Hepatic Venous Drainage Research Articles

A Simple and New Device to Avoid Hepatic Venous Outflow Obstruction in Adult Liver Transplantation

Hepatic venous drainage in liver transplantation may be reduced to the level of caval anastomosis producing an obstruction degree and leading to serious vascular complication such as the acute Budd-Chiari syndrome, which may result in organ loss. Outflow obstruction may be caused by lack of technique in caval anastomosis or by allograft malposition as a consequence of anatomical graft and recipient conditions. Fixation of the round ligament, placement of bowel loops and use of tissue expanders have been described to stabilize graft position during liver transplantation with related procedure complications. We report our experience of a simple homemade device using a surgical glove expander that allowed us to successfully avoid outflow obstruction in all of nine treated patients. No device related complications occurred. In malposed liver allografts, we strongly suggest the use of this simple and safe device to avoid hepatic venous outflow obstruction on condition that the device is early removed within 48 hours.

Selective Atrophy of the Middle Hepatic Venous Drainage Area in Hepatitis C–related Cirrhotic Liver: Morphometric Study by Using Multidetector CT

To retrospectively analyze the morphologic changes of hepatitis C-related cirrhosis, which commonly show macronodular cirrhosis, in relation to the portal venous supply and hepatic venous drainage, by using multidetector computed tomographic volumetry. Institutional ethics committee approval and informed consent were obtained. The volume of the entire liver, each portal segment, and hepatic venous drainage area with the respective proportion relative to the entire liver and the volume of hepatic area with the respective proportion relative to the anterior segment of the right lobe were measured in 74 patients without cirrhosis and with normal liver function and in 64 patients with cirrhosis classified as Child-Pugh class A and in 68 with that classified as Child-Pugh class B. The diameter and length of each hepatic vein were measured in normal liver. All measurements were statistically analyzed by using the Kruskal-Wallis test, and multiple comparisons were made by using a Bonferroni correction (P < .05). The entire liver volume was significantly smaller in patients with Child-Pugh class B cirrhosis (P = .002), whereas there was no significant difference in volume between the normal liver and the liver with Child-Pugh class A cirrhosis (P > .99). Middle hepatic venous (MHV) drainage area revealed significant atrophy in cirrhosis (P < .0001), more markedly in Child-Pugh class B. The right hepatic venous (RHV) and left hepatic venous drainage areas showed significant hypertrophy in cirrhosis (P < .0001). The anterior and medial segments showed significant atrophy (P < .0001), and the lateral and posterior segments and caudate lobe showed significant hypertrophy in cirrhosis (P < .05). In the anterior segment, the MHV drainage area showed significant atrophy (P < .0001), and the RHV drainage area demonstrated relative hypertrophy in cirrhosis, more definitely in Child-Pugh class B. The diameter of MHV was significantly the smallest (P < .0001), and the length of MHV was relatively longer in normal livers. The morphologic changes in hepatitis C-related cirrhosis (mainly macronodular cirrhosis) were attributed to a selective volume reduction of the MHV drainage area and relative enlargement of the other areas.

Rerouting Anomalous Hepatic Venous Connection to the Left Atrium

Total hepatic venous drainage into the left atrium is an extremely uncommon abnormality. We present a patient in whom the hepatic veins drained into the left atrium in the absence of other intracardiac or extracardiac anomalies. Surgical correction of the anomalous hepatic venous connection was performed by suturing the hepatic veins to the right atrium.

Hepatic Venous Drainage: How Much Can We Learn From Imaging Studies? Anatomic-Functional Classification Derived From Three-Dimensional Computed Tomography Reconstructions

