A 51-year-old male underwent liver transplantation for end-stage liver disease. A pretransplant scan demonstrated a Yerdel grade IV portal vein thrombus with spontaneous mesentericocaval shunt insertion below the junction of the inferior vena cava (IVC) and the left renal vein (Fig. 1). The caval inflow technique was modified to transform an indication for a cavoportal anastomosis (CPA) into the equivalent of a renoportal anastomosis (RPA).
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At the time of transplantation, a cavocaval bypass was installed. An attempt at portal vein thrombectomy was unsuccessful. Therefore, caval inflow to the graft was deemed necessary. Given the higher reported incidence of complications for CPAs versus RPAs, we decided upon a novel technique to transform a CPA into an RPA. The portal vein was transected, and the hepatectomy was completed. A Kocher maneuver exposed the IVC and the mesentericocaval shunt (Fig. 1). A neo portal vein retaining the left renal vein and the mesentericocaval shunt was then constructed. The IVC was transected above its junction with the left renal vein and below the insertion of the mesenteric shunt. The lower end of this segment was closed. The right renal vein was inserted into the IVC above the level of the left renal vein and was not included in the patch. The excised segment of the IVC was replaced with a Gore-Tex vascular graft (Fig. 2).
The implant started with a laterolateral cavocaval anastomosis. Then, an end-to-end anastomosis between the graft portal vein and the segment of vena cava containing the left renal vein and the mesentericocaval shunt was constructed (Fig. 2). The implantation was completed. The postoperative course was uneventful, and the patient was discharged on day 15. The results of computed tomography performed 6 months later were normal.
Caval inflow to the graft was first reported by Tzakis et al. The commonest procedures for caval inflow to the graft are RPA and CPA. Both procedures have demonstrated good short- and long-term patency rates. However, there is a high reported incidence of complications with CPAs, including lower torso edema and anastomotic or portal vein thrombosis. In addition, Selvaggi et al. reported that the second most common cause of death in their patients who had a CPA was pulmonary embolism, a complication not reported for RPAs. It has been postulated that the thrombosis might be a result of slow caval flow into the graft. In their series, Bhangui et al. performed calibration of the vena cava with a caval clip. There were no complications of lower torso edema or pulmonary embolism in their series, and this suggests that the caval calibration preserved flow in the IVC while allowing an appropriate flow rate in the portal vein.
The advantage of the technique used in our patient mirrors that described by Bhangui et al. for RPAs. In our case, caval flow was maintained by the prosthetic graft, and this reduced the risk of lower torso edema. In addition, there was no need for calibration of the vena cava, and there was a better match of flow rates between the portal vein and the left renal vein.
Riccardo Memeo, M.D.1
Chady Salloum, M.D.1
Daren Subar, M.D.2
Nicola de'Angelis, M.D.1
David Zantidenas, M.D.3
Philippe Compagnon, M.D.1
Alexis Laurent, M.D.1
Daniel Azoulay, M.D.1
1Digestive Surgery and Liver Transplantation Unit, Henri Mondor Hospital, University of Paris, Créteil, France
2Department of General and Hepatobiliary-Pancreatic Surgery, Blackburn Royal Hospital, Blackburn, United Kingdom
3Department of Hepatology, Sainte Camille Hospital, Bry sur Marne, France