Reconstruction of inferior right hepatic veins in living donor liver transplantation using right liver grafts

Abstract

Because revascularization of the inferior right hepatic vein (IRHV) is a major component of right liver graft (RLG) reconstruction, we assessed the surgical techniques and clinical outcomes of IRHV reconstruction so that we could formulate practical guidelines for standardized procedures. From July 2004 to February 2010, we performed separate IRHV reconstructions in 487 of 1142 adult RLG recipients (42.7%). These recipients included 364 patients with a natural single IRHV and 123 patients with multiple IRHVs; in the latter group, the IRHVs were unified by venoplasty, which enabled a single anastomosis. The 1-year stenosis rates for the single-vein and venoplasty groups were 23% and 18.9%, respectively, and the early stent insertion rates were 7.1% and 9.8%, respectively (P = 0.09). Late IRHV occlusion did not lead to graft dysfunction, and all large major IRHVs were patent. A morphometric analysis showed that IRHV stenosis was associated with IRHV stretching and an anastomotic level discrepancy. This led to refinements of the surgical techniques: IRHV orifices were shaped into funnels, and the IRHV anastomosis was accurately placed at the recipient inferior vena cava (IVC). In an ongoing prospective study of 35 patients, our funneling unification venoplasty resulted in only 1 episode (2.9%) of early IRHV stenosis requiring stenting at a median follow-up of 8 months. The final configurations of the reconstructed IRHVs after funneling unification venoplasty and extensive IVC dissection were very similar to those of the native donor liver. In conclusion, we suggest that in combination with extensive recipient IVC dissection, funneling and unification venoplasty techniques are useful for securely reconstructing single or multiple IRHVs during the implantation of RLGs.