Inferior vena cava replacement in living donor liver transplantation for hepatocellular carcinoma

Usability of Inferior Vena Cava Interposition Graft During Living Donor Liver Transplantation: Is This Approach Always Necessary?

PURPOSE

To share the outcome of caval reconstruction technique in patients who underwent living donor liver transplantation (LDLT) with inferior vena cava (IVC) interposition grafting.

METHODS

Between January 2009 and December 2018, an artificial or homologous interposition vascular graft was used for the continuity of resected native (IVC) due to various reasons in 29 of 1740 patients who underwent LDLT at our institute. Demographic, clinical, and radiological data were prospectively collected and retrospectively analyzed.

RESULTS

Sixteen female and 13 male patients ranging 6-67 years of age were included. Right, left, and left lobe lateral segments were used in 22, 5, and 2 patients, respectively. The three leading LDLT indications were primary or idiopathic Budd-Chiari syndrome (BCS) (n = 12), alveolar echinococcosis (n = 7), and secondary BCS (n = 5). The three leading indications for IVC interposition grafting were thrombosis, dense fibrosis, and IVC invasion caused by tumor or echinococcosis. Homologous IVC graft was used in 17, homologous aortic graft in 7, and Dacron graft in 5 patients. Throughout the follow-up period, ascites ± pleural effusion and elevated liver enzymes were detected in 12 and 4 patients, respectively. Stenosis and/or thrombosis requiring one or more procedures such as 1-6 sessions balloon angioplasty, stent, and thrombus aspiration were observed in half of the patients.

CONCLUSION

Retrohepatic IVC damages are not a contraindication for LDLT. The presence or absence of venous collateral circulation is an important indicator of the need for IVC interposition graft use.

Extensive Inferior Vena Cava Thrombosis in a Liver Transplant Patient: A Case Report

Thrombosis of the inferior vena cava is a clinical condition with very diverse presentations, ranging from asymptomatic patients to others with severe edema in the legs and lower torso. We report the case of a 27-year-old female patient, previously diagnosed with autoimmune hepatitis, with asymptomatic extensive thrombosis of the inferior vena cava. The thrombus extended from the renal veins up to the emergence of the hepatic veins, causing post-sinusoidal portal hypertension (Budd-Chiari syndrome). The patient underwent an orthotopic cadaveric liver transplant with removal of the retrohepatic vena cava and thrombectomy of blood clots from the infrahepatic vena cava. She initially recovered well from surgery, but on the 8 postoperative day she had a significant increase in hepatic injury markers and was diagnosed with rethrombosis of the inferior vena cava and hepatic veins. A surgical thrombectomy was performed, with an intraoperative finding of chronic thrombus in both renal veins, previously undiagnosed. The thrombectomy was successful, but the patient's hepatic function continued to worsen and a second liver transplant was performed. After the second transplant she underwent several imaging exams that showed no signs of rethrombosis. She was kept on postoperative anticoagulation indefinitely, first with intravenous heparin then with rivaroxaban. An extensive investigation failed to identify any causes of thrombophilia associated with this vast thrombosis. She is currently alive and with good graft function 1 year and 4 months after the second transplant.

Pediatric living donor liver transplantation with homograft replacement of retrohepatic inferior vena cava for advanced hepatoblastoma

Replacement of the retrohepatic inferior vena cava (IVC) after concurrent resection of IVC and hepatocellular carcinoma-containing liver is settled as a feasible living donor liver transplantation (LDLT) technique to cope with tumors around the IVC. This technique makes LDLT comparable to deceased-donor liver transplantation (DDLT). In the current Korean setting, the common substitute for IVC is a Dacron graft for adult recipients. In contrast, such a synthetic graft cannot be used for pediatric patients because of ongoing growth. We present one pediatric LDLT case with IVC homograft replacement for advanced hepatoblastoma. The patient was a 8 year-old boy suffering from large multiple hepatoblastomas. The tumors encroached the retrohepatic IVC. Thus there was high risk of residual tumor cells at the IVC, if it was preserved. Thus, we decided to replace IVC at the time of LDLT. After waiting for >1 month, we finally obtained cold-stored IVC homograft and LDLT was performed with the mother's left liver. A 4 cm-long IVC allograft was anastomosed at the back table. The left liver graft with IVC interposition was implanted along standard procedure similar to DDLT. The patient recovered uneventfully and is undergoing scheduled adjuvant chemotherapy. We have performed >20 cases of IVC replacement in adult recipients with hepatocellular carcinoma or Budd-Chiari syndrome, but all vessel substitutes were synthetic, because sizable IVC homograft is unavailable. In pediatric recipients, various vein homografts such as iliac vein, IVC and other large-sized veins, can be used depending on body size of recipient and availability of vessel grafts.

