Iliac Vein Graft Research Articles

Renoportal Anastomosis and Its Complications: A Complex Case Report

Renoportal anastomosis (RPA) is an effective technique in cases of complex portal vein thrombosis with the presence of a splenorenal shunt. The objective of this report is to describe the possible complications related to RPA. A 50-year-old man with alcohol-related and hepatitis C-related cirrhosis and 2 hepatocellular carcinomas underwent liver transplant. He presented a portal vein thrombosis Yerdel IV, a splenorenal shunt, and another shunt between the inferior mesenteric vein (IMV) and the perirectal plexus. During surgery, the flow of the left renal vein was 891 mL/min, and this rose to 1050 mL/min after IMV clamping. RPA was made through iliac vein graft interposition, and the IMV was ligated. Portal flow was 832 mL/min but drastically decreased because of mesenteric root compression. After finishing the liver transplant, a renoiliac graft percutaneous transhepatic stent was put in place. The patient presented graft dysfunction and acute kidney injury. On postoperative day +18, a second stent was put in place because of a thrombosis in the splenomesenteric confluence. The patient subsequently presented partial distal rethrombosis and a pancreaticoduodenal arteriovenous fistula, which required several embolizations. The patient developed ascites, recurrent gastrointestinal bleeding, and persistent bacterial peritonitis. Finally, a modified Sugiura procedure (without splenectomy) was performed, achieving a portal flow of 1800 mL/min. However, the patient developed sepsis and multiorgan failure, and died on postoperative day +70. Despite long-term patient and graft survival within accepted limits after LT, RPA is a challenging technique not exempt from complications.

Feasibility of modified endarterectomized aortic allograft for middle hepatic vein reconstruction in living donor liver transplantation: A retrospective cohort study

BackgroundCryopreserved allografts and artificial vascular grafts were introduced to meet the increasing demand for adequate vascular substitutes for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT). This study evaluated patency outcomes after engraftment of a modified endarterectomized aortic allograft (MEAA) without any additional patches. MethodsThis retrospective double-arm study was conducted in single tertiary referral center between January 2015 and July 2018. Of 1,047 adult patients who underwent single-graft LDLT with a modified right lobe (MRL), 111 patients who received grafts with MHV reconstruction using MEAA were selected. The control group comprised 434 patients who underwent MHV reconstruction using iliac vein allografts. The main outcome measure was the short-term patency of the MEAA. The secondary outcome was the incidence of graft-associated complications. ResultsClinically significant MHV stenoses requiring stenting occurred in 3 patients (2.7%) in the MEAA group and in 17 patients (3.9%) in the iliac vein group (P = 0.778). Three-month and one-year patency rates on Doppler ultrasonography and computed tomography were 88.5% and 54.0%, respectively, in the MEAA group and 84.0% and 42.2%, respectively, in the iliac vein group, indicating the superior patency outcomes with MEAA (P = 0.017). ConclusionsMHV reconstruction using MEAA during LDLT of a MRL graft is technically simple, achieves clinical outcomes comparable to iliac vein grafts, and is effective in expanding the allograft vessel pool for LDLT.

Distal pancreatectomy with celiac artery resection (DP-CAR) & portal vein resection as a conversion surgery after neoadjuvant chemotherapy for pancreatic adenocarcinoma

The authors performed distal pancreatectomy with celiac artery resection (DP-CAR) & portal vein (PV) resection and reconstruction with allogeneic iliac vein as a conversion surgery after neoadjuvant chemotherapy for locally advanced pancreas cancer (LAPC) and report here with video. A 58-year-old man presented with LAPC. There was a 4 cm sized tumor at pancreas body abutting celiac axis, superior mesenteric artery, common hepatic artery, splenic artery and portosplenic confluence. There was no evidence of distant metastasis. Modified FOLFIRINOX was given for 17 cycles per 8 months. The tumor shrunk to 3.2 cm with markedly decreased area of abutment to major vasculatures. The DP-CAR procedures were proceeded as planned except portosplenic confluence management where resection and reconstruction with an allogeneic iliac vein graft of 4 cm length was performed. The operation took 355 minutes. Intraoperatively blood loss amounted 900 g with no transfusion. R0 resection was achieved pathologically. There was one lymph node metastasis. Postoperatively infected fluid collection due to pancreas leakage was identified and percutaneous drainage was inserted 3 weeks after the operation. PV graft was stenotic due to the fluid collection. PV stent was inserted. PCD tube was removed 6 weeks after its insertion. He is well except diarrhea 3 times a day 3 months after the operation. DP-CAR with PV resection and reconstruction is a demanding operation. PV reconstruction should be anticipated and prepared before surgery when pancreas body cancer abuts portosplenic confluence. Interposition graft rather than primary anastomosis should be considered when PV resection is needed during DP-CAR.

