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INDICATIONS

  • 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

TECHNIQUE

  • 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).

FIGURE 88-1

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.

FIGURE 88-2

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

FIGURE 88-3

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

FIGURE 88-4

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.

FIGURE 88-5

Completed proximal anastomosis.

FIGURE 88-6

Completed distal shunt anastomosis.

FIGURE 88-8

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.

FURTHER READING

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

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