Venous Cuff Research Articles

Distal Adjuncts for High-Risk Lower Extremity Bypasses

This review will discuss the use of distal adjuncts for improving graft patency in high-risk lower extremity bypasses. Factors that contribute to the increased risk of failure in high-risk lower extremity bypasses, such as the use of nonautogenous conduits, the creation of bypasses to very distal arterial targets, and bypasses in patients with significant tibial arterial disease, will be discussed. The use of surgical techniques such as creating venous cuffs, venous patches, and arteriovenous fistulas have been shown to improve the patency of high-risk bypasses. Despite the increased risk of failure, the use of surgical adjuncts such as cuffs, patches, and arteriovenous fistulas can improve the patency rates of high-risk lower extremity bypasses.

Feasibility of venous cuff using an open round ligament or inferior mesenteric vein around the hepatic vein for a left lobe graft in living-donor liver transplantation.

Living-donor liver transplantation (LDLT) is an established treatment for patients with end-stage liver disease or acute liver failure, and outflow reconstruction is considered one of the most vital techniques in LDLT. To date, many strategies have been reported to prevent outflow obstruction, which can be refractory to liver dysfunction and can cause life-threatening graft loss or mortality. In addition, in this era of laparoscopic hepatectomy in donor surgery, especially LDLT using a left liver graft, it has been predicted that cutting the hepatic vein with automatic linear staplers will lead to more outflow-related problems than with conventional open hepatectomy because of the short neck of the anastomosis orifice. We herein review 10 cases of venoplasty performed with a novel venous cuff system using a donor's round ligament around the hepatic vein in LDLT with a left lobe graft, which makes anastomosis of the hepatic vein sterically easy for postoperative venous patency.

Femorodistal bypasses using venous “cuffs”

Background/Aim. Although distal venous patch and cuff techniques are recommended to improve the patency of by-pass in the lower extremities, the advantage of these techniques remains unproven. Autovenous bypass graft remains the method of choice, but when there is no possibility of using the great saphenous vein, the venous cuff method may have an advantage. The aim of this study was to evaluate the results of femorodistal bypass procedures with a venous cuff in critical lower extremity ischemia. Methods. The study described the results of femorodistal bypass procedures after a follow-up period of 6 to 24 months. We followed 28 patients with distal composite anastomosis of femorodistal arterial reconstruction. Indications for surgical treatment were set on the basis of the clinical exam and morphological criteria based on multidetector computed tomographic angiography. Three types of distal graft-arterial anastomoses were applied: Miller?s cuff, Taylor?s patch, and St. Mary?s vein boot anastomosis. Results. After 6 months of surgery, all bypasses were passable; after one year, 2 (7%) patients had graft occlusion and above-knee amputation, and 8 (28%) patients died; after 24 months, 18 (64%) patients had primary bypass patency. Conclusion. Femorodistal bypass procedures using a synthetic graft and venous cuff have good long-term results. The optimal anastomosis type is St. Mary?s boot. A longer follow-up period and comparison with the autovenous bypass are necessary for a more detailed assessment of the final conclusion.

Time-domain NIRS system based on supercontinuum light source and multi-wavelength detection: validation for tissue oxygenation studies.

We present and validate a multi-wavelength time-domain near-infrared spectroscopy (TD-NIRS) system that avoids switching wavelengths and instead exploits the full capability of a supercontinuum light source by emitting and acquiring signals for the whole chosen range of wavelengths. The system was designed for muscle and brain oxygenation monitoring in a clinical environment. A pulsed supercontinuum laser emits broadband light and each of two detection modules acquires the distributions of times of flight of photons (DTOFs) for 16 spectral channels (used width 12.5 nm / channel), providing a total of 32 DTOFs at up to 3 Hz. Two emitting fibers and two detection fiber bundles allow simultaneous measurements at two positions on the tissue or at two source-detector separations. Three established protocols (BIP, MEDPHOT, and nEUROPt) were used to quantitatively assess the system’s performance, including linearity, coupling, accuracy, and depth sensitivity. Measurements were performed on 32 homogeneous phantoms and two inhomogeneous phantoms (solid and liquid). Furthermore, measurements on two blood-lipid phantoms with a varied amount of blood and Intralipid provide the strongest validation for accurate tissue oximetry. The retrieved hemoglobin concentrations and oxygen saturation match well with the reference values that were obtained using a commercially available NIRS system (OxiplexTS) and a blood gas analyzer (ABL90 FLEX), except a discrepancy occurs for the lowest amount of Intralipid. In-vivo measurements on the forearm of three healthy volunteers during arterial (250 mmHg) and venous (60 mmHg) cuff occlusions provide an example of tissue monitoring during the expected hemodynamic changes that follow previously well-described physiologies. All results, including quantitative parameters, can be compared to other systems that report similar tests. Overall, the presented TD-NIRS system has an exemplary performance evaluated with state-of-the-art performance assessment methods.