The knowledge of "venous dominance" is essential to prevent serious venous congestion in live donor liver transplantation and extended liver resections. The purpose of our study was to delineate our proposed anatomic-functional classification of hepatic venous drainage. One hundred forty consecutive live liver donor candidates underwent three-dimensional computed tomography reconstructions and three-dimensional virtual hepatectomies. Five different venous dominance types were defined on drainage volumes or territories. "Risky" configurations were identified and classified. The right hepatic vein (RHV) was dominant for the entire liver and right hemiliver (RHH) in most (83.5%) cases irrespective of the presence of inferior (accessory) hepatic veins (IHVs). The middle hepatic vein (MHV) was dominant for the total liver (TL) in 15.5% of cases and for the RHH in 27% of cases. The left hepatic vein was almost always (92%) dominant for the left hemiliver. When associated with a large IHV drainage volume, a RHV/IHV complex dominant for the TL led to a RHH dominant MHV (mean 59.5%RHH) if the IHV was not reconstructed. Our proposed anatomic-functional classification provides a valuable insight into hepatic vein dominance patterns. RHH venous drainage patterns at "high risk" for venous congestion include (1) a dominant MHV for the TL and (2) a dominant RHV/IHV complex with a large IHV drainage volume.

Analysis of intrahepatic venovenous shunt by hepatic venography

The necessity of preserving hepatic venous drainage in hepatectomy and liver transplantation has recently been accepted; however, the hepatic vein (HV) can be removed when an effective intrahepatic venovenous shunt (VV shunt) exists. Occlusion venography of the right HV (RHV) was performed in 51 patients to investigate the VV shunt characteristics. Twenty patients had a shunt between the RHV and large HVs whose root diameters were >3 mm, such as the superficial or inferior RHV, or the middle HV. Twenty patients had a shunt between the RHV and small HVs with root diameters < or =3 mm. Eleven patients had no shunt. The change in anterior portal vein blood flow after RHV occlusion, evaluated by Doppler ultrasonography, was minimal (5 +/- 3%) in patients with a shunt between the RHV and large HVs, and less than in patients with a shunt between the RHV and small HVs (38% +/- 18%) or without a shunt (50% +/- 17%; P < .0001). A shunt between the RHV and large HV was less frequently seen in those patients with cirrhosis (3/20) than in those without cirrhosis (17/31; P = .0044). The existence of the shunt between the RHV and large HVs was unpredictable, however, from computed tomographic findings or laboratory data. A hemodynamically significant VV shunt between the RHV and large HV was observed in fewer than half of the patients and less frequently in cirrhotic patients. Preservation of hepatic venous drainage should be considered in patients without a hemodynamically significant VV shunt in liver surgery.

Extended left hepatectomy of the left and middle hepatic venous drainage areas along the anterior fissure

Background Extended left hepatectomy including the middle hepatic vein (MHV) may potentially induce right paramedian sector congestion of the remnant liver. Methods To prevent venous congestion in the right paramedian sector, we performed extended left hepatectomy including the left hemiliver and anterior segment, which drain into the MHV and left hepatic vein (LHV), for 15 patients. Results In 11 of 15 patients (73%), temporary clamping of the common trunk of the MHV and LHV and the proper hepatic artery provided the anterior fissure. Regeneration rate of the middle segment was similar to that of the right lateral sector (10.8% vs 11.2%) on postoperative computed tomography (CT) after 3 months. Conclusions This procedure could represent a useful method for preventing postoperative venous congestion.

Intraatrial Baffle Repair of Anomalous Systemic Venous Return Without Hepatic Venous Drainage in Heterotaxy Syndrome

A 7-month-old boy with heterotaxy syndrome had partial atrioventricular septal defect and interrupted inferior vena cava with hemiazygos continuation to a left superior vena cava. The left side of the common atrium receiving all the venous drainage was in connection with the left ventricle and the aorta. The small atrium and the proximity of the pulmonary and hepatic vein orifices precluded complete baffling. This report describes an intraatrial baffle repair of anomalous systemic venous return without hepatic venous drainage. This resulted in good oxygenation postoperatively, with oxygen saturation ranging from 93% to 98%.

