Author Affiliations: Liver Transplant Unit, Hospital Universitari de Bellvitge, Barcelona, Spain (Llado L, Ramos E, De LaSerna S and Fabregat J)

Corresponding Author: Laura Llado, PhD, Liver Transplant Unit, Hospital Universitari de Bellvitge, 08907 Barcelona, Spain (Tel: +34-93-2607940; Fax: +34-93-2607603; Email: 31513llg@comb.cat)

 

© 2014, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(14)60296-4

Published online September 25, 2014.

 

Contributors: RE proposed the study. LL and DLS performed research and wrote the first draft. All authors contributed to the design and review of the study and to further drafts. LL is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

ABSTRACT: Domino liver transplantation (LT), using livers from familial amyloidotic polyneuropathy (FAP) patients, is a well described technique useful to expand donor pool. One of the main difficulties of this type of LT arises from the necessity to share the vascular pedicles between the graft and the donor. The most important challenge resides in restoring a proper hepatic venous outflow in the FAP-liver recipient. This is specially challenging when using the piggy-back technique, because the hepatic stumps may be too short. To overcome this issue, surgeons explored several techniques using different types of venous grafts. We describe a new technical option by using an arterial graft from the deceased donor. By using both iliac arteries a long graft is created and sutured as needed to the hepatic vein stump. We describe herein this new technique employed in a domino liver recipient who underwent retransplantation for ischemic cholangitis. The procedure was performed using the piggy-back technique; the venous stump of the FAP liver was reconstructed with the arterial graft. The patient had uneventful postoperative and mid-term hepatic function, and anastomosis was patent 24 months after LT.

 

(Hepatobiliary Pancreat Dis Int 2014;13:551-554)

 

KEY WORDS: liver transplantation; technique; graft; hepatic vein; iliac artery

 

 

Domino or sequential liver transplantation (LT) is a widely used technique. Since its description in 1997,^[1] the global safety of the procedure has already been established.^[2-5] Nowadays, several techniques are used to improve the outcomes. One of the main difficulties of this type of LT arises from the necessity to share the vascular pedicles between the graft and the domino donor. The imperative to obtain a correct vein outflow has led many centers to perform domino LT by using the classical technique. However, the piggy-back technique may have some hemodynamic advantages. These advantages are even more important in patients with familial amyloidotic polyneuropathy (FAP) who have a special hemodynamic liability. Indeed, we should remember that FAP patients are not cirrhotic and do not have portal hypertension. Therefore, in this setting we consider the piggy-back technique associated with temporary portacaval shunt the best technical option. When using piggy-back technique, the obtained domino graft has short hepatic veins. In order to obtain longer hepatic veins, it has been proposed the section of pericardium to lengthen the vena cava stumps.^[6] However, this procedure is associated with possible serious complications, and indeed it may not achieve enough caval stump. An alternative to overcome this issue is the completion of hepatic vein reconstruction during bench surgery. Different technical options have been proposed in the literature with good results.^[7-12]

 

The concern in venous reconstruction resides in the imperative to obtain a correct outflow in order to preserve hepatic function and avoid postoperative Budd-Chiari syndrome, which occurs in 2%-8% of liver transplanted patients.

 

In 2002, a Portuguese group described for the first time the possibility to perform domino LT with piggy-back technique and venous outflow reconstruction by using a caval-common iliac bifurcation graft.^[7] After this first description, several groups have reported their experience with this type of graft;^[7-10] others have proposed similar technical options by using the portal vein^[11] or a reopened obliterated umbilical vein.^[12]

 

Our group performed in 1997 the first domino LT in Spain.^[13] Since then 36 domino LTs have been performed at our institution. The first 24 patients were transplanted with the classical technique, but in the last 12 we have used the piggy-back technique. Different outflow reconstructions have been employed.

 

Herein we describe the possibility to use an arterial cadaveric graft to be interposed between the hepatic veins stumps in order to reconstruct the outflow in the domino graft.

 

 

A 42-year-old woman diagnosed with FAP agreed to donate her liver. Hepatectomy in the FAP patient was performed using the piggy-back technique. The procedure was uneventful, and veno-venous bypass was not required.

 

The FAP liver was used as a domino graft. It was perfused on the backtable, through the portal vein and hepatic artery. The bile duct was flushed as usually. No attempts were made to lengthen the hepatic stump in the domino liver; thus the hepatic vein stumps were short.

 

At the backtable, the three hepatic veins orifices were joined together to obtain a single stump. Then, two cadaveric iliac arteries were employed as an interposed graft to reconstruct the hepatic veins of the domino graft. The two iliac arteries were opened longitudinally (Fig. 1A), and sutured to obtain a large arterial graft. This graft was placed upon the single venous stump (Fig. 1B), and sutured with an everting 6/0 polypropylene suture. This procedure was allowed to obtain a large drainage conduit of the domino graft (Fig. 1C).

 

The recipient of the domino graft was a 54-year-old patient who underwent retransplantation for ischemic cholangitis and who agreed to accept the FAP liver. The procedure was also performed with the piggy-back technique. The reconstructed hepatic venous cuff was sutured to the junction of all 3 hepatic veins of the recipient. The portal vein, artery and biliary anastomosis were performed in the standard fashion. The postoperative course of the FAP patient was characterized by a low-volume biliary leakage, which solved spontaneously 10 days later and did not cause any change in patients' clinical management. The postoperative course of the domino recipient was uneventful.

 

The recipient had no complications, except for self-limited postoperative ascites. All anastomosis were confirmed to be patent with two ultrasonographies before discharge, and a computed tomography performed one month after LT (Fig. 2A). After 24 months of follow-up, the patient is alive with normal hepatic function; vascular anastomosis is patent with normal hepatic vein, arterial and portal flows, confirmed by every 6 months Doppler ultrasonographies and actual computed tomography (Fig. 2B).

 

 

As stated by Tzakis et al,^[14] it is important to "play domino" and not to lose these good grafts. But we have to find the safest way to "play domino".^[14] The piggy-back technique in domino LT has been proved a safe technique.^{[2-6, 15]} To avoid some of the pitfalls of domino transplantation, several technical options have been described.^[3] As far as we know, all previously described techniques have used different types of venous grafts.^[6-12]

 

In cardiac and vascular surgery, some authors have shown that arterial conduits typically maintain patency at higher rates than venous conduits. There are no specific studies comparing the results of the arterial and venous grafts used for venous reconstruction in LT, and our group is working in this field. Previous papers on living donor LT have described the use of iliac artery grafts for venous outflow reconstruction.^[16] To the best of our knowledge the use of arterial grafts for venous outflow reconstruction has never been published in the setting of domino LT.

 

In our opinion, the arterial graft is another option and may have some advantages compared to the previously described techniques. Firstly, it is always feasible to obtain an arterial graft, either aortic or iliac from the deceased donor for the FAP patient. As described by Pinheiro et al,^[10] grafts may be obtained from another cadaveric donor. Secondly, it is easy to obtain a large graft by using both iliac arteries, as described herein. This will allow joining the graft as long as needed upon the single venous stump. Finally, because of the consistency of the arterial graft, we feel more confident about the vascular patency of this type of reconstruction compared to the venous grafts.

 

In conclusion, the use of arterial grafts for venous outflow reconstruction in domino LT can be safely performed and should be added to the already available techniques. Further studies are needed to compare this new technique with venous reconstruction.

 

 

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