Successful Application of Supraceliac Aortohepatic Conduit Using Saphenous Venous Graft in Right Lobe Living Donor Liver Transplantation

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1 LETTERS FROM THE FRONTLINE Successful Application of Supraceliac Aortohepatic Conduit Using Saphenous Venous Graft in Right Lobe Living Donor Liver Transplantation TO THE EDITOR: Hepatic artery (HA) reconstruction in living donor liver transplantation (LDLT) is technically demanding due to the smaller diameter of the graft HA, and it remains a crucial step that is vital to graft function in the postoperative period. Vascular complications are not uncommon after LDLT and are reported to occur in up to 15% of recipients. (1) HA complications such as hepatic artery thrombosis (HAT) can lead to primary nonfunction of the liver allograft and septic hepatic infarction, which is often fatal in the absence of retransplantation. The common recipient-related factors that can lead to anatomical HA reconstruction difficulties are as follows: HA intimal dissection during the recipient hepatectomy, HA scarring from a previous operation, and poor caliber of the HA due to multiple transarterial chemoembolizations (TACEs) for patients with hepatocellular carcinoma (HCC). (2) In such situations, an arterial conduit other than a native recipient HA, termed as extra-anatomic, remains the most suitable alternative. An arterial Abbreviations: CT, computed tomography; DDLT, deceased donor liver transplantation; GRWR, graft-to-recipient weight ratio; HA, hepatic artery; HAT, hepatic artery thrombosis; HCC, hepatocellular carcinoma; LDLT, living donor liver transplantation; TACE, transarterial chemoembolization. Address reprint requests to Long-Bin Jeng, M.D., Organ Transplantation Center, China Medical University Hospital, 2, Yuh-Der Road, Taichung, Taiwan, Telephone: , ext. 1765; FAX: ; otc@mail.cmuh.org.tw Received October 23, 2016; accepted December 20, Copyright VC 2017 by the American Association for the Study of Liver Diseases. View this article online at wileyonlinelibrary.com. conduit can also be used if a complication of the HA occurs, ie, HA stenosis or HA aneurysm. Extraanatomic HA revascularization can be achieved by using the recipient right gastric artery, right gastroepiploic artery, left gastric artery, or splenic artery without an interpositional vascular conduit. (3) However, gastroepiploic arterial flow may not be adequate for liver grafts with higher graft-to-recipient weight ratio (GRWR). Similarly, the splenic artery of the recipient or the celiac trunk is not a suitable alternative for the partial liver graft. Hence, when HA anastomosis cannot be accomplished using the abovementioned arterial sources, interpositional vascular conduits are used for HA reconstruction from the recipient celiac trunk or from the aorta as an aortohepatic conduit. Aortohepatic conduits can be vital extrahepatic alternatives for HA reconstruction in situations of failure in using the recipient HA for reconstruction. The safety of the aortohepatic conduit when used for HA reconstruction in either the infrarenal (3) or supraceliac (4) location has been proven. However, the experience of the aortohepatic conduit in LDLT has not been discussed. In deceased donor liver transplantation (DDLT), the graft HA has considerable length to be used as a conduit, either supraceliac or infrarenal. However, in LDLT to establish the extra-anatomical HA anastomosis, a vascular conduit is required. A supraceliac aortohepatic conduit using an interposition graft, such as a saphenous vein, can act as an ideal alternative. Herein, we describe our successful experience of using the aortohepatic conduit for HA anastomosis in LDLT. Patients and Methods From January 2002 to October 2015, 659 LDLTs DOI /lt Potential conflict of interest: Nothing to report. were performed at China Medical University Hospital, Taiwan. In 11 recipients, supraceliac aortohepatic conduits were used to establish HA flow using great 976 LETTERS FROM THE FRONTLINE

