Inferior Vena Cava Anastomosis Research Articles

Laparoscopic-assisted full-sized liver transplantation with magnetically fast portal vein anastomosis: an initial cohort study.

Some cases of laparoscopic-assisted liver transplantation (LA-LT) with utilization of reduced-size grafts has been reported. The authors here introduced successful utilization of LA-LT with whole liver grafts and magnetic portal vein anastomosis. Eight patients with liver cirrhosis were included for LA-LT using donor organs after cardiac death. The surgical procedures included purely laparoscopic explant hepatectomy and whole-liver graft implantation via the midline incision. After explant removal, the whole-liver graft was then placed in situ, and a side-to-side cavo-caval anastomosis with 4-5cm oval opening was performed. The magnetic rings were everted on the donor and recipient portal vein, respectively, and the instant attachment of the two magnets at the donor and recipient portal vein allowed fast blood reperfusion, followed by continuous suturing on the surface of the magnets. The median operation time was 495 (range 420-630). The median time of explant hepatectomy and inferior vena cava anastomosis was 239 (range 150-300) min and 14.5 (range 10-19) min, respectively. Of note, the median anhepatic time was 25 (range 20-35) min. All the patients were discharged home with no major complications after more than 12 months follow-up. LA-LT with full-size graft is feasible and utilization of magnetic anastomosis would further simplify the procedure.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Clinical progress note: Noncardiac complications in adults with congenital heart disease.

Clinical progress note: Noncardiac complications in adults with congenital heart disease.

Robot-Assisted Laparoscopic IVC Treatment Strategy in Retroperitoneal Tumors.

ObjectivesTo show the practice of robot-assisted laparoscopic inferior vena cava (IVC) treatment strategies in patients with retroperitoneal tumors.Patients and MethodsFrom October 2020 to July 2021, 17 patients with retroperitoneal tumors successfully underwent robot-assisted laparoscopic tumor resection with IVC management. The patient details, tumor characteristics, intraoperative data, pathological features and severe complications were assessed. The IVC treatment strategies were divided into 4 ways: ①local resection and primary repair of the IVC; ②IVC ligation; ③ IVC reconstruction by bovine pericardial grafts; and ④ IVC transection and anastomosis.ResultsIn terms of IVC management, 5 cases had conventional total occlusion of the IVC and its branches, 3 cases had delayed occlusion of the proximal IVC technique, 2 cases had IVC resection by Satinsky clamp, 5 cases had IVC ligation, 1 case had IVC reconstruction by bovine pericardial grafts and 1 case had IVC transection and anastomosis. The median operation time was 151 min, and blood loss was 500 ml. There was no severe complication perioperatively. The follow-up time of 17 patients was 8 to 17 months (median: 12 months). No local recurrence or overall death was found during follow-up.ConclusionsThese robot-assisted laparoscopic IVC treatment strategies were considered to be safe and feasible in experienced centers, as well as helpful to completely remove the tumor for better oncological prognosis and restore the blood reflux of IVC as much as possible to ensure fewer postoperative complications.

Inferior Vena Cava Constriction After Liver Transplantation Is a Severe Complication Requiring Individually Adapted Treatment: Report of a Single-Center Experience

BackgroundReports on vena cava occlusion after liver transplantation (LT) are rare, but this finding represents a severe complication in the early postoperative period. In the context of the complex presentation of a patient after LT, symptoms are often misinterpreted and can be subtle.Material/MethodsIn our cohort of 138 LTs performed between 2014 and 2017 at our University’s Transplantation Department, 117 transplantations were valid for further analysis after exclusion of pediatric transplantations and transplants with primary non-function grafts. In 101 cases (73%), patients received a deceased-donor full-size organ. Living-donor LT was performed in 8 patients (6.4%) and 8 patients (6.4%) received a split graft. We report on 6 patients who had inferior vena cava (IVC) occlusion and summarize the treatment choices.ResultsIn our series, patients with positive findings (age 38–70 years) received an orthotopic full-size deceased-donor graft with end-to-end IVC anastomosis. In the subsequent period, imaging revealing IVC occlusion was done on a follow-up basis (n=2), due to dyspnea (n=1), and for progressive ascites (n=2). In 3 cases, a thrombus was found. We give detailed information on our treatment options from interventional treatment to transcardial thrombus removal and anastomosis augmentation.ConclusionsIVC constriction and subsequent thrombosis are severe complications after LT that require individually adapted treatment in specialized centers. Since patients often present with subclinical symptoms, vascular diagnosis should be performed early to detect caval anastomosis pathologies. Despite regular ultrasonography, we favor CT and cavography for subsequent quantification. We also review the literature on IVC occlusion after LT.