Back-table surgery pancreas allograft for transplantation: Implications in complications.

To describe the main aspects of back-table surgery in pancreatic graft and the problems arising from poor technique. Back-table surgery for pancreatic graft is a complex, meticulous and laborious technique on which the success of implant surgery and perioperative results depends. The technique can be described in the following steps: Preparation of the sterile table, ex-situ inspection of the pancreas-spleen block, management of the duodenum, identification of the bile duct, preparation of the portal vein, preparation of the own graft arteries and anastomosis to the arterial graft, spleen management and graft preservation prior to implantation in the recipient. A careful inspection of the pancreas-spleen block should be performed. It is important to identify the stump of the main bile duct, the portal vein cuff, and the arrangement of the superior mesenteric artery and splenic artery. The redundant duodenum must be removed. The availability of a good venous cuff facilitates the portal vein anastomosis and the positioning of the graft, two key points to prevent thrombosis. The section line of the arteries must be clean, without atherosclerosis, to prevent arterial thrombosis. The superior and splenic mesenteric arteries are generally separated by dense fibrolymphatic tissue. The artery can be reconstructed by interposing a "Y" graft from the donor iliac artery; or with an end-to-end anastomosis between the splenic artery and the superior mesenteric artery. An exquisite technique of bench work helps to prevent the most feared complications of pancreas transplantation: Thrombosis and graft pancreatitis.

The Effect of Geometric Graft Modification on Arteriovenous Graft Patency in Haemodialysis Patients: A Systematic Review and Meta-Analysis

Arteriovenous grafts (AVGs) are the second best option for haemodialysis access when native arteriovenous fistulae placement is not possible, because they have a lower patency owing to neointimal hyperplasia at the venous anastomosis. This review aimed to evaluate the effect of geometric graft modification to the graft–vein interface on AVG patency. The MEDLINE and Embase (OvidSP) databases were systematically searched for relevant studies analysing the effect of geometrically modified AVGs on graft patency and stenosis formation (last search July 2019). Data regarding AVG type, patency, and graft outlet stenosis was extracted for further evaluation. Data were pooled in a random effects model to estimate the relative risk of graft occlusion within one year. Follow up, number of patients, and relevant patient characteristics were extracted for the quality assessment of the included studies using Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The quality of the evidence was determined according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Search strategies produced 2772 hits, of which eight articles met predetermined inclusion criteria. Overall, the included articles had low to moderate risk of bias. In total, 414 expanded polytetrafluoroethylene AVGs (232 geometrically modified and 182 standard) were analysed, comprising two modified AVG types: a prosthetic cuff design (Venaflo®) and grafts with a Tyrell vein patch. Overall, modified grafts did not show a statistically significantly higher one year primary (relative risk [RR] 0.86, 95% confidence interval [CI] 95% 0.64–1.16; GRADE: “low to very low”) or secondary patency (RR 0.57, 95% CI 0.32–1.02; GRADE: “low to very low”) when compared with standard AVGs. Analysis of prosthetic cuffed grafts (112 patients) separately demonstrated a statistically significantly higher one year primary (RR 0.75, 95% CI 0.61–0.91) and one year secondary patency (RR 0.47, 95% CI 0.30–0.75) compared with standard grafts (92 patients). The results on stenosis formation were inconclusive and inadmissible to quantitative analyses. The meta-analysis showed that a prosthetic cuff design significantly improves AVG patency, while a venous cuff does not. Although the heterogeneity and low number of available studies limit the strength of the results, this review shows the potential of grafts with geometric modification to the graft–vein anastomosis and should stimulate further clinical and fundamental research on improving graft geometry to improve graft patency.