The impact of standardized methods of hepatic vein reconstruction with an external iliac vein graft.

Liver tumors that invade the hepatic vein are surgically challenging, especially in patients with liver dysfunction. Preservation of as much of the parenchyma as possible is important; thus, when feasible, we perform hepatectomy with hepatic vein reconstruction (HVR) using an external iliac vein (EIV) graft. We conducted a retrospective study to investigate the benefit of HVR and to evaluate our procedure. The study included patients treated by hepatectomy with HVR using EIV grafts and vascular clips. We reviewed the surgical outcomes, including total operation and HVR times, postoperative complications, and postoperative liver function. The surgeries included right HVR (n=13), left HVR (n=3), and middle HVR (n=1). The total operation time was 277±72 minutes (155-400 minutes), and the HVR time was 27±5 minutes (19-40 minutes). Graft patency was confirmed in 14 (82%) of the patients. One patient who underwent HVR with running sutures required emergency surgery due to graft thrombosis. Clavien-Dindo > grade IIIa postoperative complications occurred in 4 (23.5%) patients, but there were no treatment-related deaths. In conclusion, our hepatic resections with HVR using the same techniques and graft materials showed acceptable surgical outcomes. From our experience, we believe that preparatory hepatic resection with HVR is an effective treatment, especially for patients with decreased liver function or with a small residual liver parenchyma.

Hepatopancreatoduodenectomy with simultaneous resection of the portal vein and hepatic artery for locally advanced cholangiocarcinoma: Short- and long-term outcomes of superextended surgery.

Only a few authors have reported negative results for hepatopancreatoduodenectomy (HPD) with simultaneous resection of the portal vein and hepatic artery in a limited number of patients. The aim of the current study was to outline our experience with this superextended surgery and to discuss its clinical value. Medical records of consecutive patients who underwent resection of perihilar cholangiocarcinoma between 2007 and 2020 were retrospectively reviewed. During the study interval, 650 patients with perihilar cholangiocarcinoma underwent resection. The superextended surgery was performed in only nine (1.4%) patients. Left or right trisectionectomy was primarily performed. For portal vein reconstruction, external iliac vein graft was required in seven patients. For hepatic artery reconstruction, rotating left gastric artery was often used. The median operative time was 870minutes and blood loss was 2,598mL. Postoperatively, pancreatic fistula and liver failure occurred in all patients, followed by intraabdominal abscess (n=8), and bacteremia (n=4). One patient died on day 86 due to multiple organ failure. Two patients survived for more than 7years. HPD with simultaneous resection of the portal vein and hepatic artery is demanding but worth performing as the last option, with careful patient selection in experienced centers.

Liver Transplantation in Patients With Complete Portal Vein Thrombosis: Renoportal or Varicoportal Anastomosis Using Cryopreserved Vein Grafts

BackgroundDespite technical developments in transplantation surgery, complete portal vein thrombosis still remains a challenge for restoration of adequate portal vein inflow. Renoportal or varicoportal anastomosis provides an effective alternative solution for patients with complete portal vein thrombosis. This study describes our experience with renoportal and varicoportal anastomosis during liver transplantation. Patients and methodsBetween January 2014 and May 2016, 5 patients with complete portal vein thrombosis underwent extra-anatomic portal anastomosis. In 3 cases, varicoportal anastomosis was performed and for the others, end-to-end renoportal anastomosis. We used iliac cryopreserved vein grafts to restore portal anastomosis in 3 cases. Epidemiology, risk factors, surgical techniques, complications, and outcomes of these procedures were evaluated over short- and long-term follow-ups. ResultsThe follow-up time is 3 years for our first renoportal case, which was performed in a cadaveric liver transplantation; it was also first nationwide case. The other renoportal anastomosis was practiced in a living donor liver transplantation and the follow-up time is 8 months. The patient and graft survival rates were 100% at the last follow-up. The follow-up times are 10.9 and 4 months for the patients with varicoportal anastomosis. One of these patients died due to recurrence of hepatocellular carcinoma. The other two patients are alive with good graft functions. ConclusionOur experience suggests that reno-varicoportal anastomosis is a useful technique for patients with complete portal vein thrombosis and cryopreserved grafts may be safely used.