Fast and Effective Nonsuture Anastomosis of Magnetic Artificial Blood Vessel Transplantation for Caval Reconstruction in Canines

The resection and reconstruction of the vena cava is frequently needed in tumor resection. The goal of this study was to evaluate the performance of the magnetic compression anastomosis (MCA) device for fast nonsuture anastomosis of caval reconstruction with artificial blood vessel transplantation after resection in canines. The MCA device consisted of paired neodymium-ferrum-boron (Nd-Fe-B) magnetic rings that were coated with titanium nitride and embedded in a polypropylene shell. Artificial blood vessel transplantation procedure was performed in sixteen canines and then they were divided into 2 groups: MCA group (n=8), in which the novel magnetic pinned-ring device was used, and the traditional manual suture group (n=8). In situ artificial blood vessel anastomoses were performed in the inferior vena cava (IVC). The anastomosis time and anastomotic patency and quality were investigated through ultrasonographic scans, angiographic, gross observation, histological staining, and scanning electron microscopy at 24weeks postoperatively. The IVC anastomoses were reconstructed successfully in all canines and all animals survived. In the MCA group, the operation time for IVC anastomosis with artificial blood vessel was significantly shorter than that in the tradition manual suture group (P<0.05). Vena cava angiography and ultrasound showed good blood patency. The scanning electron microscope showed the re-endothelialization was smooth and endothelial cells were arranged regularly at the anastomotic site. Histological examination confirmed that the MCA group was associated with infiltration of inflammatory cells compared with the manual suture group. The MCA device combined with artificial blood vessels is applicable in reconstruction of large vessels after resection. The magnetic pinned-ring device offers a simple, fast, reliable, and effective technique for nonsuture artificial blood vessel anastomosis of caval reconstruction in canines, and the anastomosis is functionally better than the traditional sutured anastomosis.

Lung perfusion scintigraphy in the assessment of pulmonary circulation after completion of surgical treatment of a hypoplastic left heart syndrome (HLHS).

Hypoplastic left heart syndrome (HLHS) is an inborn complex heart malformation. A multi-stage treatment is initiated in a neonatal period with a Norwood surgery. The next step is Glenn surgery - a bidirectional superior cavo-pulmonary anastomosis. At the last stage anastomosis of inferior vena cava (IVC) with the right pulmonary artery (RPA) is formed as a result of a Fontan surgery. The aim of this study was to assess lung perfusion in patients with HLHS after completion of a surgical therapy, using a scintigraphic method. In 92 patients with HLHS a planar lung scintigraphy in anterior and posterior projections after administration of 99mTc-macroaggregates in activity 18-111MBq was carried out twice (in several day intervals). At first, a radiopharmaceutical was administered to the right extremity in order to assess the lung distribution of blood flowing through the anastomosis of superior vena cava (SVC) with RPA. In the next study, after administration of the tracer to the right lower extremity, the distribution of blood flowing through the anastomosis of IVC with RPA was assessed. The relative percentage of each lung in the total lung perfusion was calculated on a Xeleris workstation using the "Lung perfusion analysis" program. Lung perfusion was considered close to symmetrical when the proportion was in the range of 40-60%. In spite of the fact that mean relative values of distribution of blood flowing through the anastomosis of SVC with RPA to the left lung (LL) and right lung (RL) in the entire study group did not differ significantly: LLmean = 47%; RLmean = 53%, p = 0.14, relative values of perfusion of both lungs were differentiated - in 26% of patients LL was better perfused, in 38% RL was better perfused and in 36% a perfusion of both lungs was similar. The analysis of blood distribution by anastomosis of IVC with RPA showed that the mean relative perfusion of RL was significantly higher than that of LL (70% vs. 30%, p < 0.0000001). No signs of pulmonary emboli were detected. In 13% of studied patients, uptake of the radiopharmaceutical in kidneys was shown indicating the presence of shunt "from right to left". After completion of surgical treatment of patients with HLHS, differentiated blood supply of the lungs was observed through SVC with RPA anastomosis and a tendency to higher blood supply of RL than LL by anastomosis of IVC with RPA. No signs of pulmonary embolism were detected. The study revealed a "right to left" shunt in some patients.