The Effect of Geometric Graft Modification on Arteriovenous Graft Patency in Haemodialysis Patients: A Systematic Review and Meta-Analysis

Arteriovenous grafts (AVGs) are the second best option for haemodialysis access when native arteriovenous fistulae placement is not possible, because they have a lower patency owing to neointimal hyperplasia at the venous anastomosis. This review aimed to evaluate the effect of geometric graft modification to the graft-vein interface on AVG patency. The MEDLINE and Embase (OvidSP) databases were systematically searched for relevant studies analysing the effect of geometrically modified AVGs on graft patency and stenosis formation (last search July 2019). Data regarding AVG type, patency, and graft outlet stenosis was extracted for further evaluation. Data were pooled in a random effects model to estimate the relative risk of graft occlusion within one year. Follow up, number of patients, and relevant patient characteristics were extracted for the quality assessment of the included studies using Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The quality of the evidence was determined according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Search strategies produced 2772 hits, of which eight articles met predetermined inclusion criteria. Overall, the included articles had low to moderate risk of bias. In total, 414 expanded polytetrafluoroethylene AVGs (232 geometrically modified and 182 standard) were analysed, comprising two modified AVG types: a prosthetic cuff design (Venaflo®) and grafts with a Tyrell vein patch. Overall, modified grafts did not show a statistically significantly higher one year primary (relative risk [RR] 0.86, 95% confidence interval [CI] 95% 0.64-1.16; GRADE: "low to very low") or secondary patency (RR 0.57, 95% CI 0.32-1.02; GRADE: "low to very low") when compared with standard AVGs. Analysis of prosthetic cuffed grafts (112 patients) separately demonstrated a statistically significantly higher one year primary (RR 0.75, 95% CI 0.61-0.91) and one year secondary patency (RR 0.47, 95% CI 0.30-0.75) compared with standard grafts (92 patients). The results on stenosis formation were inconclusive and inadmissible to quantitative analyses. The meta-analysis showed that a prosthetic cuff design significantly improves AVG patency, while a venous cuff does not. Although the heterogeneity and low number of available studies limit the strength of the results, this review shows the potential of grafts with geometric modification to the graft-vein anastomosis and should stimulate further clinical and fundamental research on improving graft geometry to improve graft patency.

Standard orthotopic heart transplantation.

The very first clinical transplants used a technique, with anastomoses of atrium to atrium, which had been developed to allow successful canine experiments (1). A small modification by Barnard led the suture line away from the sino-atrial node. Many years later Sievers (2) described the intact right atrium, with separate caval anastomoses, now the standard procedure, with a proven decrease in need for permanent pacemakers. A further refinement, with intact left atrium and separate pulmonary venous cuff anastomoses (3), the “total orthotopic transplant" has not proven popular.

Lung Transplantation and the Routine Use of Cardiopulmonary Bypass and Median Sternotomy: Experience at the Ochsner Multi-Organ Transplant Institute.

From 1990-2005 at Ochsner Medical Center in New Orleans, LA, cardiopulmonary bypass (CPB) was used only when necessary during lung transplantation surgeries. Ochsner's lung transplant program was closed for more than 4 years after Hurricane Katrina, and since the program's reestablishment in 2010, the majority of lung transplantation surgeries have been performed with the patient on CPB and with a median sternotomy incision. The purpose of this study was to compare the outcomes of the CPB and non-CPB groups. After institutional review board approval, we conducted a retrospective review of the entire program using the Ochsner lung transplant database to identify patients in the non-CPB group from 1990-2005 and in the CPB group from 2010-2014. We calculated 1- and 3-year survival rates for each patient and reviewed medical records for evidence of stroke, the need for operative reexploration, and venous stenosis. We also performed a subgroup analysis of the first 20 consecutive patients undergoing lung transplantation on CPB with median sternotomy from February 2010 through April 2011 to examine intraoperative blood product use, the quantity of blood products administered, CPB cannulation and pump complications, ischemic time, and primary graft dysfunction. Of the 208 patients in the non-CPB group, 74% had 1-year graft survival and 55% had 3-year survival following transplantation. After February 2010, 79 patients underwent lung transplantation on CPB with median sternotomy, and 90% of those patients had 1-year graft survival. Of the 46 patients available for 3-year follow-up, 59% were alive with functional grafts. The difference in 1-year survival rates between the 2 cohorts was statistically significant. Two deaths, 3 strokes, and 5 reexplorations of the chest for bleeding occurred during the perioperative time period in the CPB group, but no mortality was associated with these perioperative events. One patient who had perioperative complications died within the first year; the death was attributable to gastric perforation. Patients' early outcomes appear to have improved with the use of CPB and median sternotomy; however, 3-year survival is similar to the non-CPB group. Technical benefits of CPB with median sternotomy include decreased warm ischemia time during graft implantation, controlled hemodynamics and reperfusion, avoidance of single-lung ventilation of a freshly implanted graft, and the option to open the left atrium for implantation of a venous cuff without using a clamp. The surgical exposure facilitated by CPB with median sternotomy for lung transplantation appears to be a safe and feasible approach for lung transplantations.

