80 S . P . Butt et al .: J Extra Corpor Technol 2024 , 56 , 77 – 81
Table 1 . Indications for VV bypass utilization and indications .
Case Indication
1 High MELD score 2 Previous abdominal surgery and adhesions 3 High MELD score 4 Multiple spontaneous bacterial peritonitis causing “ cocoon abdomen ” 5 Portal vein thrombosis 6 High MELD score 7 Extensive abdominal adhesions 8 Pre-existing cardiovascular disease 9 Portal vein thrombosis 10 High MELD score 11 Portal vein thrombosis Sakai et al . reported that the adoption of the retrohepatic caval preservation technique in LT has significantly reduced the need for VVB , marking a notable advancement in surgical methodology . However , VVB remains a valuable adjunct in LT procedures . Traditionally , the insertion of the venous return cannula via a cut-down technique through the axillary vein posed significant risks such as lymphorrhea , infection , or nerve damage . Since 2001 , attending anesthesiologists have routinely performed percutaneous insertion of the internal jugular venous return cannula in adult liver transplant surgeries as part of their clinical practice , providing a safer alternative . This approach not only reduces associated risks but also enhances the overall safety and efficacy of the surgical intervention [ 9 ].
A retrospective study assessed VVB ’ s impact on post-liver transplant acute kidney injury ( AKI ). Among 1037 patients , 247 received VVB . AKI incidence was lower in VVB patients with pretransplant renal dysfunction ( Cr 1.2 mg / dL ), and VVB was independently associated with reduced AKI risk . No significant differences were observed in renal replacement or 1-year mortality . In patients with normal renal function ( Cr < 1.2 mg / dL ), AKI incidence did not differ between groups . This study suggests intraoperative VVB may mitigate posttransplant AKI risk in those with compromised renal function , necessitating further investigation [ 10 ].
A study by Rocco et al . presents two cases of complex orthotopic LT where VVB with the insertion of a venous graft into either the inferior mesenteric vein ( IMV ) or the splenic vein ( SV ) was utilized for decompression of the portomesenteric compartment . In both cases , femoroaxillary percutaneous VVB was established prior to abdominal opening to alleviate massive collateral veins in the abdominal wall . The first patient had the IMV connected to a donor vein graft , while the second patient required splenectomy due to an excessively enlarged spleen , with the SV connected to a donor vein graft . In both instances , connecting the distal part of the vein graft to the VVB facilitated decompression of the portomesenteric compartment , reducing portal hypertension and enabling access to the hepatic hilum for the intricate dissection necessitated by previous major surgeries . This technique demonstrates safety and simplicity , proving beneficial for patients requiring VVB without standard access to the portal compartment , especially in cases of severe portal hypertension and re-LTs [ 5 ].
A case report presents a pioneering method for VVB during LT utilizing a patent para-umbilical vein , a previously undocumented technique . In a patient necessitating VVB during LT , a pre-transplant CT scan identified a sizable patent para-umbilical vein . Prior to abdominal opening , a femoro-axillary percutaneous VVB was established , linking the para-umbilical vein to the VVB . This inventive approach effectively facilitated splanchnic venous decompression throughout the surgery . The utilization of the para-umbilical vein in VVB during LT signifies a promising avenue for similar cases in the future [ 11 ].
At our center , we employed VVB for LT in 11 patients with diverse indications outlined in Table 1 , including High Model for End-Stage Liver Disease ( MELD ) scores , previous abdominal surgeries and adhesions , multiple spontaneous bacterial peritonitis , portal vein thrombosis , and coronary artery disease with heart failure .
In our experience , none of the cases exhibited vascular complications associated with cannulation or issues related to VVB . Furthermore , post-reperfusion syndrome was not observed in any of the cases . Conclusion
The integration of VVB into routine liver transplant procedures requires expertise and specialized equipment . However , as more centers gain experience and refine their protocols , the widespread implementation of VVB holds great potential . Further research and clinical trials are necessary to refine techniques , explore long-term benefits , and ensure the seamless incorporation of VVB into the surgical armamentarium . In our experience , VVB is a valuable technique in LT that offers numerous benefits , including facilitating complex surgeries , maintaining hemodynamic stability , and enhancing safety for recipients . No vascular complications or VVB-related issues were observed in our cases , and there were no instances of post-reperfusion syndrome .
Funding The authors received no funding to complete this research .
Conflicts of Interest The authors declare no conflict of interest .
Data availability statement The research data is available on request from the authors .
Author contribution statement
Salman Pervaiz Butt : Lead conceptualization , supporting data curation , lead supervision , lead formal analysis , lead validation , lead visualization , lead writing original draft , lead methodology and project administration . Arun Kumar : Lead review and editing , supporting data curation , supporting validation , supporting writing , supporting project administration . Fazil Ashiq : Supporting visualization , supporting writing , supporting project administration . Andrei Minou : lead data curation . Giuseppa Iuppa : Supporting supervision , supporting project