Living Donor Liver Transplantation With Vena Cava Replacement

OBJECTIVES

This study sought to evaluate the indications, techniques, and results of inferior vena cava (IVC) replacement at living donor liver transplantation (LDLT).

MATERIALS AND METHODS

We performed 821 LDLTs and 11 (1.3%) patients required concomitant IVC replacement. We analyzed the indications, replacement materials, and outcomes.

RESULTS

Right, left, and left lateral liver lobes were transplanted in 7, 2, and 2 patients, respectively. The indications for IVC replacement were thrombosis/fibrosis in 7 patients (Budd-Chiari 4, hereditary tyrosinemia 1, congenital hepatic fibrosis 1, cryptogenic 1), involvement with mass in 3 patients (Echinococcus alveolaris 2, hepatoblastoma 1) and iatrogenic narrowing at IVC in 1 patient. Cryopreserved grafts (aorta n = 5, IVC n = 4, iliac vein n = 1) or synthetic graft (n = 1) were used for replacements. In 1 patient, hepatic outflow obstruction developed at 39 days and was treated successfully by interventional radiology. There was only 1 hospital mortality (8.9%) that was unrelated to caval replacement (subarachnoid hemorrhage). Of the remaining patients, the caval grafts were patent after a mean 7.7 months of follow-up (range 1 to 17 months).

CONCLUSIONS

Although rare, IVC replacement can be necessary at LDLT. Budd-Chiari and E. alveolaris are the main underlying diseases for replacement requirements. Caval replacement with cryopreserved vascular grafts can provide successful short-term and long-term patency.

Criteria for case selection and perioperative management in liver transplantation for primary liver carcinoma

AIM: To summarize our experience with the treatment of hepatocellular carcinoma (HCC) by liver transplantation.

METHODS: The clinic data for 46 HCC patients treated by liver transplantation from November 2005 to January 2011 were analyzed retrospectively. The effects of factors such as the number and diameter of tumors, vascular invasion and perioperative management on the prognosis were analyzed.

RESULTS: Piggy-back liver transplantation was performed in 42 cases, and conventional liver transplantation was performed in 4 cases. Liver transplantation was successful in 45 cases, and 19 patients are still alive. The longest tumor-free survival was 63 mo. Recurrence occurred in 2 patients at 2 and 17 mo after operation, respectively.

CONCLUSION: Portal vein invasion should be the contradiction for liver transplantation. Modified piggy-back liver transplantation could be the choice for the treatment of primary liver carcinoma. Perioperative management with cool-tip radiofrequency ablation (RFA) is beneficial to the prognosis.

Retrohepatic vena cava deroofing in living donor liver transplantation for caudate hepatocellular carcinoma

The removal of tumor together with the native liver in living donor liver transplantation for hepatocellular carcinoma is challenged by a very close resection margin if the tumor abuts the inferior vena cava. This is in contrast to typical deceased donor liver transplantation where the entire retrohepatic inferior vena cava is included in total hepatectomy. Here we report a case of deroofing the retrohepatic vena cava in living donor liver transplantation for caudate hepatocellular carcinoma. In order to ensure clear resection margins, the anterior portion of the inferior vena cava was included. The right liver graft was inset into a Dacron vascular graft on the back table and the composite graft was then implanted to the recipient inferior vena cava. Using this technique, we observed the no-touch technique in tumor removal, hence minimizing the chance of positive resection margin as well as the chance of shedding of tumor cells during manipulation in operation.