Antonio D. Pinna

Atsushi Sugitani

Foley

John J. Fung

Kang

LeVeen

Luigi Marongiu

Moskovitz

Patricia Thistlethwaite

Satoru Todo

Shaw

Smadja

Thomas E. Starzl

Tzakis

Yoogoo Kang

English

PubMed

Crossref

VENOUS-RIGHT ATRIAL BYPASS FOR SUPERIOR VENA CAVA THROMBOSIS DURING ORTHOTOPIC LIVER TRANSPLANTATION

Pinna, AD

Sugitani, A

Thistlethwaite, P

Kang, Y

Marongiu, L

Todo, S

Starzl, TE

Fung, JJ

D-Scholarship@Pitt

0041-1337/97/6303-471$03.00/0 TRANSPLANTATION Copyright © 1997 by Williams & Wilkins Vol . 63, 471-484, No.3 , February 15, 1997 Printed in U.S.A. Transplan tation ® BRIEF COMMUNICATIONS VENOUS-RIGHT ATRIAL BYPASS FOR SUPERIOR VENA CAVA THROMBOSIS DURING ORTHOTOPIC LIVER TRANSPLANTATION ANTONIO D. PINNA,I,2 ATSUSHI SUGITANI,I P LUIGI MARONGru/ SATORU TODO, E,3 YOOGOO KANG,4 K~KKf:KKm~r AND JOHN J. FUNGI Thomas E. Starzl Transplant Institute and Departments of Cardiothoracic Surgery and Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213 The introduction of veno-venous bypass during orthotopic liver transplantation (OLT*) in 1984 avoided venous stagna-tion and hemodynamic instability during the anhepatic phase (1). In patients with superior vena cava (SVC) throm-bosis or stenosis, the use of veno-venous bypass with the standard technique should be avoided because it can precip-itate the onset of severe SVC syndrome (2). We describe here the use of a veno-right atrial bypass in a patient with SVC thrombosis who underwent simultaneous OLT and ltidney transplantation. A 51-year-old man with the diagnosis of cryptogenic cir-rhosis and chronic renal failure underwent simultaneous OLT and renal transplantation at our institution on Febru-ary 5, 1995. A LeVeen shunt had been implanted elsewhere in October 1994 for refractory ascites and was subsequently removed 4 weeks later due to infection and occlusion. At the time of transplantation, insertion of an oxymetric pulmonary artery catheter was attempted through both the right and left internal jugular veins, but it could not be advanced on either side. An intraoperative venogram showed thrombosis of the SVC with several small collaterals draining caudally (Fig. 1). An oximetric pulmonary artery catheter was subse-quently inserted through the right femoral vein and posi-tioned in the pulmonary artery. In order to infuse volume during the transplant, a Biomedicus venous cannula with a side port was inserted through the left femoral vein. This cannula also served as the outflow catheter for the inferior vena cava (IVC) during the subsequent bypass. After a me-dian sternotomy, a single straight Bard cannula (no. 32), modified in order to have a side port for volume infusion, was placed in the right atrium and secured with two 2-0 Ethi-bond pledgeted purse-string sutures (Fig. 2). After transec-tion of the bile duct and the hepatic artery, the portal vein was cannulated with a Gott shunt cannula (no. 9) and con-nected with the other cannulas to a centrifugal force pump. 1 Thomas E. Starzl Transplant Institute. 2 Address correspondence to: Antonio D. Pinna, MD, Thorn E. Starzl Transplant Institute, Falk Clinic, 4th Floor, 3601 Fift Ave-nue, Pittsburgh, PA 15213. 3 Department of Cardiothoracic Surgery. 