Reconstruction of the Outflow Tract in Cross-Auxiliary Double-Domino Donor Liver Transplantation.

Auxiliary liver transplantation is accepted as an effective manner to expand the liver donor pool. A difficult surgical technical challenge of the procedure is hepatic vein reconstruction of the graft. To resolve this problem, complex techniques are used to perform an innovative outflow tract reconstruction in the world's first cross-auxiliary double-domino donor liver transplantation with two whole liver grafts. The inferior vena cava-sparing hepatectomy technique was applied at harvest in the two domino liver donors. For each donor, the three major hepatic veins (right, middle, and left) were joined together to create one single orifice, but there was no sufficient tissue to perform a direct anastomosis. The hepatic vein was reconstructed with the use of a longitudinally opened iliac vein graft from a cadaveric donor to prolong the outflow tract for the piggyback suturing. This new technique might provide an innovative surgical approach for reconstructing the complex outflow tract of domino transplantation.

En Bloc Resection of the Hepatoduodenal Ligament for Advanced Biliary Malignancy

BackgroundEn bloc resection of the hepatoduodenal ligament (HDL) for advanced biliary malignancy by hepato-ligamento-pancreatoduodenectomy (HLPD) or hepatoligamentectomy (HL) remains challenging, and only short-term outcomes have been reported. We showed our surgical technique of HLPD and HL, and retrospectively investigated surgical outcomes of the patients. MethodsBetween 2003 and 2014, we performed four HLPD and three HL including major hepatectomy with concomitant caudate lobectomy. Portal vein reconstruction (PVR) was performed with a right external iliac vein graft, and hepatic artery reconstruction (HAR) was accomplished with the heterogeneous artery using the continuous suturing method. ResultsMean operation time and blood loss were 575 ± 111 min and 1539 ± 950 mL, respectively, and patency of the reconstructed vessels was confirmed postoperatively in all cases. Histologically, negative surgical margins (R0) were achieved in 57 % of patients, while the resected vascular invasion was confirmed in all patients. Overall morbidity was high at 57 %, but we have achieved no postoperative mortality. Overall median survival time of the patients was 36 months, and a patient of HL survived over 5 years. ConclusionsEn bloc resection of the HDL based on steady vascular reconstruction can improve the surgical outcome of biliary cancer in selected patients.

Banking of cryopreserved iliac artery and vein homografts: clinical uses in transplantation.

Iliac artery and vein homografts are critical for revascularization in living-donor liver transplantation. Since 2010, National Cardiovascular Homograft Bank and National University Hospital have collaborated in the pioneer endeavor of banking iliac vessel homografts for such surgeries in Singapore. This article aims to demonstrate that the processing, decontamination and cryopreservation techniques that our bank follow, help preserve iliac vessel homografts for a longer duration as compared to homografts preserved using short-term preservation techniques. This paper reports the first 4 years of post-operative outcome for recipients as a preliminary report for a longer-term outcome study. Criteria for donor assessment, techniques of iliac vessel homograft recovery, processing, decontamination, cryopreservation and storage according to the American Association of Tissue Banks standards are also described. From 2010 until 2013, we discovered of the iliac vessel homografts processed, 17 (94.4 %) were suitable for clinical use. Nine iliac artery grafts (64 %) and one iliac vein graft (14 %) were implanted. Irrespective of vessel type, homografts <90 mm in length were of little use. Of the nine current iliac vessel homograft recipients, eight patients (89 %) had living-donor liver transplantation and one patient (11 %) had reconstruction of the right internal carotid artery after resection of an aneurysm. Our preliminary results supports existing literatures that suggest cryopreserved iliac vessel homografts can be successfully used for revascularization in liver transplantation and reconstruction of carotid artery. Encouraging short-term post-operative patient outcomes have been achieved, with no report of adverse event attributed to implanted homografts. We believe that our processing, decontamination and cryopreservation techniques have helped preserve the homografts for longer duration as compared to homografts preserved using short-term preservation techniques.