Simultaneous implantation of bilateral liver grafts in living donor liver transplantation by fusion venoplasty

Small-for-size syndrome is a serious complication after living donor liver transplantation (LDLT). LDLT using dual grafts offers an alternative to solve this problem. In case of a right and left liver graft adopted for dual graft LDLT, sequential implantation of the right graft followed by the left graft is the usual approach. However, left hepatic vein and portal vein anastomosis could be challenging when the right subphrenic space is occupied by the right liver graft, and this problem could be avoided by simultaneous implantations of bilateral grafts. In this video, the technique of simultaneous implantation of bilateral living donor liver grafts via fusion venoplasty (FV) in a 59-year old patient with acute liver failure was presented. We performed FV at the backtable to join the right hepatic vein (RHV) and middle hepatic vein (MHV) to create one venous outflow in the right liver graft, the left liver was approximated to the right liver graft at the backtable followed by FV joining the left hepatic vein to the R/MHV venous cuff before anastomosis with the inferior vena cava. The right and left portal veins were then joined together to create one common orifice before anastomosis with the recipient's main portal vein. The graft right and left hepatic artery were anastomosed with the recipient's right and left hepatic artery respectively. Biliary reconstruction was performed via a duct-to-duct anastomosis for the right liver graft and a hepaticojejunostomy for the left liver graft. [Bilateral liver grafts after fusion venoplasty]

Monitoring of partial and full venous outflow obstruction in a porcine flap model using laser speckle contrast imaging

In microsurgery, there is a demand for more reliable methods of post-operative monitoring of free flaps, especially with regard to tissue-threatening obstructions of the feeding arteries and draining veins. In this study, we evaluated laser speckle contrast imaging (LSCI) and laser Doppler flowmetry (LDF) to assess their possibilities to detect partial and full venous outflow obstruction, as well as full arterial occlusion, in a porcine flap model. Cranial gluteal artery perforator flaps (CGAPs) were raised, and arterial and venous blood flow to and from the flaps was monitored using ultrasonic flow probes. The venous flow was altered with an inflatable cuff to simulate partial and full (50% and 100%) venous obstruction, and arterial flow was completely obstructed using clamps. The flap microcirculation was monitored using LSCI and LDF. Both LDF and the LSCI detected significant changes in flap perfusion. After partial (50%) venous occlusion, perfusion decreased from baseline, LSCI: 63.5±12.9PU (p=0.01), LDF 31.3±15.7 (p=0.64). After 100% venous occlusion, a further decrease in perfusion was observed: LSCI 54.6±14.2PU (p<0.001) and LDF 16.7±12.8 PU (p<0.001). After release of the venous cuff, LSCI detected a return of the perfusion to a level slightly, but not significantly, below the baseline level 70.1±11.5PU (p=0.39), while the LDF signal returned to a level not significant from the baseline 36.1±17.9PU (p>0.99). Perfusion during 100% arterial occlusion decreased significantly as measured with both methods, LSCI: 48.3±7.7 (PU, p<0.001) and LDF: 8.5±4.0PU (p<0.001). During 50% and 100% venous occlusion, LSCI showed a 20% and 26% intersubject variability (CV%), respectively, compared to 50% and 77% for LDF. LSCI offers sensitive and reproducible measurements of flap microcirculation and seems more reliable in detecting decreases in blood perfusion caused by venous obstruction. It also allows for perfusion measurements in a relatively large area of flap tissue. This may be useful in identifying areas of the flap with compromised microcirculation during and after surgery.

