Ann Liver Transplant.  2021 May;1(1):86-94. 10.52604/alt.21.0004.

Quilt unification venoplasty of the right hepatic veins enabling double inferior vena cava anastomosis in living donor liver transplantation using a right liver graft

• Jung DH
• Hwang S
• Ahn CS
• Moon DB
• Ha TY
• Song GW
• Park GC
• Na BG
• Lee SG

• KMID: 2560856
• DOI: http://doi.org/10.52604/alt.21.0004

Abstract

The inferior right hepatic veins (IRHVs) and major short hepatic veins (SHVs) are indicated for vascular reconstruction to prevent hepatic venous congestion of the right liver grafts. As separate anastomoses of multiple IRHV/SHVs are vulnerable to stenosis, single large anastomosis through the unification of multiple hepatic vein openings is preferred. All right hepatic vein (RHV) openings can be unified through quilt unification venoplasty (QUV). After the introduction of QUV in 2004, we have developed several techniques and institutional guidelines for QUV. There are two types of QUV, all-in-one and RHV types. All-in-one QUV unifies the orthodox RHV, IRHV, SHV, and middle hepatic vein (MHV) branches using a large patch and MHV conduit. QUV for RHVs unifies the orthodox RHV, IRHV, and SHV, with separate reconstruction of the MHV conduit because a conjoined MHV conduit can be associated with outflow problems. For side-to-side anastomosis of QUV as like the double vena cava reconstruction, deep side-clamping of the recipient inferior vena cava is usually performed; however, shallow partial clamping can be used if necessary. The anatomy of the donor liver SHVs and the availability of sizable vessel patches are the primary determinants for designing the individualized configuration of QUV. We suggest that QUV using various vessel patches is useful for secure reconstruction of multiple IRHVs and SHVs to achieve successful implantation of the right liver grafts.

Keyword

Hepatic vein outflow obstruction; Right hepatic vein; Vein homograft; Stenosis; Living donor liver transplantation

Figure

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  Figure 1 Computational simulations models to assess the morphometric changes in two unified inferior right hepatic veins (IRHVs). (A) Conventional unification venoplasty appears patent in normal position, but at least one of two IRHVs becomes stenotic in the stretched state (asterisk). (B) Funneling unification venoplasty makes the shapes of IRHVs take after those of the donor liver, in which IRHVs appear patent in both normal and stretched positions. This small difference in the anastomotic configuration provides patency tolerance against various extrinsic factors. Different color coding was applied to the liver capsule (brown), extrahepatic IRHV branches (black), vein patches (red), and donor/recipient inferior vena cava (blue).

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  Figure 2 Intraoperative photographs showing anomalous anatomy of the right hepatic vein and short hepatic veins (SHVs). (A) The right hepatic vein (red arrow) and one SHV (yellow arrows) are visible after transection of the two SHVs (blue arrows). (B) Four right hepatic vein openings at the inferior vena cava area and two middle hepatic vein openings (green arrows) are visualized.

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  Figure 3 Intraoperative photographs showing quilt unification venoplasty technique. (A) A segment of autologous greater saphenous vein (GSV) patch is placed between the 4 SHVs, and running sutures are performed at the medial halves of the SHV circumferences. (B) A circumferential fence is attached with a long GSV segment around the central patch and 4 SHV openings. (C) This patchwork results in a 6 cm-long orifice at the donor retrohepatic vena cava portion. (D) A wide side-to-side anastomosis is performed under total clamping of the recipient inferior vena cava.

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  Figure 4 Institutional guidelines for reconstructing one or multiple major short hepatic veins (SHVs) concerning the orthodox right hepatic vein (RHV).

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  Figure 5 Intraoperative photographs showing all-in-one quilt unification venoplasty. (A) The right liver graft has one right hepatic vein opening, two inferior right hepatic vein openings, and one middle hepatic vein openings. (B) The orthodox and inferior right hepatic vein openings are unified with an aorta homograft patch. (C) An iliac artery homograft conduit is connected between the segment V vein and the aorta patch. (D) The aorta patch is anastomosed to the recipient’s inferior vena cava in a side-to-side fashion.

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  Figure 6 Three-dimensional reconstruction of 1-week computed tomography showing the normal configuration of all the reconstructed graft hepatic veins.

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  Figure 7 Intraoperative photographs showing all-in-one quilt unification venoplasty. (A) The right liver graft has one right hepatic vein opening, three inferior right hepatic vein openings and two middle hepatic vein openings. (B) The orthodox and three inferior right hepatic vein openings are unified to anastomose with an aorta homograft. (C) An iliac vein homograft conduit is connected between the segment V and VIII veins and the aorta. (D) The aorta patch is anastomosed to the recipient’s inferior vena cava in a side-to-side fashion. (E) The interposed iliac vein conduit appears excessively redundant. (F) Another vein conduit is added to the recipient’s middle hepatic vein stump to make a Y-shaped conduit to offset the redundancy.

