Korean J Hepatobiliary Pancreat Surg.  2011 Aug;15(3):184-188. 10.14701/kjhbps.2011.15.3.184.

Cavo-caval intervention stent insertion after deceased-donor liver transplantation using side-to-side piggyback technique: report of a case

• Kim IG
• Kim BS
• Jeon JY
• Kwon JW
• Kim JS
• Kim DJ
• Jung JP
• Chon SE
• Kim HJ
• Jeon EY
• Kim MJ
• Lee K

• KMID: 2130991
• DOI: http://doi.org/10.14701/kjhbps.2011.15.3.184

Abstract

Liver transplantation with preservation of the recipient vena cava (piggyback technique) has been performed as an alternative to the conventional method. Outflow disturbance or obstruction of the vena cava in the early period after liver transplantation is associated with high morbidity and mortality. We used side-to-side cavo-caval anastomosis (modified piggyback technique) in a deceased-donor liver transplantation (DDLT) for venous outflow reconstruction. On postoperative day 9, the patient developed abdominal discomfort, and abnormal liver function showing serum total bilirubin of 6.2 mg/dl and serum AST/ALT of 297/597 IU/L. Doppler ultrasound showed mono-phasic wave forms of the hepatic vein. Computed tomography showed focal narrowing of 9.5 mmx12 mm in diameter at the cavo-caval anastomosis site. Liver biopsy was showed that there was no evidence of acute allograft rejection. Direct venogram showed stenosis of the cavo-caval anastomosis with a pressure gradient of 12 mmHg. An interventional stent was inserted in the stenotic site of the inferior vena cava, and the pressure gradient decreased to 2 mmHg. He was discharged from hospital on postoperative day 23 without any other complications. Herein we report a case of deceased-donor liver transplantation using the modified piggyback technique, who received an inferior vena cava stent due to stricture of the reconstructed orifice of the vena cava.

Keyword

Liver transplantation; Outflow obstruction; Anastomotic stenosis; Stent

MeSH Terms

Bilirubin
Biopsy
Constriction, Pathologic
Hepatic Veins
Humans
Liver
Liver Transplantation
Rejection (Psychology)
Stents
Transplantation, Homologous
Vena Cava, Inferior
Bilirubin

Figure

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  Fig. 1 Doppler sonogram obtained on the fourth postoperative day. The spectral Doppler waveform of the middle hepatic vein shows a mono-phasic flow pattern suggesting hepatic outflow stenosis.

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  Fig. 2 CT scan images of portal phase at postoperative day 6. (A) There is focal luminal narrowing (arrow) at the side-to-side anastomotic site of the intrahepatic inferior vena cava. (B) Mild focal luminal narrowing (arrow) is also seen at the end-to-end anastomotic site of the main portal vein.

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  Fig. 3 Interventional stent placement at the cavo-caval anastomosis site on postoperative day 11. (A) Right hepatic venography shows contrast pooling in the donor inferior vena cava (IVC) and faint filling of the recipient IVC and right atrium (thick arrows) due to tight stenosis (thin arrows). (B) Hepatic venography after stent insertion across the stenosis (left anterior oblique 44° view). Early contrast flow into the right atrium (arrows) is visible. The pressure gradient between the right hepatic vein and the recipient IVC decreased from 12 mmHg to 2 mmHg after stent insertion.

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  Fig. 4 Follow-up CT images at 1 day after stent insertion. (A) The CT image shows a patent stent without narrowing in the cavo-caval anastomosis. (B) The CT image reveals resolution of the stenosis at the portal vein anastomotic site after stenting.

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