A technique of veno-venous bypass without heparin has been developed for use during the anhepatic phase of transplantation of the liver. With this method, the ability to compress the temporarily obstructed vena caval and portal venous systems has made hepatic transplantation an easier procedure

Bahnson, HT

Griffith, BP

Hardesty, RL

Iwatsuki, S

Shaw, BW

Starzl, TE

PubMed

Shaw Jr, BW

Name not available

Veno-venous bypass without systemic anticoagulation for transplantation of the human liver

D-Scholarship@Pitt

\: VENO-VENOUS BYPASS WITHOUT SYSTEMIC ANTICOAGULATION FOR TRANSPLANTATION OF THE HUMAN LIVER Bartley P. Griffith, M.D., Byers W. Shaw, Jr., M.D., Robert L. Hardesty, M.D., F.A.C.S., Shunzaburo Iwatsuki, ~iaKI Henry T. Bahnson, M.D., F.A.C.S., and Thomas E. Starzl, ~1KaKI PH.D., F.A.C.S., Pittsburgh, Pennsylvania :\ CRl:CIAL intraoperative period during ortho-topic liver transplantation occurs during mobili-zation of the diseased recipient liver prior to he-patectomy and during the subsequent anhepatic phase of the hepatectomy and implantation of the new liver. During this time, obstruction of the portal vein and inferior vena cava can result in a fall in cardiac output and arterial pressure (1), consequent hypoperfusion of critical organs, damage to the engorged subdiaphragmatic capil-lary beds and extensive bleeding from high pres~ sure venous collaterals. These non physiologic conditions have been responsible for intraopera-tive or delayed deaths and have contributed to the lack of wide application of replacement of the li- . ver (2). -When orthotopic liver transplantation was developed in dogs, bypass techniques were used to shunt blood from the lower to the upper half of the body without pumps and systemic heparini-zation (3,4). The clinical application of the pas-sive bypass resulted in the formation of clots in the tubing with the consequent passage of multi-ple "emboli" to the lungs (5). The use of a pump driven bypass under systemic heparinization was discouraged by major difficulties in reversing the heparin effect in patients with endstage hepatic disease and multiple pre-existing coasulation de-fects (2. 6, 7). We report herein upon a pump driven nonheparin bypass system that was tested in dogs and was subsequently applied in 23 patients who underwent replacement of the liver. From the Department of Surgery. University of Pillsburgh. 103 Falk Clinic. Pillsburgh. Supported by research grams from the Veterans Administration; by project grant No. AM·29961 from the National Institutes of Health and by grant No. RR·OOO84 from the General Clinical Re· search Centers Program of the Division of Research Resources, National IlIS\itutes of Heahh. Reprint.' request: Dr. Thomas E. Stuzl, 3601 Fifth Avenue. Room lOt Falk Clinic. Pillsburgh. Pennsylvania 15213. TECHNIQUE The unique components of the circuit include modified heparin bonded Gott aneurysm shunt tubing (Argyle Division, Sherwood Medical) for drainage and return cannulae, plus a centrifugal blood pump (Bio-Medicus, Inc.). The cannula to drain blood from the-.inferior vena cava is ad-vanced through the saphenofemoral venous junc-tion to near the confluence of the common iliac veins (Fig. 1). The·_ cannula which removes splanchnic blood is placed end-on into th~ tran-sected portal vein (Fig. 1). The fusiform Gott shunts which are 60 centimeters long with an ex-tra side hole at one end, are i-deal for dra,inage. After intravascular insertion, these cannulae are cut where their diameter is large and joined to-gether with a three-eighths inch polished stainless steel Y type connector _ (Fig. 1). The blood is drained to a centrifugal pump which returns the effluent to the ipsilateral axillary vein (Fig. 1) through a 7 or 9 millimeter Gott cannula without a side hole. Connections of the cannulae to the blood pump and a flow ~ter are made with short segments of uncoated three-eighths inch_poly-vinyl chloride tubing. -The entire circuit may be primed and debub-bled on the operative field. After connecti~g the sterilized components,. the drainage cannube are submerged in a basin of sali~e solution. A regu-lated wall suction is then applitd. to the tip of the return cannula so that priming is completed as the saline solution is drawn through the circuit components. The disposable blood pump head may then be passed off the field