Microvascular anastomosis using fibrin glue and venous cuff in rat carotid artery

Conventional anastomosis with interrupted sutures can be time-consuming, can cause vessel narrowing, and can lead to thrombosis at the site of repair. The amount of suture material inside the lumen can impair the endothelium of the vessel, triggering thrombosis. In microsurgery, fibrin sealants have the potential beneficial effects of reducing anastomosis time and promoting accurate haemostasis at the anastomotic site. However, there has been a general reluctance to use fibrin glue for microvascular anastomoses because the fibrin polymer is highly thrombogenic and may not provide adequate strength. To overcome these problems, a novel technique was defined for microvascular anastomosis with fibrin glue and a venous cuff. Sixty-four rats in two groups are included in the study. In the experimental group (n = 32), end-to-end arterial anastomosis was performed with two stay sutures, fibrin glue, and a venous cuff. In the control group (n = 32), conventional end-to-end arterial anastomosis was performed. Fibrin glue assisted anastomosis with a venous cuff took less time, caused less bleeding at the anastomotic site, and achieved a patency rate comparable to that provided by the conventional technique. Fibrin sealant assisted microvascular anastomosis with venous cuff is a rapid, easy, and reliable technique compared to the end-to-end arterial anastomosis.

Role arteriovenous fistula in femoral-tibial bypass surgery

The article provides an overview of world literature data on existing techniques to improve the results of distal reconstructions by applying arteriovenous fistulas in the formation of the distal anastomosis in patients with obliterating diseases of the lower extremities. The data on the benefits of worldwide research of a method depending on the type, shape and location of venous cuffs or patches. Examined the immediate and long-term outcomes with the use of these techniques, data analysis, comparative application autovenous grafts, shunts combined with the use of arteriovenous fistulas in the formation of distal anastomosis and PTFE prostheses in position below the gap of the knee.

The Twisting Maneuver for Fluoroscopic-guided Removal of Nonpalpable Tunneled Central Venous Access Catheter Cuffs

The present report describes an alternative technique for the detection of nonpalpable polyester cuffs during the removal of tunneled central venous catheters. By twisting the external segment of the tunneled catheter in obese patients or those with severe edema, fluoroscopy can easily confirm the estimated site of the hidden cuff.

Artificial gravity with ergometric exercise can prevent enhancement of popliteal vein compliance due to 4-day head-down bed rest

Changes of venous compliance may contribute in part to postflight orthostatic intolerance. The purpose of the present study was to determine whether intermittent artificial gravity exposure with ergometric exercise could prevent venous compliance changes in the lower limbs due to simulated weightlessness. Twelve healthy male volunteers were exposed to simulated microgravity for 4days of head-down bed rest (HDBR). Six subjects were randomly loaded 1.0-2.0Gz intermittent artificial gravity (at foot level) with 40W of ergometric workload every day (countermeasure group, CM). The six others served as the control (CON group). Venous compliance was estimated by measuring the corresponding change of cross-sectional area (CSA) of popliteal vein at each minute of various venous occlusion pressure stages. Basal CSA was significantly lower after bed rest in the control group, and preserved in the countermeasure group. The percent increase in the CSA of CON group was significantly greater almost at each minute of various venous cuff pressures after bed rest than before. Compliance of popliteal vein of CON group was significant greater when 40, 60 and 80mmHg cuff pressure applied after bed rest than before of CON group. In conclusions, a 4-day simulated weightlessness leads to increase of popliteal venous compliance; centrifuge-induced artificial gravity with ergometric exercise can prevent enhancement of popliteal venous compliance due to 4-day head-down tilt bed rest, the effect of the countermeasure on compliance might involve changes in venous filling and changes in venous structure.

Comment améliorer le pronostic des pontages infrapoplités ?

