Cavoatrial bypass for occlusion of the inferior caval vein in a patient with Budd-Chiari syndrome

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.

A Novel Approach with Supra- and Retro-hepatic Cavocaval Bypass for Short Segmental Occlusion of Inferior Vena Cava in Budd-Chiari Syndrome

BACKGROUND

Budd-Chiari syndrome (BCS) is defined as chronic, progressive and congestive liver dysfunction resulting from obstruction of the outflow of inferior vena cava (IVC) and/or hepatic veins. One of the common types of BCS is short segmental occlusion of retrohepatic IVC (SSOR-IVC) accompanied by varied extent of obstruction of intrahepatic veins. The mainstay of surgical treatment at present for SSOR-IVC is cavoartrial bypass via thoracolaparotomic approach, in which thoracic and pulmonary complications intra- and/or post-operation are common. We have developed an abdominal approach using suprahepatic and retrohepatic inferior vena cavocaval bypass to treat SSOR-IVC, herein we compared it with the conventional thoracolaparotomic approach.

METHODS

From 2005 to 2008, we performed suprahepatic and retrohepatic inferior vena cavocaval bypass using artificial vessel in 16 BCS patients with SSOR-IVC (group A), we compared the results of this new modality with that using traditional thoracolaparotomic approach in 18 patients (group B) from 2001 to 2004.

RESULTS

In group A, one patient had intraoperative acute cardiac failure due to rapid opening of the bypassed vessel, and the symptom was resolved immediately through prompt management, while the others were not eventful during or post-operation. The length of artificial vessel required was 6 to 8 cm, and all patients had no graft vessel thrombosis after 10 to 55 months follow-up. In group B, one patient had intraoperative acute pericardial tamponment due to anastomotic leakage. The total occurrence rate of postoperative complication was 27.8%, including three pleural effusions, one pulmonary infection and one acute pericarditis. The length of the artificial vessel required was 12 to 14 cm. Three patients had graft vessel thrombosis at 37, 42 and 58 months post-operation, respectively.

CONCLUSIONS

The abdominal approach for suprahepatic and retrohepatic cavocaval bypass have advantages as follows over the traditional thoracolaparotomic approach for cavoartrial bypass: 1) Less traumatic with fewer postoperative thoracic and pulmonary complications; 2) A shorter artificial vessel required to facilitate endothelial seeding for improved long term patency; 3) Void of risk of fatal pericardial tamponment; 4) Prevention of acute pericarditis due to pericardial irritation by the artificial vessel in the thoracolaparotomic approach. We concluded that this novel abdominal approach is a safe and effective technique for treatment of SSOR-IVC.