2 LIVER TRANSPLANTATION, Vol. 23, No. 7, 2017 LI ET AL. FIG. 1. (A) Proximal end of saphenous vein is anastomosed to aorta in an end-to-side fashion. An inset picture shows the harvested left great saphenous vein. (B) Distal end of saphenous vein is anastomosed to graft HA in an end-to-end fashion. (C) HA flow is established. saphenous venous grafts. The retrospective data of the patients were studied. Intraoperative data such as graft weight, GRWR, details of the operative technique of HA anastomosis, warm ischemia time, and HA flow were recorded. TECHNIQUES OF SUPRACELIAC AORTOHEPATIC ANASTOMOSIS After extraction of the native liver, the exposure of the supraceliac aorta becomes relatively easier. In this series, the saphenous vein was used as a conduit from the aorta to establish HA blood flow due to either failure of the primary HA anastomosis or a poor caliber recipient HA. The great saphenous vein of 8 to 10 cm in length was harvested from the left thigh (Fig. 1A, inset image). The supraceliac aorta was dissected off the diaphragm, and a side clamp was applied without disturbing the distal aortic blood flow. The proximal end of the saphenous vein was anastomosed to the aorta in an end-to-side fashion using 8-0 Prolene (Fig. 1A). The distal end of the saphenous vein was brought directly up to the graft HA, and the anastomosis to the HA was end-to-end, with a continuous 8-0 Prolene LETTERS FROM THE FRONTLINE 977

3 LI ET AL. LIVER TRANSPLANTATION, July 2017 FIG. 2. (A) Intraoperative Doppler flowmeter analysis showing normal HA flow after completion of the aortohepatic anastomosis. (B and C) Posttransplant month 3 CT scan images with 3-dimensional reconstruction showing patent and well-functioning supraceliac aortohepatic conduit (shown by white arrows). suture (Fig. 1B,C). Self-retaining clamps were applied to the conduit, and the aortic clamp was removed from the aorta. HA flow was assessed by Doppler flowmeter and was found to be satisfactory. In addition, the patency of the HA conduit was assessed by protocol Doppler ultrasound assessment on posttransplant days 1, 3, and 7 and weekly thereafter until the patient was discharged. Results All the 11 recipients (male:female, 7:4) of this study cohort underwent HA reconstruction using an aortohepatic conduit using autologous great saphenous veins that were harvested after liver graft reperfusion was established using portoportal anastomosis. In 5 patients, the cause of the poor caliber HA was from repeated TACE for underlying HCC, whereas 3 patients had no HA flow even after repeated anastomotic attempts. In 3 patients, the initial HA reconstruction resulted in acute thrombosis due to intimal dissection of the recipient HA. HAT was noted during the surgery for all of these patients when the Doppler flowmeter revealed poor HA flow. Two of these patients were subjected to thrombus removal using a Fogarty catheter, and the anastomosis was revised. However, consistent poor flow was noted. The HA anastomosis was then established using an aortohepatic conduit from the supraceliac region using 8-0 Prolene 978 LETTERS FROM THE FRONTLINE