Fontan completion in patients with atrial isomerism and separate hepatic venous drainage

Fontan completion in patients with atrial isomerism, in which the inferior vena cava (IVC) and the hepatic vein (HV) drain separately, is technically challenging. Herein, we review our surgical approach to these patients. The medical records of 50 consecutive patients with atrial isomerism who underwent Fontan completion between 1998 and 2008 were reviewed retrospectively. Separate HV drainage was present in 17 patients. Patients with interrupted IVC were excluded. Patient characteristics were as follows: median age, 26 months (range 15-149); median weight, 9.6 kg (range 8.1-47.2); right atrial isomerism, 16 patients; and left atrial isomerism, one. The IVC and the separate HV at the level of diaphragm were contralateral in 16 patients, and ipsilateral in one. The surgical procedures for directing blood flow from the IVC and the separate HV to the pulmonary arteries were as follows: en bloc resection of the IVC and the HV and anastomosing these veins to an extracardiac conduit in 10 patients; connecting the IVC to the HV in a side-to-side fashion before anastomosing them to an extracardiac conduit in one; and lateral tunnel in another. When the IVC and the HV were widely separated by the vertebrae, we chose an intra-extracardiac conduit (intra-atrial septation) in four patients and an extracardiac conduit for the IVC and the right HV and lateral tunnel for the separate left HV in one. There was no mortality. Five re-operations were performed (pacemaker in two patients; one each of fenestration, release of outflow obstruction and ligation of collateral arteries). Sixteen patients underwent follow-up catheterisation, which revealed central venous pressure of 12.0 + or - 2.0 mmHg and arterial oxygen saturation of 92% + or - 6%. The mid-term results of the Fontan completion in patients with atrial isomerism and separate HV drainage were excellent. The distance between the IVC and the separate HV and the position of the vertebrae should be considered when choosing a surgical technique.

A biphasic model for sinusoidal liver perfusion remodeling after outflow obstruction

Liver resection can lead to focal outflow obstruction due to transection of hepatic veins. Outflow obstruction may cause additional damage to the small remnant liver. Drainage of the obstructed territories is reestablished via dilatation of sinusoids. Subsequently, sinusoidal canals are formed draining the blood from the obstructed territory to the neighboring unobstructed territories. We raised the phenomenological hypothesis that the blood pressure gradient is the main driving force for the formation of sinusoidal vascular canals. We generated a biphasic mechanical model to describe this vascular remodeling process in relation to the variable pressure gradient. Therefore, we introduced a transverse isotropic permeability relation as well as an evolutional optimization rule to describe the relationship between pressure gradient and the direction of the sinusoidal blood flow in the fluid phase. As a next step, we developed a framework for the calculation concept including the representation of the governing weak formulations. Then, we examined a representative numerical example with simulation of the blood flow under both conditions, the physiological situation as well as after outflow obstruction. Doing so, we were able to reproduce numerically the experimentally observed process of reestablishing hepatic venous drainage via redirection of blood flow and formation of new vascular structures in respect to the fluid flow. The calculated results support the hypothesis that the reorientation of blood flow mainly depends on the pressure gradient. Further investigations are needed to determine the micromechanical influences on the reorientation of the sinusoids.

Technique of right hemihepatectomy preserving ventral right anterior section guided by area of hepatic venous drainage

Although the consequences of partial venous outflow interruption have attracted only limited attention in liver surgery, maximal preservation of liver function after hepatic resection requires preservation of circulation in the remnant liver, especially hepatic vein drainage. Data from 30 patients undergoing 3-dimensional imaging were analyzed to clarify the relationship between the area of the ventral right anterior section (RAS) and that drained by regional hepatic vein tributaries. The feasibility of our preliminary technique of right hemihepatectomy preserving the ventral RAS also was evaluated. The median estimated volume of the ventral RAS was 230 mL (range, 88-391). The average ratio of this estimated volume of the ventral RAS to total estimated liver volume was 18.0 +/- 4.9%. The median volume of the territory served by middle hepatic vein (MHV) tributaries draining the ventral RAS, expressed as a percentage of the whole volume of the ventral RAS, was 82.5%. Findings in fusion images of portal and hepatic vein territories demonstrated an area of MHV tributaries comparable with the ventral RAS area in 73.3% of all cases. As for the results of right hemihepatectomy with the ventral RAS preserved, no tumor was exposed on transection surfaces, and no recurrence took place within the preserved ventral RAS of the remnant liver. Procedures considering the importance of regional venous drainage offer the possibility of reducing the extent of surgery without loss of effectiveness.

