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We describe the case of a 51-year-old man with end-stage liver disease associated with hepatitis C and alcoholic cirrhosis. Initially the patient was treated with a transjugular intrahepatic portosystemic shunt (TIPS) for multiple gastrointestinal bleeds and refractory ascites. Because of stenosis at the hepatic venous outflow, the TIPS was revised once. Five years and 4 months after the initial procedure, the patient underwent liver transplantation in a non-piggyback fashion. At the time of transplantation dense adhesions between the diaphragm and suprahepatic IVC were noted. The patient's postoperative course was complicated by chronic renal insufficiency, refractory ascites, lower extremity edema, and dyspnea on exertion. An inferior venacavogram 3 months posttransplantation outlined a severe, 4-cm-long stenosis of the IVC between the right atrium and the surgical anastomosis. Mean pressures were 8 mmHg in the right atrium, 28 mmHg in the right hepatic vein, and 23 mmHg in the infrahepatic IVC. The gradient was unchanged by angioplasty with 12-mm and 14-mm balloons.

Given the potential need for retransplantation in the future, it was decided not to treat the stricture with a stent. The patient was surgically explored. The whole length of suprahepatic IVC from liver parenchyma to diaphragm was strictured and fibrosed. The intrapericardial IVC and right atrium were exposed by incising the diaphragm. The duodenum was then mobilized and an area of infrahepatic IVC dissected. A 16-mm ringed synthetic graft was used to construct a venous bypass between these two sites (Fig. 1 and 2). The patient received dextran in the immediate postoperative period and was subsequently maintained on long-term aspirin therapy.

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Figure 1. Diagrammatic representation of the cavoatrial shunt. Blood flow from the splanchnic circulation reaches the shunt via retrograde flow through the retrohepatic inferior vena cava. Venous flow from the lower extremities and kidneys reaches the heart via the shunt.

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Figure 2. Intraoperative view of the finalized shunt. The arrow indicates the proximal anastomosis.

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A postoperative inferior cavagram showed patency of the prosthetic graft. The intrahepatic IVC demonstrated reversal of flow, consistent with venous drainage from the hepatic veins through the graft into the supradiaphragmatic IVC (Fig. 3 and 4). Pressures were 6 mmHg in the right atrium, 6 mmHg in the graft, 9 mmHg in the intrahepatic IVC, and 7 mmHg in the IVC distal to the origin of the graft. A Doppler ultrasound study approximately 1 year after transplantation showed a patent graft. Clinical follow-up at 2 years reported no recurrence of symptoms.

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Figure 3. Venogram demonstrating flow of blood from the infrahepatic inferior vena cava (arrowhead) through the shunt into the right atrium (arrow).

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Figure 4. Venogram demonstrating reversal of flow (arrows) through the retrohepatic inferior vena cava into the shunt and heart.

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Vascular pathologies of the IVC are among the most challenging surgical complications in liver transplantation. We believe that placement of TIPS prior to transplantation may have been associated with intimal injury and subsequent stricture formation.2, 3 Involvement of the suprahepatic IVC became evident in the immediate postoperative period.4, 5

In conclusion, construction of a cavoatrial shunt is an acceptable treatment for suprahepatic strictures after liver transplantation and it provides satisfactory results and is a safe alternative to other techniques.

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