Successful Treatment for End—Stage Hepatic Alveolar Echinococcosis With ex vivo Liver Resection and Autologous Liver Transplantation: A Case Report

3045_A.tif Figure 1: Preoperative 3D imaging analysis system revealed the retro—hepatic IVC was involved (arrow)3045_B.tif Figure 2: The irregular outflow of right/short hepatic vein reconstruction (A: great saphenous veins; B—C: right/short hepatic vein reconstruction using the great saphenous veins wall)Objective To explore the surgical process of ex—vivo liver resection and autologous liver transplantation (ERAT) for end—stage hepatic alveolar echinococcosis (HAE) and evaluate the therapeutic effect and surgical benefit. Methods The clinical data of one end—stage HAE patient treated with ERAT combined complicated hepatic vein reconstructionwas analyzed retrospectively. Preoperative examination and intraoperative exploration revealed the second hepatic portal was involved. We successfully initiated an operation through ex—vivoliver resection, hepatic vein reconstruction with the autogenous saphenous vein, and subsequent piggyback autologous liver transplantation by wide—mouth hepatic vein—artificial inferior vena cava anastomosis (end to side). Results This patient discharged uneventfully 14 days after the operation. The injection of low—molecular—weight heparin sodium and consequent oral warfarin sodium tablets were administered for anticoagulant therapy. Regular autograft ultrasound examination revealed no tarombokinesis in autologous liver and inferior vena cava. Conclusion ERAT is an ideal surgical method for end—stage HAE. Wide—mouth hepatic vein reconstruction using an autogenous saphenous vein is the key procedure. Postoperative anticoagulant therapy is significant for the improvement of transplanted liver function.3045_C.tif Figure 3: Piggyback autologous liver transplantation (A—C)

Doppler ultrasound in the diagnosis of Budd-Chiari syndrome in children after split liver transplantation

To assess the capabilities of a velocity ratio>3 for the diagnosis of Budd-Chiari syndrome (BCS) in children after split liver transplantation using Doppler ultrasonography (DUS). A total of 28 children who underwent liver transplantation using a split procedure were included. There were 11boys and 17girls with a mean age of 3.8years (range: 0.7-12years). Velocity ratio between blood velocity upstream of the anastomosis and that at the level of the inferior vena cava anastomosis was calculated. Sensitivity, specificity and accuracy of DUS for the diagnosis of BCS were estimated using a velocity ratio>3. Eight children (8/28; 29%) had BCS and 20 (20/28; 71%) did not have BCS using the standard of reference. A velocity ratio>3 on DUS yielded 88% sensitivity (95% CI: 53-98%), 80% specificity (95% CI: 58-92%) and 82% accuracy (95% CI: 64-92%) for the diagnosis of BCS. A velocity ratio>3 on DUS is a reliable finding for the diagnosis of BCS in children after split liver transplantation.

Technique for orthotopic liver transplantation in cynomolgus monkeys (Macaca fascicularis).

PurposeRecent studies investigating new strategies to modulate the immune system have utilized animal models of liver transplantation (LT). However, the anhepatic phase (AHP) remains a crucial problem in LT. The aim of the present study is to introduce a technique for successful orthotopic LT in cynomolgus monkeys using an early-reperfusion strategy.MethodsOrthotopicallo-LT was performed with seven donor/recipient pairs of cynomolgus monkeys.ResultsIn 2 recipients, liver allografts were perfused after suprahepatic inferior vena cava (SHIVC), portal vein (PV), and infrahepatic inferior vena cava (IHIVC) anastomosis. To reduce the time of AHP in five recipients, liver allografts ware perfused after SHIVC and PV anastomosis while the IHIVC was not anastomosed. In the latter strategy, the AHP was reduced from 46 minutes to 31 minutes and a 24-hour survival rate of 80% was achieved.ConclusionOur results indicate that an early-reperfusion strategy can be successfully used to establish a LT model in cynomolgus monkeys with a consistently high rate of animal survival.