4 LIVER TRANSPLANTATION, Vol. 23, No. 7, 2017 LI ET AL. sutures in a continuous running fashion. The average HA flow during intraoperative Doppler flowmeter analysis was ml/minute (range, ml/ minute) with a pulsatile index of , whereas the average portal flow was ml/minute (range, ml/minute). One patient developed intra-abdominal hematoma due to a leak from a pseudoaneurysm that occurred at the aortic side of the aortohepatic conduit. An aortic balloon was first traversed across the leak site to control the ongoing hemorrhage. The patient was then re-explored, and the aortic side of the anastomosis was securely revised in a standard end-to-side fashion as described earlier. The patient recovered well thereafter without any complications. Figure 2 shows intraoperative Doppler flowmeter assessment and postoperative computed tomography (CT) images. Discussion HA dissection leading to a failure of the anastomosis in LDLT is not uncommon. The most common indications for the extra-anatomical HA reconstruction are HAT and recipient intimal dissection. (4) In our series, 5 (62.5%) patients had intimal dissection secondary to the TACE procedure. In such situations, an extraanatomic source is the only viable option to establish HA flow. In DDLT, the liver graft has a longer arterial conduit while the liver is retrieved. Hence, it becomes suitable to perform HA anastomosis from other available recipient sources. However, in LDLT, the HA is very small in caliber as well as in length. Hence, an interpositional conduit is necessary. Arterial reconstruction using an autologous radial artery, gastric vessels, splenic artery, and celiac trunk have been tried successfully, but these sources involve technical difficulties. (4) Above all, HA flow still may be inadequate, which makes them more prone to HAT. The synthetic graft as a conduit for HA reconstruction has been tried infrequently. The aortohepatic anastomosis serves as the better alternative in recipients with a poor caliber HA. Traditionally, the infrarenal portion of the aorta is commonly used. (3) However, in LDLT this is difficult, and the conduit for the HA anastomosis needs to be passed in a retromesocolic position and placed between the recipient infrarenal aorta and the graft HA. In patients with extensive collaterals, the dissection of the infrarenal aorta is extremely difficult and has a high risk of intraoperative bleeding that may lead to hemodynamic instability. The supraceliac aorta, thus, can be a better alternative site for an aortohepatic conduit, and this can be achieved using a venous graft, such as a saphenous vein. The role of the supraceliac aortohepatic conduit using a saphenous vein has never been highlighted before in LDLT. Our experience shows 100% graft patency and graft survival with this technique. The advantages of a supraceliac aortohepatic conduit are as follows: first, the exposure of the supraceliac aorta requires less dissection which causes minimal blood loss, and the anatomical location increases the ease of the HA anastomosis; second, after the anastomosis the course of the conduit remains antegrade; and third, because of the direct aortic connection, HA flow is maximized and thus avoids postanastomosis flow insufficiencies. Earlier reports have shown excellent outcomes after using an infrarenal aortohepatic conduit from a donor iliac artery in DDLT. (5) However, no details were published before for the supraceliac aortohepatic conduit in LDLT. Our successful experience shows excellent graft outcomes and HA patency after aortohepatic anastomosis. This technique is feasible and safe in the hands of a well-experienced surgeon with excellent longterm outcomes. REFERENCES Ping-Chun Li, M.D. 1,4 Ashok Thorat, M.D. 1 Long-Bin Jeng, M.D. 1,2 Horng-Ren Yang, M.D. 1,2 Ming-Li Li, M.D. 1,4 Chun-Chieh Yeh, M.D. 1,2 Te-Hung Chen, M.D. 1,2 Shih-Chao Hsu, M.D. 1,2 Kin-Shing Poon, M.D. 3 1 Organ Transplantation Center, and Departments of 2 Surgery, 3 Anaesthesiology, and 4 Cardiovascular Surgery China Medical University Taichung, Taiwan 1) Mourad MM, Liossis C, Gunson BK, Mergental H, Isaac J, Muiesan P, et al. Etiology and management of hepatic artery thrombosis after adult liver transplantation. Liver Transpl 2014; 20: ) Uchiyama H, Shirabe K, Taketomi A, Soejima Y, Ninomiya M, Kayashima H, et al. Extra-anatomical hepatic artery reconstruction LETTERS FROM THE FRONTLINE 979

5 LI ET AL. LIVER TRANSPLANTATION, July 2017 in living donor liver transplantation: can this procedure save hepatic grafts? Liver Transpl 2010;16: ) Muiesan P, Rela M, Nodari F, Melendez HV, Smyrniotis V, Vougas V, Heaton N. Use of infrarenal conduits for arterial revascularization in orthotopic liver transplantation. Liver Transpl Surg 1998;4: ) Shaked AA, Takiff H, Busuttil RW. The use of the supraceliac aorta for hepatic arterial revascularization in transplantation of the liver. Surg Gynecol Obstet 1991;173: ) Nikitin D, Jennings LW, Khan T, Sanchez EQ, Chinnakotla S, Randall HB, et al. Twenty years of follow-up of aortohepatic conduits in liver transplantation. Liver Transpl 2008;14: LETTERS FROM THE FRONTLINE