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  • Treatment option for posttransplant suprahepatic inferior vena cava (IVC) strictures (one of the most challenging complications after liver transplantation)

  • Especially useful in:

    • Extensive IVC strictures with pressure gradients not responsive to angioplasty

    • Where placement of an IVC stent may interfere with retransplantation

  • This technique can be used in instances of other pathologies with obstruction of the IVC/hepatic veins


  • The IVC stenosis is explored to verify that there is no other associated pathology (Fig. 88-1).

  • The suprahepatic IVC, intrapericardial IVC, and right atrium are reached by incising the diaphragm without injuring the phrenic nerve. (Fig. 88-2).

  • An abdominal approach avoids the associated morbidity of a thoracotomy or sternotomy.

  • The infrahepatic IVC is accessed by mobilizing the duodenum (Fig. 88-3).

  • A 16-mm ringed graft is used to shunt the infrahepatic and suprahepatic IVC (Figs. 88-4 through, 88-7).

  • Special care should be taken to avoid causing air emboli when constructing the shunt and perfusing it with blood.

  • Dextran is given in the immediate postoperative course.

  • Aspirin is continued on a long-term basis.

  • Blood flows from the hepatic veins in a retrograde fashion through the retrohepatic IVC, joins the flow from the kidneys and lower body, and reaches the right atrium through the shunt (Fig. 88-8).


Intraoperative view of an extensive suprahepatic IVC stricture after a liver transplantation inclusive of the retrohepatic IVC. The sutures from the procedure are still visible.


The diaphragm and pericardium have been sectioned, exposing the right atrium.


The duodenum is mobilized and the infrahepatic IVC dissected and exposed at the site of the future distal shunt anastomosis.


A clamp has been placed on the nonstrictured proximal suprahepatic IVC and the exposed area of the right atrium. The proximal shunt anastomosis is being constructed.


Completed proximal anastomosis.


Completed distal shunt anastomosis.


Diagrammatic representation of the cavoatrial shunt. Blood from the hepatic veins flows in a retrograde fashion through the retrohepatic IVC, joins the venous flow from the lower extremities and kidneys, and enters the shunt to reach the right atrium.


Molmenti  EP, Grover  DS, Thuluvath  PJ,  et al. Cavoatrial shunt ...

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