Transesophageal Echocardiographic Evaluation of the Portal Vein During Living Donor Liver Transplantation: A Report of 3 Patients

Abstract

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has established itself as a diagnostic and monitoring tool inside the cardiac operating room. 1 Nicoara A Skubas N Ad N et al. Guidelines for the use of transesophageal echocardiography to assist with surgical decision-making in the operating room: A surgery-based approach: From the American Society of Echocardiography in collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr. 2020; 33: 692-734 Google Scholar It is now increasingly being used in noncardiac surgical setups, such as neurologic operating rooms, other major noncardiac surgery, and intensive care units. 2 Wang Y Wang X Chang Y. Radical nephrectomy combined with removal of tumor thrombus from inferior vena cava under real-time monitoring with transesophageal echocardiography: A case report. Medicine (Baltimore). 2020; 99: e19392 Google Scholar The risk of esophageal variceal bleed has been a limiting factor in the use of TEE in patients undergoing liver transplant surgery. 3 Pai SL Aniskevich S Feinglass NG et al. Complications related to intraoperative transesophageal echocardiography in liver transplantation. Springerplus. 2015; 4: 480 Google Scholar ,4 Burger-Klepp U Karatosic R Thum M et al. Transesophageal echocardiography during orthotopic liver transplantation in patients with esophagoastric varices. Transplantation. 2012; 94: 192-196 Google Scholar Nevertheless, it has emerged as a valuable tool in select patients undergoing liver transplant surgery, mainly due to its ability to provide real-time hemodynamic status of the patient. 5 De Marchi L Wang CJ Skubas NJ et al. Safety and benefit of transesophageal echocardiography in liver transplant surgery: A position paper from the Society for the Advancement of Transplant Anesthesia (SATA). Liver Transpl. 2020; 26: 1019-1029 Google Scholar In addition to hemodynamic monitoring, evaluation of the portal vein (PV), hepatic vein (HV), and inferior vena cava (IVC) flows are of paramount importance during liver transplant surgery, especially after the reperfusion. The current practice is to use transabdominal ultrasound for this purpose. 6 Chung YK Choi HJ Na GH et al. Postoperative Doppler ultrasonography in liver transplantation. Transplant Proc. 2018; 50: 1100-1103 Google Scholar There are a few case reports describing the use of TEE for the assessment of the hepatic outflow (ie, HV and IVC flow immediately after reperfusion). 7 Seman MT Alvord JM Gorlin AW et al. Non-traditional transesophageal echocardiographic views to evaluate hepatic vasculature in orthotopic liver transplantation and liver resection surgery. Transplant Direct. 2020; 6: e594 Google Scholar ,8 Khurmi N Seman M Gaitan B et al. Nontraditional use of TEE to evaluate hepatic vasculature and guide surgical management in orthotopic liver transplantation. Case Rep Transplant. 2019; 20195293069 Google Scholar However, it has not been used for the evaluation of the hepatic inflow (eg, PV), although its visualization is possible with TEE. Denault et al. 9 Denault AY Azzam MA Beaubien-Souligny W. Imaging portal venous flow to aid assessment of right ventricular dysfunction. J Can Anaesth. 2018; 65: 1260-1261 Google Scholar used the evaluation of PV velocity to diagnose right ventricular failure and described the method of visualizing the PV with TEE. The authors recently have started using TEE for evaluation of the hepatic inflow and outflow during liver transplant surgery. The present report describes the technique used for visualizing the PV and the evaluation of its blood flow velocity in a series of 3 patients undergoing living donor liver transplantation (LDLT).