Increased Energy Loss Due to Twist and Offset Buckling of the Total Cavopulmonary Connection

The hemodynamic energy loss through the surgically implanted conduits determines the postoperative cardiac output and exercise capacity following the palliative repair of single-ventricle congenital heart defects. In this study, the hemodynamics of severely deformed surgical pathways due to torsional deformation and anastomosis offset are investigated. We designed a mock-up total cavopulmonary connection (TCPC) circuit to replicate the mechanically failed inferior vena cava (IVC) anastomosis morphologies under physiological venous pressure (9, 12, 15 mmHg), in vitro, employing the commonly used conduit materials: Polytetrafluoroethylene (PTFE), Dacron, and porcine pericardium. The sensitivity of hemodynamic performance to torsional deformation for three different twist angles (0 deg, 30 deg, and 60 deg) and three different caval offsets (0 diameter (D), 0.5D, and 1D) are digitized in three dimensions and employed in computational fluid dynamic (CFD) simulations to determine the corresponding hydrodynamic efficiency levels. A total of 81 deformed conduit configurations are analyzed; the pressure drop values increased from 80 to 1070% with respect to the ideal uniform diameter IVC conduit flow. The investigated surgical materials resulted in significant variations in terms of flow separation and energy loss. For example, the porcine pericardium resulted in a pressure drop that was eight times greater than the Dacron conduit. Likewise, PTFE conduit resulted in a pressure drop that was three times greater than the Dacron conduit under the same venous pressure loading. If anastomosis twist and/or caval offset cannot be avoided intraoperatively due to the anatomy of the patient, alternative conduit materials with high structural stiffness and less influence on hemodynamics can be considered.

Reconstruction of Isolated Inferior Right Hepatic Vein(s) in Right Lobe Living Donor Liver Transplantation Using Polytetrafluoroethylene Grafts: A New Feasible Concept, Technique of 'Bridging Conduit Venoplasty' and Outcomes.

BACKGROUND Right lobe living donor liver transplantation (LDLT) remains the most common form of liver transplantation in Asia. However, reconstruction of the venous outflow in a right liver allograft may pose technical difficulties if hepatic venous variations are present. Recently, much emphasis has been given to the reconstruction of large and multiple inferior right hepatic veins (IRHVs). The method of reconstructive technique, type of vascular grafts, and the outcome after the procedure have been a point of debate. In this report we discuss the IRHV reconstruction techniques using expanded polytetrafluoroethylene (ePTFE) vascular grafts and the outcomes after such reconstruction. MATERIAL AND METHODS Out of 262 right liver allografts that underwent venous reconstruction using ePTFE vascular grafts, IRHVs required either venoplasty or second inferior vena cava (IVC) anastomosis in 99 recipients. Depending upon type of IRHV reconstruction, the recipients were divided in 2 groups: Group A (n=52): IRHV venoplasty using ePTFE graft, and group B (n=47): Direct IRHV-to-IVC anastomosis. The outcome after LDLT was compared for these 2 groups. RESULTS The ePTFE venoplasty group had significantly shorter warm ischemia time as compared to the direct to IVC anastomosis group (p<0.01, 95% confidence interval -10.96 to -2.92). There were no thrombotic complications in either group of recipients; 4.2% of the recipients from group B developed hepatic venous stenosis but with no clinical deterioration; and 1 patient from group A developed ePTFE graft migration in the second portion of the duodenum that required surgical exploration. CONCLUSIONS The IRHVs drain a considerable portion of the posterior sector of right liver allografts and thus must be reconstructed. Use of ePTFE vascular grafts for IRHV venoplasty is a safe and feasible concept that facilitates the outflow reconstruction of liver allografts.

