Caval preservation with reconstruction of the hepatic veins using caval-common iliac bifurcation graft for domino liver transplantation

Abstract

Domino liver transplantation has been performed routinely from livers procured from patients with Familial Amyloidosis (FA). Some technical modifications have been made on the recipient of Amyloid Hepatic Allograft (AHA) to overcome the cuff limitation such as the use of side to side cava-caval anastomosis with closure of the suprahepatic and infrahepatic cava.1 These technical innovations in the recipient AHA however have no benefit for the FA patient undergoing the hepatectomy and may in fact adversely affect the safety of the harvesting procedure by requiring high dissection of the IVC into the diaphragm.2 In addition the IVC is removed with the liver, therefore requiring complete supra-renal vena caval clamping and the use of veno-venous bypass.3, 4 We describe a safe and simple technique to recover the AHA without the IVC. FA, Familial Amyloidosis; IVC, Inferior Vena Cava; AHA, Amyloid Hepatic Allograft; MELD, Model of End Stage Liver Disease; GDA, gastro-duodenal artery. The hepatic artery was isolated at the level of the gastro-duodenal artery (GDA). The portal vein and bile duct were separately isolated at the same level. The liver was then mobilized off the IVC by ligating the short hepatic veins between the right lobe and caudate lobe of the liver and the IVC, superiorly up to the hepatic veins. The groove between the right hepatic vein and the middle-left hepatic vein trunk was developed. At this point, we were ready for the hepatectomy; the liver was now attached only by the hepatic artery, bile duct, portal vein, and the major hepatic veins (Fig. 1). The hepatic artery was transected at the level of the GDA, the portal vein above the duodenum, and the hepatic veins were transected separately between the liver and the vena cava. Allograft Hepatectomy- removal of the Amyloid liver, view from the left. Black Arrow: Hepatic veins. Blue Arrow: Inferior vena cava separated from the caudate and the right lobe of the liver, after the division of the short hepatic veins. Green Arrow: Common hepatic artery. Cyan Arrow: Portal vein. Immediately following the recovery, the AHA was perfused with cold Viaspan. The native hepatic veins on this liver were very short and the separation about 1.5 cm. An additional piece of IVC with a 2 cm segment of the common iliac veins had been procured from the deceased donor in anticipation of the back table reconstruction. The supra hepatic venous cuff was reconstructed using this deceased donor IVC. The common iliac veins were anastomosed to the right and the trunk of the middle-left hepatic veins using 5/0 prolene (Fig. 2). Reconstruction of the right hepatic vein and left-middle hepatic vein trunk with deceased donor IVC graft. Blue Arrow: IVC of the venous graft. Black Arrow: Anatomosis of the common iliac veins of the venous graft to the hepatic veins. The implantation was done in the standard piggyback fashion by suturing the reconstructed suprahepatic venous cuff to the junction of all three hepatic veins of the recipient, without clamping the IVC or veno-venous bypass. The portal vein, hepatic artery, and bile duct were completed in the standard fashion. Although the technique for piggyback transplantation is not new to the liver transplant community, this is the first time it has been described for a domino liver transplant using cadaveric IVC with common iliac veins for reconstruction. This procedure obviates the necessity for caval clamping or veno-venous bypass in the FA patient, adding to intraoperative hemodynamic stability and maximizing patient safety.