Infrapopliteal bypasses are often used for critical ischemia, in patients older than 80, in diabetics patients in 20% of cases, and patients with end-stage renal disease in 10% of cases. The goal of this paper is to analyze the systemic factors, which contribute to the clinical results, the technical aspects, which improve the patency of the bypass, and the role of postoperative follow-up. Postoperative mortality in those patients ranges from 3 to 10%, depending on several factors: age, global cardiovascular diffusion, diabetes mellitus, end-stage renal disease. A complete evaluation of concomitant cardiovascular disease including coronary, renal and carotid disease is necessary to achieve the goal of reducing early and late mortality. Previous treatment of septic lesions of the foot is very important, before revascularisation. Technical aspects of infra-inguinal revascularisations modalities are based on a complete analysis by duplex scan, magnetic resonance imaging and intra-arterial angiography, with asynchronous subtractions and lateral view of the foot. With the duplex scan, the quality and the length of the homolateral or controlateral long saphenous vein can be previewed, allowing an appropriate choice among bypass modalities. A surgically safe portion, free of proximal hemodynamic lesions, must be chosen for the proximal anastomosis: common femoral artery, superficial femoral artery (SFA), popliteal artery or tibial artery. In patients with poor arterial distal run off, and high peripheral resistances (diabetic foot, end-stage renal disease, foot infections) the proximal anastomosis must be made as distal as possible, on the popliteal or tibial artery. In case involving a short lesion of the superficial femoral artery, a combined strategy with angioplasty and distal bypass is a safe therapeutic option. The distal anastomosis must be made on an artery in continuity with the foot, and the plantar arch. In diabetic patients, the best artery is often the pedal artery. The graft is preferentially venous, which is better than prosthetic bypass. The long saphenous vein can be used in situ or reversed, or transposed, reversed after valvular disruption, when the proximal anastomosis is made below the common femoral artery. At 3 years, the primary patency of prosthetic bypasses is between 30 and 50%. Several technical artifices, (external route) or venous artifice at the distal anastomosis site (venous patch, venous cuff) can be useful. A distal arteriovenous fistula improves the flow in the grafts, but increases the distal resistances. Free tissue transfer increases outflow, allowing treatment of major tissue loss of the foot. Postoperative therapy must include a systemic heparinisation, until the patient is able to have a muscular activity. Antiplatelet therapy with aspirin is warranted for venous grafts. For prosthetic by-pass, some studies have shown that coumadin therapy provides a benefit. These bypasses require a duplex scan follow-up at 1, 6, 12 months and then annually to search for stenosis of the venous grafts. If a significant hemodynamic lesion is found, a new procedure, via an endovascular or surgical approach can improve secondary patency. In cases of acute occlusions of the graft, an aggressive approach including thrombectomy, thrombolysis and distal angioplasty, can improve the patency. A global evaluation, with medical therapy, with antiplatelets, statins, diabetes control, annual evaluation of silent myocardial ischemia, and duplex scan follow-up of carotid artery disease, may improve the quality-of-life of these patients.

Which is the best revascularization for critical limb ischemia: Endovascular or open surgery?

This review considers the roles of endovascular and open surgery for critical lower limb ischemia. The TransAtlantic Inter-Society Consensus document offers sensible guidelines for the treatment of both suprainguinal and infrainguinal disease. For bilateral/diffuse suprainguinal disease, aortobifemoral bypass remains the best option, but great care should be taken in this new era of hospital-acquired infection. Unilateral iliac occlusions should be treated by primary stenting, but an iliofemoral or femorofemoral bypass may be the best option when the disease extends down into the common femoral artery. Stents may reduce the risk of embolization in iliac stenoses but probably confer no benefit in long-term patency. Iliac stenoses should be treated by angioplasty, with stents reserved for flow-limiting complications. Although infrainguinal bypass surgery is in decline, probably due to better medical treatment and more endovascular intervention, bypass using autologous saphenous vein remains the gold standard. In the absence of leg veins, arm vein should be considered. Prosthetic grafts should be used as a last resort, and only with a venous cuff. The long-term results of the Bypass Versus Angioplasty in Severe Ischemia of the Leg (BASIL) trial favor surgery rather than angioplasty if there is a good vein and the patient is fit. Further randomized studies of infrainguinal stenting vs bypass are required. Some patients with critical lower limb ischemia are best treated by analgesia or primary amputation.

Venoplasty of hepatic venous outflow with a venous patch in domino liver transplantation