Clinical efficacy of splenectomy combined with coronary-caval shunt in treatment of portal hypertension

Objective To investigate the clinical efficacy of splenectomy combined with coronary-caval shunt in treatment of portal hypertension (PHT). Methods The retrospective descriptive study was conducted. The clinical data of 21 patients with PHT who underwent splenectomy combined with coronary-caval shunt at the First Affiliated Hospital of Xi'an Jiaotong University from January 2001 to December 2015 were collected. Observation indicators included (1) operation situations, changes of pre- and post-operative portal hemodynamics including operation time and volume of intraoperative blood loss, diameter and blood flow velocity of portal vein (PV), gastric coronary vein and superior mesenteric vein (SMV). (2) Clinical indexes in perioperative period (before operation, at postoperative 1 week and 1 month): ① blood routine test: the counts of red blood cell (RBC), white blood cell (WBC) and platelet (PLT), ② liver function: Child-Pugh score, alanine transaminase (ALT), total bilirubin (TBil), albumin (Alb), extended time of prothrombin time (PT) and international normalized ratio (INR). (3) Follow-up: postoperative 1-, 3-, 5-year complications [upper gastrointestinal re-bleeding, peritoneal effusion, hepatic encephalopathy, hepatic failure, portal vein thrombosis (PVT) and anastomotic stoma thrombosis]. The follow-up using outpatient examination and telephone interview was regularly conducted once every 3 months within postoperative 1 year and once every 6 months after postoperative 1 year up to March 2016 or end of follow-up (death). Measurement data with normal distribution were presented as ±s. The comparison of different time-point was analyzed by the repeated measures ANOVA and Student t test. Measurement data with sknewed distribution were presented as M (range). Results (1) Operation situations and changes of pre- and post-operative portal hemodynamics: 21 patients underwent successful splenectomy combined with coronary-caval shunt, including 19 receiving splenic vein bypass combined with anastomosis of gastric coronary vein and inferior vena cava and 2 receiving anastomosis of gastric coronary vein and inferior vena cava. Operation time, volume of intraoperative blood loss were (187±33)minutes and (233±114)mL. Diameter and blood flow velocity of PV, gastric coronary vein and SMV were (1.39±0.20)cm, (0.66±0.15)cm, (0.74±0.32)cm, (11.2±3.4)cm/s, (6.6±1.3)cm/s, (7.0±2.2)cm/s before operation and (1.36±0.22)cm, (0.42±0.11)cm, (0.81±0.23)cm, (10.4±2.5)cm/s, (8.2±2.5)cm/s, (6.9±2.4)cm/s after operation, respectively, showing no statistically significant difference in the diameter and blood flow velocity of PV and SMV before and after operation (t=0.46, -0.81, 0.87, 0.14, P>0.05)and with statistically significant differences in the diameter and blood flow velocity of gastric coronary vein before and after operation (t=5.91, -2.60, P 0.05). There were statistically significant differences in the ALT and extended time of PT (F=7.97, 4.37, P<0.05)and in the ALT and extended time of PT between 1 week postoperatively and before operation (t=3.23, 2.21, P<0.05). (3) Follow-up: 21 patients were followed up for 3-168 months with a median time of 37 months. During follow-up, 3 patients were dead. One, 1, 2 patients were complicated with upper gastrointestinal re-bleeding at postoperative 1, 3, 5 years and received hemostatic therapy under endoscopy, and then 2 were dead. Three, 2 and 2 patients had peritoneal effusion and were improved by symptomatic treatment. One patient had hepatic encephalopathy and hepatic failure at postoperative 5 years and was dead after conservative treatment. PVT and anastomotic stoma thrombosis at postoperative 1, 3, 5 years were detected in 2, 2, 1 and 2, 1, 1 patients, with anticoagulant therapy, and 1 patient received vascular recanalization. Conclusion Coronary-caval shunt is a highly selective portosystemic shunt, it can significantly down regulate the regional pressure while ensure the normal blood flow of liver and decrease the rate of rebleeding, hepatic encephalopathy and thrombosis, meanwhile, it might be a potential therapy in management of PHT. Key words: Portal hypertension; Coronary-caval shunt; Upper gastrointestinal hemorrhage

Rat Heterotopic Abdominal Heart/Single-lung Transplantation in a Volume-loaded Configuration.

