Use of a donor aortic interposition allograft to treat stenosis of the suprahepatic inferior vena cava after liver transplantation

✍ Scribed by Kourosh Saeb-Parsy; Asif Jah; Andrew J. Butler; Stephen Large; Gavin J. Pettigrew; Raaj K. Praseedom; Christopher J. Watson; Neville V. Jamieson

• Publisher: John Wiley and Sons
• Year: 2009
• Tongue: English
• Weight: 200 KB
• Volume: 15
• Category: Article
• ISSN: 1527-6465
• DOI: 10.1002/lt.21655

✦ Synopsis

Partial or complete obstruction of the inferior vena cava (IVC), due to anastomotic stenosis or thrombosis leading to hepatic outflow obstruction, is a recognized complication of orthotopic liver transplantation (OLT). Although its overall incidence is less than 2%, it is more commonly reported after a classical caval replacement procedure or a piggyback reconstruction (compared to cavocavostomy), in which the suprahepatic donor IVC is anastomosed to the confluence of the left and middle hepatic veins of the recipient. [1][2][3][4] Early stenosis is often due to a technical issue such as tight anastomosis, donor-recipient size mismatch (in an end-to-end anastomosis), torsion at the IVC, or an intimal flap. Late anastomotic stenosis is more likely to be secondary to perivascular fibrosis, intimal hyperplasia, or external compression by a hypertrophied liver graft. 1 It is less common when side-to-side cavocavoplasty is used.

Although late stenosis can often be treated successfully by angioplasty with or without stents, 5-7 early stenosis usually requires surgical revision of the anastomosis or retransplantation. Revision of the anastomosis, however, poses significant difficulties due to the need to clamp the hepatic outflow with ensuing warm ischemic insult during the revision of the anastomosis. Revision of the anastomosis is also constrained by the available length and intimal quality of the suprahepatic IVC, and this often leaves retransplantation as the easiest option. Here we report the successful use of an interposition graft of the donor aorta to bypass an anastomotic stenosis affecting the suprahepatic IVC occurring early after OLT in which graft outflow had been fashioned with a side-to-side cavocavostomy technique below an unrecognized caval stenosis in 2 patients.