Complications Analysis of Polytetrafluoroethylene Grafts Used for Middle Hepatic Vein Reconstruction in Living-Donor Liver Transplantation

BackgroundWe previously showed that ringed polytetrafluoroethylene (PTFE) grafts combined with small allograft patches showed high patency rates similar to those of iliac vein grafts and therefore that they can be used for middle hepatic vein (MHV) reconstruction. Although such use of PTFE graft showed high patency rates, its long-term safety regarding infection and other types of complications were not presented. In this study, we investigated the actual risk of complications directly associated with PTFE graft interposition for MHV reconstruction. MethodsDuring the study period of 30 months, we performed 215 cases of adult living-donor liver transplantation with modified right lobe graft and PTFE grafts. We classified the potential complications directly associated with PTFE graft interposition as infectious and surgical complications. The medical records of study patients were retrospectively reviewed. ResultsMHV graft patency rate was 76.3% at 6 months and 36.7% at 12 months. Their 1-year graft and patient survival rates were 92.6% and 93.5%, respectively. The 1-year actual incidences of infectious complication and surgical complication were near zero and 1 case (0.5%), respectively. In 1 recipient, the PTFE graft penetrated into the stomach wall 6 months after transplantation, but the patient did not complain of any specific symptoms. The PTFE graft was removed with the use of laparotomy, and the patient recovered uneventfully. ConclusionsAlthough the incidence of PTFE graft–associated complication rate is very low, we suggest that it is necessary to closely monitor the PTFE graft, because unexpected complications can happen during long-term follow-up.

Complex hepatic outflow reconstruction in domino liver transplantation

Domino liver transplantation has been accepted as a safe procedure to further expand the organ donor pool. The most important technical challenge of the procedure resides in restoring a proper hepatic venous allograft outflow in the familial amyloidotic polyneuropathy-liver recipient. To overcome this issue, combined techniques were used to perform an innovative outflow reconstruction. A domino liver transplantation was successfully performed with reconstruction of complex venous outflow. The inferior vena cava sparing hepatectomy technique in the familial amyloidotic polyneuropathy-donor was used to cut the hepatic vein to the liver parenchyma. To overcome this issue the venous outflow tract was reconstructed using a longitudinally opened iliac vein graft from a post-mortem donor to create a new outflow tract using a diamond patch between the right and middle/left hepatic veins.

The portal vein‐variceal anastomosis: an important technique for establishing portal vein inflow

Adequate portal vein inflow is critical to successful orthotopic liver transplantation. While an end-to-end donor to recipient portal vein anastomosis is fashioned in the majority of liver transplant recipients, approximately 2% of recipients will require a complex vascular reconstruction due to inadequate recipient portal vein inflow. In this series, we describe our experience with five patients in which porto-variceal anastomosis was used to treat extensive porto-mesenteric thrombosis. Charts for patients who underwent liver transplantation from January 1, 2006, to December 31, 2011, were reviewed for patients requiring porto-variceal anastomosis. Five patients had extensive porto-splenomesenteric thrombosis requiring utilization of a varix as portal inflow. An iliac vein graft was utilized in four patients, and a direct anastomosis was performed in one patient. The patient with the direct anastomosis required revision with the use of an iliac vein graft the following day. Follow-up imaging documented portal vein patency at a minimum of threemonths post-transplant. No patients suffered post-operative variceal hemorrhage and all five patients are alive with a functional primary graft at a median follow-up of 2.3yr. A porto-variceal anastomosis should be feasible in the majority of patients with extensive porto-mesenteric thrombosis with excellent durability.

Pancreatoblastoma with portal vein involvement in a child: A case report

Pancreatoblastoma is a rare pancreatic tumor in children. Its biologic behavior is aggressive with frequent local invasion, recurrence, and metastasis , for which there has been no standard treatment regimen. A 13-year old Japanese girl had pancreatoblastoma arising from the pancreas head and body and invading the portal vein. The tumor was resected with pancreaticoduodenectomy combined with reconstruction of the portal and splenic vein using native left common iliac vein graft, followed by chemotherapy. The tumor recurred in the liver and periportal lymph node but was treated with surgical resection and chemotherapy followed by autologous peripheral blood stem cell transplantation. The reconstructed portal vein has been patent with no sign of stricture for 3.5 years after the first operation. She has been well with a second complete remission for 10 months. Complete surgical resection has been considered for long-term survival of patients with pancreatoblastoma. Portal venous involvement is not a contraindication of surgical resection of pancreatic tumors and may be aggressively treated by pancreaticoduodenectomy with portal venous reconstruction using a venous conduit. Autologous peripheral blood stem cell transplantation has been used in only two other pediatric cases in the literature for treating pancreatoblastoma. Although our follow-up period is short, aggressive surgical and chemotherapeutic regimen may hold therapeutic promise for managing advanced or relapsed pancreatoblastoma in children.

