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TO THE EDITORS:

In a recent letter from the frontline, Waits et al.[1] described a technique for ensuring an adequate length of infracardiac inferior vena cava (IVC) for both liver and cardiac grafts during organ procurement. The authors highlighted that advances in liver and cardiac transplantation techniques require sharing of the IVC between the 2 transplant teams, and they proposed a 1-cm length of the IVC above the hepatic veins for the liver graft.

There are times, however, when a lack of coordination between cardiac and abdominal retrieval teams or, simply, operator error can lead to a very short IVC length or indeed injuries to the suprahepatic vena cava. Although significant injuries to the vena cava or the hepatic veins are infrequent (3%),[2] the lack of a suitable length of suprahepatic IVC jeopardizes hepatic venous outflow after standard implantation techniques; therefore, the graft requires some form of vascular reconstruction to enable successful transplantation.

The experience from domino liver transplantation has led to various options for surgical reconstruction, which include the use of the IVC–common iliac bifurcation,[3] a vein patch, or the infrahepatic cava for anastomosis. However, these options are not always practical; therefore, alternative reconstructive strategies should be considered.

Recently, at our center, we had a series of 3 liver grafts in which the suprahepatic IVC was divided very close to, or at the level of the hepatic vein ostia during organ procurement. Here we describe 3 different surgical options that allowed the safe reconstruction of suprahepatic caval injuries with no or minimal modification of our routine venous implantation technique.

We routinely employ the modified piggyback implantation technique described by Belghiti[4]: the suprahepatic and infrahepatic IVC is closed, and a side-to-side cavocavostomy is created.

In the first case, the suprahepatic IVC was divided 3 mm above the hepatic veins at the time of retrieval, and this provided an inadequate length for closure without outflow compromise. During bench surgery, a 1.5 cm cuff of the infrahepatic IVC was transected and transposed to extend the suprahepatic IVC. di Francesco et al.[5] described a similar approach but implanted the liver with the standard piggyback technique. In our case, the caval ends were oversewn, and a cavotomy was created and extended close to the suture line (Fig. 1) to allow modified piggyback implantation.

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Figure 1. An infrahepatic IVC cuff is transposed to the suprahepatic end. The caval ends are oversewn, and a cavotomy is made in preparation for side-to-side cavocavostomy implantation.

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In the second case (with a similar injury), the infrahepatic IVC was too short to allow a cuff transposition. A donor common iliac vein was prepared and opened in half. This was sutured as a circumferential collar to the suprahepatic IVC to create an extension tube. The caval ends were oversewn, and a cavotomy was created as described previously.

In the third case, the suprahepatic IVC was divided at the level of the middle hepatic vein (MHV) and left hepatic vein (LHV) junction at the time of organ retrieval (Fig. 2). At this level, the suprahepatic caval diameter was wider than the infrahepatic IVC, so a cuff would not have allowed reconstruction as described previously. Because no iliac vein graft was available, a novel approach was used: an infrahepatic IVC cuff was divided to create a strip. This was sutured onto the anterior wall of the suprahepatic cava and hepatic veins and extended three-quarters of the circumference, as shown in Fig. 3. The posterior wall of the IVC was incised to ensure a wide opening for the piggyback anastomosis. The reconstructed suprahepatic IVC was then anastomosed end to side onto a triangular opening in the anterior wall of the recipient IVC.[6]

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Figure 2. Suprahepatic cava retrieval injury at the level of the MHV and LHV junction.

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Figure 3. An infrahepatic IVC cuff is taken, opened, and sutured extending the anterior three-quarters of the suprahepatic end of the cava with a posterior incision on the donor IVC and end-to-side cavocavostomy implantation.

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All 3 patients in this miniseries underwent successful liver transplantation. An inadequate length of the suprahepatic IVC is an uncommon occurrence, but reconstruction is mandatory to avoid venous outflow problems. Advances in the surgical management of outflow issues in living liver donation have added a new dimension to IVC reconstruction choices. One must be aware of the various surgical options and adapt the reconstructive technique to the nature of the injury and the availability of donor vessels.

  • Stuart Falconer, MB.ChB., M.R.C.S.

  • James J. Powell, M.D., F.R.C.S.

  • Gabriel C. Oniscu, MB.ChB., M.D., F.R.C.S.

  • Scottish Liver Transplant Unit

  • Royal Infirmary of Edinburgh

  • Edinburgh, United Kingdom

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