Herein, we describe a novel technique for heterotopic abdominal heart-lung transplantation (HAHLT) in rats. The configuration of the transplant graft involves anastomosis of donor inferior vena cava (IVC) to recipient IVC, and donor ascending aorta (Ao) to recipient abdominal Ao. The right upper and middle lung lobes are preserved and function as conduits for blood flow from right heart to left heart. There are several advantages to using this technique, and it lends itself to a broad range of applications. Because the graft is transplanted in a configuration that allows for dyamic volume-loading, cardiac function may be directly assessed in vivo. The use of pressure-volume conductance catheters permits characterization of load-dependent and load-independent hemodynamic parameters. The graft may be converted to a loaded configuration by applying a clamp to the recipient's infra-hepatic IVC. We describe modified surgical techniques for both donor and recipient operations, and an ideal myocardial protection strategy. Depending on the experimental aim, this model may be adapted for use in both acute and chronic studies of graft function, immunologic status, and variable ventricular loading conditions. The conducting airways to the transplanted lung are preserved, and allow for acute lung re-ventilation. This facilitates analysis of the effects of the mixed venous and arterial blood providing coronary perfusion to the graft. A limitation of this model is its technical complexity. There is a significant learning curve for new operators, who should ideally be mentored in the technique. A surgical training background is advantageous for those wishing to apply this model. Despite its complexity, we aim to present the model in a clear and easily applicable format. Because of the physiologic similarity of this model to orthotopic transplantation, and its broad range of study applications, the effort invested in learning the technique is likely to be worthwhile.

Percutaneous intravascular stent treatment of hepatic venous outflow obstruction after pediatric liver transplantation

Objective To evaluate the therapeutic effectiveness of percutaneous endovascular treatment of hepatic venous outflow obstruction (HVOO)after pediatric liver transplantation(LT).Methods From January 2008 to January 2013,10 children with obstruction of hepatic vein (HV) or inferior vena cava (IVC) anastomosis underwent percutaneous transluminal angioplasty (PTA) with balloon dilation or stent placement.The hepatic venous outflow obstruction occurred 10-455 days (median,125 days) after pediatric liver transplantation.According to the time of obstruction,the obstruction was divide into early onset (＜1 month) and late onset(＞1 month).The effectiveness of PTA was analyzed.Results Twenty-one procedures were performed.One treatment was ineffective,and technical and initial clinical success ratio was 95.2％ (20/21) and 70.0％ (7/10),respectively.In 3 cases with early onset after LT,operation was performed after unsuccessful PTA in 1 case.One patient who developed recurrent stenosis was treated with PTAS.The other patient died of acute rejection.Late onset after LT was found in 7 cases,who were treated with PTA or stent successfully.Conclusions In cases of venous outflow obstruction resulting from HV and/or IVC lesions after pediatric liver transplantation,percutaneous endovascular treatment with balloon dilation or stent placement is a safe and effective alternative treatment that results in midterm and long-term patency.Early-onset or hepatic veins combined with superior vena cava obstruction should be implanted with stents as early as possible.Late-onset or hepatic veins obstruction alone can be get better results with Balloon Dilatation. Key words: Liver transplantation; Hepatic veins; Vena cava, inferior; Radilogy, interventional