Isolated resection of hemangioma in the caudate lobe

Isolated resection of bemangioma in the cau-date lobe is challenging due to the surgical anatomy of caudate lobe. The caudate lobe consists three portions: Spiegel's lobe, paracaval portion and caudate process. Most of the blood supply of caudate lobe is provided by the posterior segmental branches of the portal vein and left hepatic artery. The hepatic venous drainage encompasses a few sizable and several small branches that join the inferior vena cava. Selection of the ideal route for bepatectomy, adequate mobilization of the liver, preparatory placement of band for hepatic vascular occlusion are key factors during the operation. Key words: Caudate lobe; Hepatic hemangioma; Hepatectomy

Regeneração do fígado de ratos após oclusão parcial da drenagem venosa hepática

INTRODUÇÃO: A regeneração hepática é um mecanismo para superar a perda de tecido funcional do fígado. Este processo é estudado através de diferentes métodos. OBJETIVO: Avaliar o efeito da oclusão parcial da drenagem venosa hepática sobre a regeneração do fígado remanescente de ratos submetidos à hepatectomia parcial. MÉTODO: Foram colhidas biópsias de fígado em 30 ratos Wistar machos, e a seguir realizada hepatectomia a dois terços. Os animais foram divididos em três grupos: um grupo controle e dois grupos de estudo, submetidos a diferentes graus de estenose da veia hepática direita. Após 96 horas do estímulo para regeneração hepática, todos submeteram-se à outra biópsia hepática. Analisaram-se os fragmentos por imunoistoquímica para os marcadores Ki-67 e fator de von Willebrand. Para a leitura das amostras utilizou-se o sistema SAMBA 4000. A deposição de colágeno foi avaliada pela coloração tricrômico de Masson. RESULTADOS: A proliferação celular dos animais submetidos à hepatectomia parcial e estenose moderada ou severa da veia hepática direita persistiu mais elevada quando comparada ao grupo controle. O Índice de Marcação para o Ki-67 foi significativamente mais elevado após a hepatectomia nos grupos submetidos à oclusão parcial da veia hepática, tanto moderada quanto severa. A expressão de fator de von Willebrand estava diminuída após a hepatectomia parcial nos três grupos. Houve pouco depósito de colágeno no tecido hepático nos animais dos dois grupos com estenose da veia hepática direita. CONCLUSÃO: A oclusão parcial da drenagem venosa hepática em ratos submetidos à hepatectomia parcial prolonga o tempo de proliferação de células hepáticas quando comparado aos animais com veias de calibre normal. Como consequência, também houve atraso na restauração da matriz extracelular e na formação de novos vasos sinusoidais.

Invited Commentary

Pulmonary arteriovenous fistulas (PAVFs) are pathologic channels that permit pulmonary arterial blood to traverse the lung without participating in gas exchange, resulting in cyanosis [1]. Evidence for the role of hepatic venous blood in both inhibiting the development and promoting the regression of PAVFs is substantial. The PAVFs are seen in single ventricle patients who have undergone superior cavopulmonary shunt (BCPS), in patients with two-ventricle anatomy with hepatic venous drainage to the pulmonary venous atrium, and among patients with liver failure [1–6].

Multidetector Computed Tomography Findings of Double-Outlet Right Ventricle Associated with Multiple Cardiac and Visceral Anomalies

A 25-year-old woman who had undergone the Blalock-Taussig shunt operation for double-outlet right ventricle (DORV) in her childhood was admitted to our hospital with mild cyanosis and dyspnea on exertion. To evaluate the precise complex anatomy of this abnormality, we carried out multidetector computed tomography (MDCT) angiography. MDCT clearly revealed both an occluded Blalock-Taussig shunt and a complex cardiac anatomy, including DORV, a doubly committed ventriculoseptal defect, pulmonary stenosis, persistent left superior vena cava, minor aortic arch anomalies, and total anomalous hepatic venous drainage. To our knowledge, our report is the first description of such a complex cardiac anatomy to be revealed with MDCT.