4 Department of Anesthesiology. * Abbreviations: NC, inferior vena cava; OLT, orth opic liver transplantation; SVC, superior vena cava. FIGURE 1. Intraoperative SVC venogram shows obstruction of the SVC at the junction with the Jeft subclavian vein, right subclavian vein thrombosis with collaterals. During the bypass, the flow was maintained at 3 Umin. The central venous pressure during bypass was 12 mmHg, and the pulmonary capillary wedge pressure was 16 mmHg. 471 472 TRANSPLANTATION Vol. 63, No.3 ~ SVC occlusion ~o FIGURE 2. As shown in this scheme of the portal-atrial bypass, a femoral vein cannula and a right atrial cannula were used as infu-sion ports for volume replacement. The hepatectomy was performed using the piggyback tech-nique (3) to maintain blood flow through the Ive and pre-serve the pulmonary catheter. During the veno-atrial bypass, the patient was hemodynamically stable with a total blood loss of 7 U of packed red blood cells. Mter reperfusion of the liver allograft, the right atrial cannula was removed and the purse-string suture was ligated to close the right atrial de-fect. Two no. 28 thoracostomy tubes were left in the mediati-num, and the sternum was closed with interrupted wire. The left kidney from the same donor was transplanted into the left iliac fossa. The patient had an uneventful postoperative course. He received an antiarrhytmic agent for prophylaxis against atrial fibrillation, and the immunosuppression was iniated using tacrolimus and steroids. The LeVeen modification for the peritoneovenous shunt has been used extensively for the treatment of refractory ascites since its introduction in 1974 (4). The incidence of sve thrombosis or stenosis after Le Veen shunt has been reported with a variable incidence between 18.6% and 43% (5-7). Performing a liver transplantation in the presence of an SVC obstruction carries potential hemodynamic conse-quences, especially during the anhepatic phase. Volume in-fusion and hemodynamic monitoring were assured in this patient with an NC access; interruption of the Ive was avoided by using the piggyback technique, and venous return was optimized with a portal-atrial bypass by right atrial cannulation. Given the concerns that had arisen because of this case, we currently assess sve patency with Doppler ultrasound and sve cavogram as needed in all candidates with prior LeVeen shunt in order to detect the presence of sve thrombosis or stenosis before liver transplantation. It would also be possible to use transesophageal echocardiogra-phy instead of a pulmonary artery catheter for hemodynamic monitoring if occlusion of the Ne is necessary (e.g., in the case of cancer patients). REFERENCES 1. Shaw BW, Martin DJ, Marquez JM, et al. Venous by-pass in clinical liver transplantation. Ann Surg 1984; 20: 524. 2. Kang Y, Videira R, DeWolf AM, et al. The superior vena caval syndrome during orthotopic liver transplantation: a complica-tion of LeVeen shunt and veno-venous by- pass. Transplant Proc 1989; 23(3): 1998. 3. Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 1989; 210: 649. 4. LeVeen HH, Christoudias G, Moon JP, et al. Peritoneovenous shunting for ascites. Ann Surg 1974; 180: 580. 5. Foley WJ, Elliott JP, Smith RF, et al. Central venous thrombosis and embolism associated with peritoneovenous shunt. Arch Surg 1984; 119: 713. 6. Smadja C, Tridard D, Franco D. Recurrent ascites due to central venous thrombosis after peritoneojugular (LeVeen) shunt. Sur-gery 1986; 100: 535. 7. Moskovitz M. The peritoneovenous shunt: expectations and re-ality. Am J Gastroenterol 1990; 85: 917. Received 21 March 1996. Accepted 28 August 1996. 

Venous-right atrial bypass for superior vena cava thrombosis during orthotopic liver transplantation

A. D. PINNA

A. SUGITANI

P. THISTLETHWAITE

Y. KANG

S. TODO

T. E. STARZL

J. J. FUNG

MARONGIU, LUIGI

Archivio istituzionale della ricerca - Università di Cagliari

Venous-right atrial by-pass for superior vena cava thrombosis during orthotopic liver  transplant

http://d-scholarship.pitt.edu/5355/1/31735062134261.pdf

Venous-right atrial bypass for superior vena cava thrombosis during orthotopic liver transplantation

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Archivio istituzionale della ricerca - Università di Cagliari