RNase A in (Xeno)Transplantation

BackgroundCell injury, particularly as consequence of ischemia/reperfusion or acute rejection after (xeno)transplantation, leads to release of intracellular components like RNA. Extracellular RNA, (i) causes edema as a result of increasing permeability of blood vessels [1], (ii) is described as a procoagulation factor by activation of the contact phase system leading to thrombus formation and vessel occlusion [2], and (iii) promotes leukocyte recruitment to the vascular system by mobilising proinflammatory cytokines [3], and thus, triggers immune response. In rodent models of stroke and thrombosis, treatment with counteracting RNase A, a ribonuclease that specifically degrades single‐stranded RNA, was shown to result in less edema formation and vessel occlusion [4]. In search of additive drugs to protect (xeno)grafts from dysfunction, we investigated if treatment with RNase A in a rat model of heterotopic heart transplantation results in less edema and less coronary occlusion, and, therefore, in improved graft survival.MethodsBrown Norway rat cardiac allografts were transplanted into the abdomen of Lewis rats after perfusion with Bretschneider cardioplegic solution. Microvascular technique for aorto‐aortic anastomosis and pulmonary artery to inferior vena cava anastomosis (Langendorff) was used. Recipients were intravenously treated directly before transplantation and every other day with RNase A (50 μg/kg) or vehicle (saline, n = 6 in each group). In addition, in six cases the donor graft was perfused with Bretschneider solution containing RNase A (8 μg in 10 ml), and afterwards transplanted into RNase A treated recipients. The primary end point of the study was graft survival, which was determined by daily examination of the graft function by palpation and in case of inconclusiveness by echocardiography. A tolerance study was performed treating animals daily with 50 μg/kg of RNase A, with 1,000 μg/kg of RNase A, or vehicle, respectively, for 28 days (n = 3 in each group). All explanted hearts were collected for histological evaluation.ResultsMean graft survival was 6.5 ± 0.55 day (range 6–7 day) in vehicle treated animals vs. 10.2 ± 1.0 day (range 9–11 day) in RNase A treated animals (P = 0.002). Directly after explantation donor grafts had a mean weight of 0.94 ± 0.03 g (range 0.89–0.98 g). After been rejected, donor graft weight increased to 2.06 ± 0.52 g (range 1.59–2.77 g) in vehicle treated recipients, in contrast to 1.28 ± 0.27 g (1.05–1.61 g) in RNase A treated recipients (P = 0.017). No supplemental benefit was observed by additive using of RNase A in Bretschneider solution (graft survival 9.50 ± 1.52 day, graft weight 1.38 ± 0.15 g) compared to single treatment of the recipient (graft survival P = 0.394, graft weight P = 0.589). Tolerance studies showed neither macroscopic nor histological differences compared to saline treated animals.Outlook: Further histological analyses will help to clarify if RNase A will keep the promise to reduce edema formation even in the field of transplantation, as suggested by the significant less graft weight in RNase A treated recipients. Moreover, we will investigate, if RNase A prevents leukocyte recruitment in the context of rejection reaction. Therefore, grafts of RNase A treated and untreated rats will be explanted on day 4 after transplantation.ConclusionsRNase A significantly improved graft survival. On the basis of these sweeping results, however, we suppose that RNase A could be an important adjuvant drug not only in allotransplantation but even in xenotransplantation.

Venous outflow obstruction and portopulmonary hypertension after orthotopic liver transplantation

Patient: Female, 54Final Diagnosis: Suprahepatic inferior vena cava anastomosis strictureSymptoms: Ascites • fatigue • lower limb edema • hepatomegalyMedication: —Clinical Procedure: —Specialty: Transplantology • Critical Care MedicineObjective:Unusual clinical courseBackground:Suprahepatic inferior vena cava anastomosis stricture is an unusual vascular complication after orthotopic liver transplantation with the “piggyback” technique. Clinical manifestations are dependent upon the severity of the stenosis. Portopulmonary hypertension after orthotopic liver transplantation is a complication that carries high mortality due to cardiopulmonary dysfunction. The pathogenesis of pulmonary vascular disorders after orthotopic liver transplantation remains uncertain.Case Report:We report a case of acute right heart pressure overload after surgical correction of the suprahepatic inferior vena cava anastomotic stricture in a 54-year-old woman who had preexisting pulmonary arterial hypertension associated with portal hypertension after orthotopic liver transplantation. Twenty months posttransplantation, she developed fatigue and progressive ascites. On admission, the patient had hepatomegaly, ascites, and lower limb edema. Symptoms in the patient developed gradually over time.Conclusions:Recurrent portal hypertension by vascular complications is a cause of pulmonary arterial hypertension after orthotopic liver transplantation. Clinical manifestations of suprahepatic inferior vena cava anastomotic stenosis are dependent upon their severity. Sildenafil is an effective drug for treatment of pulmonary arterial hyper-tension after portal hypertension by vascular complications.