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  Figure 8 Different shapes of quilt unification venoplasty. (A, B) A cryopreserved iliac vein homograft patch is used to unify three hepatic vein openings. (C, D) Two fragments of cryopreserved aorta patch are used to unify two hepatic vein openings. (E, F) Autologous greater saphenous vein patch is used to unify three hepatic vein openings. (G) A cryopreserved iliac vein homograft patch is used to unify three hepatic vein openings. (H) A wide cryopreserved common iliac vein homograft patch is used to unify four hepatic vein openings.

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  Figure 9 Side-to-side anastomosis of quilt unification venoplasty under near-total or partial side clamping of the recipient inferior vena cava (IVC). (A, B) The recipient IVC is deeply clamped with long Satinsky clamps, which mostly occludes the IVC flow. (C, D) A shallow partial side clamping is performed to preserve the IVC blood flow.

Reference

References

1. Uchida K, Taniguchi M, Shimamura T, Suzuki T, Yamashita K, Ota M, et al. 2010; Three-dimensional computed tomography scan analysis of hepatic vasculatures in the donor liver for living donor liver transplantation. Liver Transpl. 16:1062–1068. DOI: 10.1002/lt.22109. PMID: 20818744.

2. Varotti G, Gondolesi GE, Goldman J, Wayne M, Florman SS, Schwartz ME, et al. 2004; Anatomic variations in right liver living donors. J Am Coll Surg. 198:577–582. DOI: 10.1016/j.jamcollsurg.2003.11.014. PMID: 15051012.

3. Hwang S, Lee SG, Park KM, Kim KH, Ahn CS, Lee YJ, et al. 2004; Hepatic venous congestion in living donor liver transplantation: preoperative quantitative prediction and follow-up using computed tomography. Liver Transpl. 10:763–770. DOI: 10.1002/lt.20178. PMID: 15162471.

4. Lee SG. 2006; Techniques of reconstruction of hepatic veins in living-donor liver transplantation, especially for right hepatic vein and major short hepatic veins of right-lobe graft. J Hepatobiliary Pancreat Surg. 13:131–138. DOI: 10.1007/s00534-005-1019-7. PMID: 16547674.

5. Hwang S, Ha TY, Ahn CS, Moon DB, Kim KH, Song GW, et al. 2012; Reconstruction of inferior right hepatic veins in living donor liver transplantation using right liver grafts. Liver Transpl. 18:238–247. DOI: 10.1002/lt.22465. PMID: 22140053.

6. Hwang S, Lee SG, Park KM, Kim KH, Ahn CS, Moon DB, et al. 2005; Quilt venoplasty using recipient saphenous vein graft for reconstruction of multiple short hepatic veins in right liver grafts. Liver Transpl. 11:104–107. DOI: 10.1002/lt.20314. PMID: 15690544.

7. Radtke A, Sotiropoulos GC, Sgourakis G, Molmenti EP, Schroeder T, Saner FH, et al. 2010; Hepatic venous drainage: how much can we learn from imaging studies? Anatomic-functional classification derived from three-dimensional computed tomography reconstructions. Transplantation. 89:1518–1525. DOI: 10.1097/TP.0b013e3181dd6bac. PMID: 20410853.

8. Sugawara Y, Makuuchi M, Imamura H, Kaneko J, Kokudo N. 2003; Outflow reconstruction in extended right liver grafts from living donors. Liver Transpl. 9:306–309. DOI: 10.1053/jlts.2003.50021. PMID: 12619029.

9. Sugawara Y, Makuuchi M, Akamatsu N, Kishi Y, Niiya T, Kaneko J, et al. 2004; Refinement of venous reconstruction using cryopreserved veins in right liver grafts. Liver Transpl. 10:541–547. DOI: 10.1002/lt.20129. PMID: 15048798.

10. Namgoong JM, Choi JU, Hwang S, Oh SH, Park GC. 2019; Pediatric living donor liver transplantation with homograft replacement of retrohepatic inferior vena cava for advanced hepatoblastoma. Ann Hepatobiliary Pancreat Surg. 23:178–182. DOI: 10.14701/ahbps.2019.23.2.178. PMID: 31225421. PMCID: PMC6558128.

11. Namgoong JM, Hwang S, Oh SH, Kim KM, Park GC, Ahn CS, et al. 2020; Living-donor liver transplantation with inferior vena cava replacement in an infant recipient with advanced hepatoblastoma. Ann Hepatobiliary Pancreat Surg. 24:72–77. DOI: 10.14701/ahbps.2020.24.1.72. PMID: 32181433. PMCID: PMC7061035.

12. Kwon H, Kwon H, Hong JP, Han Y, Park H, Song GW, et al. 2015; Use of cryopreserved cadaveric arterial allograft as a vascular conduit for peripheral arterial graft infection. Ann Surg Treat Res. 89:51–54. DOI: 10.4174/astr.2015.89.1.51. PMID: 26131446. PMCID: PMC4481033.