in selected patients if performed by experienced clinicians. We suggest that, prior to its use, proper positioning of the cannula should be confirmed with a chest radiograph. In all patients this approach provided for excellent flow rates during the bypass phase of the operation and excellent venous access for volume infusion during the remainder of the operation. Burkhard F. Spiekermann, MD David L. Bogdonoff, MD Jane E. Hershey, MD Joseph D. McLaughlin, MD Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, VA 22908