Successful Treatment of Refractory Ascites after Liver Transplantation with Splenic Artery Embolization

Introduction: Refractory ascites after orthotopic liver transplantation is rare. While secondary precipitating causes can be identified in a sizable number, a small proportion of the patients with post-transplantation ascites have no identifiable cause. Splenic artery embolization has recently been reported as an effective method of treating refractory ascites in such cases. We present a case of successful treatment of refractory ascites after liver transplantation with partial splenic artery embolization. Case: A 52-year-old Caucasian male had received an orthotopic liver transplant in March, 2011 for hepatocellular carcinoma and chronic hepatitis C induced liver cirrhosis. The patient developed refractory ascites 2 months after transplantation requiring repetitive therapeutic paracenteses. Liver biopsy and echocardiography showed no evidence of rejection or recurrent hepatitis and congestive heart failure, respectively. Transjugular hepatic venogram and pressure evaluation showed a kink at the anastomosis of right hepatic vein and inferior vena cava which was successfully stented with resolution of pressure gradient post intervention. The patient continued to have refractory ascites despite these measures and underwent partial splenic artery embolization (SAE) to decrease the inflow of blood to the portal circulation. After SAE, the patient had significant reduction in ascites with decreased need for paracentesis, improved renal function and reduced diuretic requirement. Discussion: Refractory ascites (RA) is an uncommon complication of orthotopic liver transplantation which poses a serious challenge to the clinician. It is associated with increased risk of renal failure and peritoneal infections, increased hospital stay and shortened survival. In majority of patients with RA, treatment of secondary causes including right sided heart failure, acute or chronic graft rejection and hepatic inflow or outflow obstruction, leads to resolution of ascites. In the patients with no identifiable cause, treatment of ascites is challenging. Transjugular intrahepatic portosystemic shunting has shown mixed results as a treatment strategy. Splenic artery embolization leading to decreased splenic inflow and decreased portal hypertension has shown encouraging results in the recent years. Conclusion: Owing to its effectiveness in decreasing portal hypertension and low complication risk, splenic artery embolization appears to an attractive treatment option for the challenging problem of refractory ascites after liver transplantation.

Leiomyosarcoma of the Inferior Vena Cava in a Patient With Double Inferior Vena Cava

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor arising from its smooth muscle cells. We report the case of a 38-year-old woman presenting with back pain and weight loss who was diagnosed with a 22-cm leiomyosarcoma of the right IVC and thrombosis of the left IVC. The patient is alive and free of recurrence a year after radical tumor resection with removal of the affected IVC, reconstruction with polytetrafluoroethylene prosthetic graft, and anastomosis of both right and left IVC. Leiomyosarcoma is a rare and aggressive tumor with a deceitful course. Radical surgical en bloc resection is the mainstay of treatment for IVC leiomyosarcomas. For an adequate restoration of venous return, complex vascular repair may be necessary.

Heterotopic abdominal heart transplantation in rats for functional studies of ventricular unloading

IntroductionChronic changes in mechanical load regulate long-term cardiac function. Chronic overload of the ventricle results in myocardial failure. Clinical use of ventricular assist devices shows that chronic reduction in load has a number of different consequences on the myocardium, including beneficial reverse remodeling as well as undesired remodeling (e.g., myocardial atrophy and fibrosis, both of which could have negative functional implications). The complex response to mechanical unloading necessitates reproducible animal models of mechanical unloading for use in the laboratory. This article aims to describe the operative technique of two animal models of mechanical unloading in detail, to enable the reproducible use of these animal models. MethodsIn 1964, Abbott et al first described the heterotopic abdominal heart transplantation technique as a means to study the biology of transplanted cardiac grafts. This involves an aorto-aortic anastomosis and a pulmonary artery to inferior vena cava anastomosis. In this model, the left ventricle is virtually completely volume unloaded, receiving only thebesian venous return, and substantially but not entirely pressure unloaded. In this report we describe two refined techniques for mechanical unloading of healthy or failing hearts based on experience with over 500 operations. ResultsWe describe an operative technique, including cardioprotective strategies, that provides a model of mechanical unloading with no immunological rejection and allows measurements of parameters of myocardial structure and function for many months. We describe a refined technique that achieves a lesser degree of left ventricular volume unloading, involving transplantation of both heart and lungs via a single aorto-aortic anastomosis. ConclusionsThis article is the first to describe these two techniques in sufficient detail to enable novices to attempt and understand these operations and the differences between them. The technique we describe provides an effective and reproducible model of complete and partial mechanical unloading.