Computational Simulation-Based Vessel Interposition Reconstruction Technique for Portal Vein Hypoplasia in Pediatric Liver Transplantation

BackgroundTo enhance the technical feasibility of portal vein (PV) interposition grafting for pediatric PV hypoplasia, we performed a computational simulation to establish a customized surgical technique allowing a secure anastomosis of an iliac vein graft to a severely hypoplastic PV stump. MethodsBased on the literature and on our own experience with reconstruction of PV hypoplasia, we devised three types of recipient PV stump preparations and three types of interposition vein grafts, yielding five technically feasible combinations. ResultsThe computational simulation model for PV reconstruction using an interposition vein graft revealed the most feasible combination to be a sequential inverted-T incision to the confluence of the superior mesenteric vein and splenic vein with a longitudinal slit in the transverse vein graft end, the technical feasibility was validated by an artificial suture model. This reconstruction was clinically applied to treat a 7.2-kg 10-month-old female patient with biliary atresia and a severely hypoplastic PV. The PV reconstruction was successful; the patient recovered uneventfully. ConclusionsWe have presented a simplified surgical technique for PV interposition that is applicable to pediatric PV hypoplasia, which also appears to be a feasible option for pediatric liver transplantation.

Quality of life and the venous function of the lower limb after harvest of autologous external iliac vein grafts: a clinical follow-up study

To investigate the quality of life and venous function of the lower limbs after right external iliac vein (REIV) grafting for digestive surgery. The study subjects included 66 patients treated surgically for hepatopancreatobiliary malignancy who underwent concomitant resection with REIV for use as autologous grafts. Fifteen patients completed the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ), and the venous function was assessed using air plethysmography (APG) and duplex ultrasound in 10 patients. The outcomes of the 15 patients were analyzed statistically. Postoperative morbidity related to graft harvest occurred in three of the 66 patients (5 %). The right legs of the follow-up patients were 6 ± 3 % larger than the left legs. The mean CIVIQ score was acceptably low at 27; however, moderate symptoms (e.g., pain upon long-time standing or walking) occurred in seven of the 15 patients. APG revealed moderate to severe outflow obstructions that did not improve during long-term observation. The blood flow depicted on duplex ultrasonography was significantly associated with the patients' symptoms. No deep venous reflux was encountered, and no right leg skin changes or venous claudication developed. The symptoms occurring after REIV resection can be unexpectedly prolonged. These unfavorable effects must be kept in mind and the possible sequelae should be carefully explained to patients preoperatively.

Salvage Dual LDLT for HCC after Major Hepatectomy

Recurrence is the most frequent cause of treatment failure after hepatocellular carcinoma (HCC) resection. Salvage liver transplantation is a rescue treatment for recurrent HCC. However, salvage LT is considered about the technical feasibility in patients who have undergone prior liver surgery. Especially prior performance of a major liver resection, such as right lobectomy, makes subsequent recipient hepatectomy technically difficult. We report a successful case about salvage dual living donor liver transplantation(LDLT) after major hepatectomy. A 48-year-old male was transferred to our hospital because of gastrointestinal bleeding. He underwent the right hepatectomy due to hepatocelluar carcinoma four years ago. The gastroduodenoscopy and computed tomography demonstrated variceal beeding at duodenal 3rd portion. We performed transjugular intrahepatic portosystemic shunt(TIPS) and the coil embolization of collaterals. We recommended LDLT and because the right lobe volume of one donor, his wife was was not sufficient for the recipient and right to left lobe proportion of the other donor, his young sister is smaller than 30%, we performed dual LDLT from two donors who were his wife and young sister. At the operation, portal vein anastomosis of the right lobe graft was done using an interposing cadaveric iliac vein graft and the right gastroepiploic artery was anastomosed to the hepatic artery of the left lobe graft. Adequate portal venous and hepatic artery blood flow was demonstrated by intraoperative and postoperative Doppler ultrasound studies. Salvage dual LDLT could be undertaken successfully in adult patients with prior major hepatectomy under the accurate preoperative planning and proper surgical techniques.

Hepatobiliary resection with concomitant resection of the inferior vena cava for advanced intrahepatic cholangiocarcinoma: report of a case

A 65-year-old female was diagnosed with intrahepatic cholangiocarcinoma involving the inferior vena cava (IVC). The patient underwent right trisectionectomy and caudate lobectomy with bile duct resection and concomitant resection of the IVC. The IVC was reconstructed using the right external iliac vein. Histologically, the tumor had invaded the IVC. Despite the administration of postoperative prophylactic anticoagulant therapy, IVC thrombosis developed, probably due to the difference in diameter between the IVC and the graft. Following the development of collateral vessels, the patient was discharged and is now healthy without recurrence 18 months after surgery. IVC reconstruction using an external iliac vein graft may lead to the development of IVC thrombosis. Therefore, the graft used for IVC reconstruction should be very carefully selected.