and connected to its motor console. Alternatively, the cannulae may be individually primed by a bulb type syringe and connected to the remainder of the circuit which has been primed by the extracor-poreal perfusion team in a closed loop manner. While the former method does not require input 271 I II .j I " \ r K~K ';'11. .)urgery, 0ynecotogy C" UI:JSlemcs . ,\1arcli I y~j from a perfusionist, the latter has caused the least operative interruption and is currently preferred. The rotation of the centrifugal blood pump is adjusted to deliver the maximum blood return at the minimal revolutions per minute. In adults, total flow has averaged 4 liters per minute and has ranged between 1.5 and 6.0 liters. In many patients, the portal circulation has contributed more than one-half of the total flow. The veno-venous bypass has often been initiated prior to extensive retrohepatic resection, and its average duration of 100 minutes (a range of 70 to 158) has, therefore, included the time required for completion of recipient hepatectomy plus im-plantation of the donor graft. Venous reservoirs are not needed in this system. All circuit tubing is shortened as much as possible to minimize exposure to foreign surfaces. Except for the rare formation of fine fibrin strands on the rims of the connectors and on the pump cone supports, there has been no evidence of ex vivo thrombosis. In one patient, a soft iliac vein thrombosis was removed with the drainage . cannula, but there has been no clinical or autopsy evidence in any patient of venous embolism. Component blood replacement during the period of bypass has actually improved the pre-existing coagulopathy --during the bypass in spite of a tendency for the'. platelet counts to fall during this time. _ So far, this system has been used only in adults. Children have been 'found to tolerate the com-bined portal and venacaval occlusion far better than adults, and it is possible that the system should be used in younger liver recipients only ~ otume 100 when indicated by vasomotor instability durin~ test cross clamping. In adults, the advantages 01 the bypass are so great that it has become a rou· tine part of transplantation of the liver. pt:~fMAov A technique of veno-venous bypass without heparin has been developed for use during tht anhepatic phase of transplantation of the liver. With this method, the ability to compress the temporarily obstructed vena caval and portal ve-nous systems has made hepatic transplantation an easier procedure. obcbob~Cbp 1. PAPPAS, G., PALMER, W. M., MARTlSEAU, G. L, and others. Hemodynamic alterations caused during ortho-topic liver transplantation in humans. Surgery, 1971, 70: 872-875. 2. STARZL, T. E., IWATSUKl, S., V AN THIEL,. D. H., and others. Evolution of liver transplantation. Hepatology, 1982, 2: 614-636. 3. MOORE, F., WHEELER, H., DEMISSIANOS, H., and others. Experimental whole-organ transplantation of the liver and of the spleen. Ann. Surg., 1960, 152: 374-387. 4. STARZL, T. E., KAUPP, H. A., BROCK, D. R., and others . Reconstructive problems in canine liver homotransplan-tation with special reference to the postoperative role of hepatic venous Row. Surg. Gynecol. Obstel., 1960, 111: 733-743. 5. STARZL, T. E. Experience in hepatic transplantation. With the assistance of C. W. PUTS AM. Pp. 122-125; 154; 166-167. Philadelphia: W. B. Saunders. Co., 1969. 6. CALNE, R. Y., McMASTER, P., SMITH, D. P., and others. Use of partial cardiopulmonary bypass during the an-hepatic phase of orthotopic liver grafting. Lancet, 1979, 2: 612-614. 7. AZPEITlA, D., DEMIGUEL, E., TUFFE, A., and others. Techniques de derivation pendant la periode anhepatique de la transplantation du foie. Ann. Chir., 1973, 29: 155-160. - .. --_ .... " i. '. '-suprahepatic VC bare area commanDile In frahepatic YC .ex.t. tilGC vein //~~~ 1-- \ \ D--~ - -' K~I . FIG. 1. Anhepatic stage of transplantation of the liver with cavoportal to axillary bypass circuit. Veno- Venous Bypass Without Syslnnic Anticoagulation for Transplantation of the Human Lil.Jer.-Bartley P. Griffith, Byers W. S/uJw,jr., Robert L. Hardesty. Shunzaburo fwatsuki, Henry T Bahnson and Thomas E. Star: 

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Veno-venous bypass without systemic anticoagulation for transplantation of the human liver

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