Variation in the venous drainage of left lateral segment liver graft requiring reconstruction of segment III vein with donor iliac artery

Variation in the venous drainage of left lateral segment liver graft requiring reconstruction of segment III vein with donor iliac artery

Comparação entre exames de imagem e achados operatórios em doadores para transplante hepático intervivos

Success in living donor liver transplantation is associated to donor vascular and biliar anatomy. Compare pre-operative and per-operative findings in living liver donors related to portal vein, hepatic artery, bile duct and hepatic venous drainage anatomy. Donors charts of living donor liver transplants done at Clinics Hospital of the Federal University of Paraná, Curitiba, PR, Brazil, were reviewed between March 1998 and August 2005. On the pre-operative period the anatomy was analysed through: celiac and mesenteric arteriography of the hepatic artery and portal vein (venous phase); magnetic resonance imaging of the venous drainage, portal vein and bile duct. Normality was determined based on data of the literature. Pre-operative findings were compared to per-operative findings. Portal vein and hepatic artery were studied in 44 patients, 16 females and 28 males, mean age of 33 years old. In 8 cases the left liver lobe was used to pediatric receptor, in 36 cases the right liver lobe was used to adult receptor. Bile duct anatomy was studied in 37 cases and venous drainage in 32. Over all, the findings related to pre-operative and per-operative anatomy were not coincident in 36.36% of the cases. In the case of hepatic artery, they were not coincident in 11.36%, in the case of the portal vein in 9.1%, in the case of the venous drainage in 9.37% and in the case of the bile duct in 21.6%. The pre-operative and per-operative findings related to vascular and bile duct donor anatomy are frequently different in living donor liver transplantation.

Emergency stent implantation into obstructed inferior caval vein in a patient with heterotaxy and anomalous hepatic venous drainage

Emergency stent implantation into obstructed inferior caval vein in a patient with heterotaxy and anomalous hepatic venous drainage

Redirection of the Hepatic Venous Flow for the Treatment of Pulmonary Arteriovenous Malformations after Fontan Operation

A 45-month-old boy who had complex cardiac anomalies with interrupted inferior vena cava and polysplenia underwent extracardiac Fontan operation. He redeveloped deep cyanosis postoperatively. Cardiac catheterization showed a preferential flow of the hepatic venous blood to the right lung and arteriovenous malformations (PAVMs) in the left lung. He underwent revision of the conduit to attain balanced hepatic venous drainage with subsequent regression of the PAVMs and disappearance of cyanosis. Our experience shows that deficiency of hepatic venous flow played a crucial role in the development of PAVMs and that redistribution of the flow retained potential to ameliorate the pathological condition.

Preoperative volume calculation of the hepatic venous draining areas with multi-detector row CT in adult living donor liver transplantation: impact on surgical procedure

The purpose was to assess the volumes of the different hepatic territories and especially the drainage of the right paramedian sector in adult living donor liver transplantation (ALDLT). CT was performed in 40 potential donors of whom 28 underwent partial living donation. Data sets of all potential donors were postprocessed using dedicated software for segmentation, volumetric analysis and visualization of liver territories. During an initial period, volumes and shapes of liver parts were calculated based on the individual portal venous perfusion areas. After partial hepatic congestion occurring in three grafts, drainage territories with special regard to MHV tributaries from the right paramedian sector, and the IRHV were calculated additionally. Results were visualized three-dimensionally and compared to the intraoperative findings. Calculated graft volumes based on hepatic venous drainage and graft weights correlated significantly (r = 0.86, P < 0.001). Mean virtual graft volume was 930 ml and drained as follows: RHV: 680 ml, IRHV: 170 ml (n = 11); segment 5 MHV tributaries: 100 ml (n = 16); segment 8 MHV tributaries: 110 ml (n = 20). When present, the mean aberrant venous drainage fraction of the right liver lobe was 28%. The evaluated protocol allowed a reliable calculation of the hepatic venous draining areas and led to a change in the hepatic venous reconstruction strategy at our institution.

Anomalous Hepatic Venous Drainage

We present a 3-year-old boy born with anomalous hepatic venous drainage into the left atrium and a small sinus venosus atrial septum defect, in whom pulmonary arteriovenous malformations developed with progressive cyanosis. Surgical redirection of the hepatic venous drainage to the right atrium and closure of the atrial septal defect led to regression of the pulmonary arteriovenous malformations. However, in contrast to other reports, progressive pulmonary hypertension developed postoperatively.