A new technique for the reconstruction of complex portal vein anomalies in right lobe living liver donors

Living donor liver right lobe transplantation using donors with variation of the right sectorial portal vein is considered a challenging procedure in terms of the donor's safety and the complexity of reconstruction in the recipient. We describe an innovative technique to reconstruct double portal vein orifices via a deceased donor iliac vein graft. The postoperative course of the recipient was uneventful. Doppler ultrasound on the fourth postoperative month revealed equivalent flow in both portal vein branches. Reconstruction of double right portal vein branches using a cryopreserved iliac vein is a valuable technique for utilizing right lobe grafts with challenging portal vein anatomy.

Usability of ringed polytetrafluoroethylene grafts for middle hepatic vein reconstruction during living donor liver transplantation

Large vein allografts are suitable for middle hepatic vein (MHV) reconstruction, but their supply is often limited. Although polytetrafluoroethylene (PTFE) grafts are unlimitedly available, their long-term patency is relatively poor. We intended to enhance the clinical usability of PTFE grafts for MHV reconstruction during living donor liver transplantation (LDLT). Two sequential studies were performed. First, PTFE grafts were implanted as inferior vena cava replacements into dogs. Second, in a 1-year prospective clinical trial of 262 adults undergoing LDLT with a modified right lobe, MHV reconstruction with PTFE grafts was compared with other types of reconstruction, and the outcomes were evaluated. In the animal study, PTFE grafts induced strong inflammatory reactions and luminal thrombus formation, but the endothelial lining was well developed. In the clinical study, the reconstruction techniques were revised to make a composite PTFE graft with an artery patch on the basis of the results of the animal study. MHVs were reconstructed with cryopreserved iliac veins (n = 122), iliac arteries (n = 43), aortas (n = 13), and PTFE (n = 84), and these reconstructions yielded 6-month patency rates of 75.3%, 35.2%, 92.3%, and 76.6%, respectively. The overall 6-month patency rates for the iliac vein and PTFE grafts were similar (P = 0.92), but the 6-month patency rates with vein segment 5 were 51.0% and 34.7%, respectively (P = 0.001). The overall graft and patient survival rates did not differ among these 4 groups. In conclusion, ringed PTFE grafts combined with small vessel patches showed high patency rates comparable to those of iliac vein grafts; thus, they can be used for MHV reconstruction when other sizable vessel allografts are not available.

Transplantation of an allogeneic vein bioengineered with autologous stem cells: a proof-of-concept study

Extrahepatic portal vein obstruction can have severe health consequences. Variceal bleeding associated with this disorder causes upper gastrointestinal bleeding, leading to substantial morbidity and mortality. We report the clinical transplantation of a deceased donor iliac vein graft repopulated with recipient autologous stem cells in a patient with extrahepatic portal vein obstruction. A 10 year old girl with extrahepatic portal vein obstruction was admitted to the Sahlgrenska University Hospital in Gothenburg, Sweden, for a bypass procedure between the superior mesenteric vein and the intrahepatic left portal vein (meso Rex bypass). A 9 cm segment of allogeneic donor iliac vein was decellularised and subsequently recellularised with endothelial and smooth muscle cells differentiated from stem cells obtained from the bone marrow of the recipient. This graft was used because the patient's umbilical vein was not suitable and other strategies (eg, liver transplantation) require lifelong immunosuppression. The graft immediately provided the recipient with a functional blood supply (25-30 cm/s in the portal vein and 40 mL/s in the artery was measured intraoperatively and confirmed with ultrasound). The patient had normal laboratory values for 9 months. However, at 1 year the blood flow was low and, on exploration, the shunt was patent but too narrow due to mechanical obstruction of tissue in the mesocolon. Once the tissue causing the compression was removed the graft dilated. We therefore used a second stem-cell populated vein graft to lengthen the previous graft. After this second operation, the portal pressure was reduced from 20 mm Hg to 13 mm Hg and blood flow was 25-40 cm/s in the portal vein. With restored portal circulation the patient has substantially improved physical and mental function and growth. The patient has no anti-endothelial cell antibodies and is receiving no immunosuppressive drugs. An acellularised deceased donor vein graft recellularised with autologous stem cells can be considered for patients in need of vascular vein shunts without the need for immunosuppression. Swedish Government.