Vena Cava Complications

The left lateral segment of the split liver  requires implantation of the left hepatic vein directly onto the venous system of the recipient. This can result in disparity in the shape and orientation of the graft, as well as conditioning difficulties with vascular continuity. These technical difficulties are increased if the donor to recipient weight ratio increases. Partial or total impairment of hepatic vein flow may occur, conditioning graft enlargement and fluid retention.
Several potential causes of hepatic outflow obstruction have been described. Failure of the right side of the heart can occur acutely after reperfusion &, causing graft’s enlargement, with a marked increase in venous bleeding, even more difficult to manage in split liver transplantation in which a cut parenchymal section is present. In liver transplantation using full-size grafts, distortion of the hepatic vein may occur when the liver is too large. Initially, the left hepatic vein of the left lateral segment from reduced-size or split liver transplantation was anastomosed end-to-end to the common orifice of the left and middle hepatic vein. This method has two drawbacks – the liver is free to rotate and thereby cause kinking, and because of the location of the hepatic vein anastomosis towards the left, the liver must remain in the midline position to preserve vascular continuity. After closure of the abdomen, however, the graft rotates into the right upper quadrant and can thereby kink the hepatic vein.
Clinical syndromes compatible with hepatic vein obstruction have been described by Emond and colleagues &. They reported 16% of hepatic vein obstruction after transplantation of left-sided grafts, and 33% of obstruction when an end-to-end anastomosis was performed. To address this high incidence of complication they proposed the triangular anastomosis that produces a hepatic vein orifice of optimal size and correct orientation of the liver graft in its final resting position in the hepatic fossa.
The first split liver recipient in our series developed a venous outflow obstruction due to a stenosis of the left hepatic vein anastomosis. Stenosis was dilated successfully by balloon dilation $. After the adoption of the triangulation technique $, we did not observe venous outflow obstructions, except in one child transplanted with a left lateral segment graft with two independent hepatic veins from segments II and III, that did not allow for the creation of a common anastomotic stump. The patients developed acute graft congestion, with primary non-function, and underwent successful retransplantation, with a reduced-size graft.