Synthetic graft for reconstruction of middle hepatic vein tributaries in living-donor liver transplant.

OBJECTIVES: In middle hepatic vein dominant livers, the anterior segment of the right lobe of the liver (segments V and VIII) drains mainly into the middle hepatic vein. In these donors, when right lobe grafts are procured without the middle hepatic vein, the graft may harbor large segment V and/or VIII veins that need reconstruction to avoid graft congestion and subsequent graft dysfunction. Draining these middle hepatic vein tributaries using autologous or cryopreserved vessels is a solution, despite the possible difficulties of their preparation. However, these vessels are not always available. Our objective was to evaluate the effectiveness and safety of using a synthetic vascular graft. MATERIALS AND METHODS: Between January 2012 and October 2013, eighteen adult recipients underwent living-donor liver transplant using right lobe grafts without the middle hepatic vein at Dar Al Fouad Hospital, 6th of October City, Egypt. All grafts had a large tributary of the middle hepatic vein. Eight-mm ringed expanded polytetrafluoroethylene vascular grafts were used to drain 15 segment V vein tributaries and 3 segment VIII vein tributaries directly to the inferior vena cava. Follow-up was done using duplex ultrasound to evaluate the patency of the vascular graft and the liver congestion and the liver function tests including liver enzymes. RESULTS: Intraoperative Duplex ultrasound confirmed patency and absent segmental congestion in all 18 recipients. The vascular graft patency was 17/18 at 1 week (94.4%) and 15/18 at 1 month (83.3%). No recipients developed graft infection at 1 month. CONCLUSIONS: Synthetic vascular expanded polytetrafluoroethylene grafts could be used effectively and safely in middle hepatic vein tributary reconstruction to overcome the unavailability of autologous or cryopreserved vessel grafts or just to avoid the additional burden of recovering autologous grafts thus simplifying the procedure.

Major vascular complications in living-donor liver transplant recipients: single center team experience.

OBJECTIVES: Vascular problems such as thrombosis and stenosis of the hepatic artery, portal vein, and hepatic vein are serious complications after living-donor liver transplant and can cause increased morbidity, graft loss, and patient death. The aim of this study was to assess the incidence, treatment, and outcome of recipient vascular complications after living-donor liver transplant in a single Egyptian center. MATERIALS AND METHODS: Between November 2006 and March 2014, we performed 226 living-donor liver transplants for 225 patients at Dar Al Fouad Hospital in 6th of October City in Egypt. Review of all patients with vascular complications was performed. RESULTS: In 20 of 225 recipients (8.9%), there were vascular complications that occurred from day 0 to 14 (mean, 5.6 ± 3.4 d). Complications included isolated hepatic artery thrombosis in 7 patients (35%), isolated portal vein thrombosis in 6 patients (30%), isolated hepatic vein stenosis in 3 patients (15%), and isolated hepatic artery stenosis in 1 patient (5%). Combined portal vein thrombosis and hepatic artery thrombosis occurred in 2 patients (10%), and combined portal vein thrombosis and hepatic vein stenosis occurred in 1 patient (5%). Complications were identified with duplex ultrasonography and confirmed with computed tomographic angiography and direct angiography when needed. Multidisciplinary treatment included percutaneous transarterial or transvenous thrombolysis with or without balloon dilation and stenting, open surgical exploration with thrombectomy, vascular revision, or retransplant. There were no intraoperative deaths, but mortality occurred in 15 of 20 patients (75%). Survival ranged from 6 days to 70 months. Preoperative portal vein thrombosis was observed in 3 of 7 patients (43%) who had postoperative portal vein thrombosis. CONCLUSIONS: Major vascular complications in living-donor liver transplant recipients have poor outcome despite early detection and prompt multidisciplinary intervention. Preoperative recipient portal vein thrombosis is a risk factor for postoperative portal vein thrombosis.

Crucial issues of hepatic artery reconstruction in living donor liver transplantation: our experience with 133 cases at Dar El-Fouad Hospital, Egypt.

Hepatic artery (HA) reconstruction is a crucial step in living donor liver transplantation (LDLT). However, many important aspects specific to this challenging step are still inadequately documented. From August 2001 through March 2007, we performed a total of 133 cases of LDLT at Dar El-Fouad Hospital. The magnifying loupe was used for performing microanastomoses in the first 31 cases, and the operating microscope was used for 98 cases. There were 128 adult and five pediatric patients. One hundred twenty-five patients received right lobe grafts, and seven patients received left lobe grafts. One patient died intraoperatively and was excluded from analysis. Arterial complications occurred in four patients of the first group (4/30, 13%) in the form of early thrombosis. One patient underwent successful interventional thromboembolectomy, two patients underwent surgical reexploration with revision of anastomoses; these three patients survived. The fourth patient died from fulminant liver failure. Regarding the second group, all arterial anastomoses were patent after reconstruction. Signal problems occurred in the form of intraoperative intermittent flow and postoperative no diastole phenomenon. Our overall arterial complication rate was 4.5%; however, we lost only one patient due to HA thrombosis (0.8%). Microsurgical reconstruction of the HA carries its own challenges. The use of operating microscope reduces the risk of complications, and aggressive interference including salvage surgery maximizes the success of HA reconstruction.