The domino donor (DD) was a 16-year-old boy with homozygous familial hypercholesterolemia. He received a whole liver graft from a 9-year-old deceased donor. We designed the hepatic outflow to be reconstructed by side-to-side cavocaval anastomosis for the first liver transplantation, so the DD hepatectomy was performed with preservation of the inferior vena cava (IVC) and the stumps of 3 hepatic veins were preserved as long as possible. DD, domino donor; IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. At the back-table, the hepatic veins of the domino graft were jointed together easily (Fig. 1) by 6/0 prolene. A vein graft including the lower portion of the IVC in continuity with the left and right common iliac veins from the deceased donor was used. The graft was opened longitudinally to become a venous patch. One midline incision of the vein patch was done appropriately to be anastomosed with hepatic veins by 6/0 prolene sutures (Fig. 2). The external edge of the vein patch was further fashioned to be a wide cuff (Fig. 3). The domino liver graft. The orifices of RHV, MHV, and LHV were jointed together by 6/0 prolene sutures. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The midline of the venous patch was incised appropriately to be anastomosed with hepatic veins by 6/0 prolene sutures. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The external edge of the vein patch was further fashioned to be a wide cuff. Abbreviations: LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. The second recipient was a 59-year-old man with hepatitis B cirrhosis and hepatocellular carcinoma. The recipient's hepatectomy was performed with preservation of the IVC. The domino liver was implanted in the standard piggyback fashion by the suturing of the reconstructed suprahepatic venous cuff to the junction of all 3 hepatic veins of the recipient with clamping of the IVC but without venous-venous bypass. The cold ischemic time, warm ischemic time, and operative blood loss were 480 minutes, 34 minutes, and 450 cc, respectively, for the DD and 435 minutes, 38 minutes, and 3300 cc, respectively, for the second recipient. The DD was discharged on the 19th postoperative day with an uneventful recovery. The second recipient was discharged on the 12th postoperative day but was readmitted for anastomotic bile leakage 8 days after discharge. He was treated by a percutaneous transhepatic biliary stent and subsequently was well with normal liver functions. The Doppler ultrasound showed normal triphasic flow into all major hepatic veins of the domino liver 6 weeks after transplantation. There have been a few reports regarding the techniques of outflow reconstruction for conditions similar to our case.1-4 Our case followed the technique described by Cescon et al.,4 and the successful outcome reassures us of the usefulness of this technique. In addition, we suggest side-to-side caval anastomosis5 for the first whole liver implantation in order to retrieve longer stumps of hepatic veins of the domino liver. The long stumps of hepatic veins are easily jointed together, and this in turn makes the vein-patch technique for outflow reconstruction of the domino liver graft easier.

Technical Solutions for Venous Outflow Reconstruction in Damaged Liver Grafts During Procurement: Case Reports

The incidence and clinical consequences of hepatic injuries (parenchymal, vascular, and biliary) due to surgical handling during multiorgan procurement are still underestimated. Surgical damage to liver grafts may lead to an increased mortality and graft dysfunction rate; therefore, multiorgan procurements require a high level of expertise and training. We report our experience in two cases of accidental venous outflow damage during liver procurement focusing on our repair strategies. In one case, a short suprahepatic inferior vena cava (IVC) was extended by a venous cuff obtained from a long infrahepatic IVC from the same liver graft. In the second case, we observed a complete transection of the middle hepatic vein during in situ splitting procedure. The damage was reconstructed by cadaveric iliac vein interposition. In both cases, liver transplantation was successfully performed without venous complication. An adequate surgical technique in liver procurement and venous reconstruction during living donor and domino liver transplantation are formidable tools to achieve successful liver transplantation with a damaged graft.

Ultrasound assessment of popliteal vein compliance during a short deflation protocol

The purpose of the present study was to determine whether ultrasound is a useful tool to measure the venous characteristics of the lower extremity during a standard venous collecting cuff deflation protocol. To accomplish this, lower extremity pressure-cross-sectional area (CSA) and pressure-volume relationships were measured in eight (25 +/- 1 yr) supine subjects. Popliteal vein CSA was assessed by using high-resolution ultrasound, while calf volume changes were simultaneously assessed by using venous occlusion plethysmography (VOP). Pressure-CSA and pressure-volume relationships were assessed at baseline, during the cold pressor (CP) test, and following sublingual nitroglycerin (NTG) administration. Relationships were modeled with a quadratic regression equation, and beta(1) and beta(2) were used as indexes of venous compliance. Popliteal vein regression parameters beta(1) (8.485 +/- 2.616 vs. 7.638 +/- 2.664, baseline vs. CP; 8.485 +/- 2.616 vs. 7.734 +/- 3.076, baseline vs. NTG; both P > 0.05) and beta(2) (-0.0841 +/- 0.0241 vs. -0.0793 +/- 0.0242, baseline vs. CP; -0.0841 +/- 0.0241 vs. -0.0771 +/- 0.0280, baseline vs. NTG; both P > 0.05) were not affected by CP or NTG. Similarly, calf regression parameters beta(1) and beta(2), obtained with VOP, were not altered during either trial. Intraclass correlations for venous compliance assessed with ultrasound and VOP were 0.92 and 0.97, respectively, indicating acceptable reproducibility. These data suggest that ultrasound is a functional and reproducible tool to assess the venous characteristics of the lower extremity, in addition to VOP. Additionally, popliteal vein and calf compliance were not affected by the CP test or NTG.