Hwang S, Jung DH, Ha TY, et al. Usability of ringed polytetrafluoroethylene grafts for middle hepatic vein reconstruction during living donor liver transplantation

Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-Gu, Seoul, Korea.
Liver Transplantation (Impact Factor: 4.24). 08/2012; 18(8):955-65. DOI: 10.1002/lt.23456
Source: PubMed


Large vein allografts are suitable for middle hepatic vein (MHV) reconstruction, but their supply is often limited. Although polytetrafluoroethylene (PTFE) grafts are unlimitedly available, their long-term patency is relatively poor. We intended to enhance the clinical usability of PTFE grafts for MHV reconstruction during living donor liver transplantation (LDLT). Two sequential studies were performed. First, PTFE grafts were implanted as inferior vena cava replacements into dogs. Second, in a 1-year prospective clinical trial of 262 adults undergoing LDLT with a modified right lobe, MHV reconstruction with PTFE grafts was compared with other types of reconstruction, and the outcomes were evaluated. In the animal study, PTFE grafts induced strong inflammatory reactions and luminal thrombus formation, but the endothelial lining was well developed. In the clinical study, the reconstruction techniques were revised to make a composite PTFE graft with an artery patch on the basis of the results of the animal study. MHVs were reconstructed with cryopreserved iliac veins (n = 122), iliac arteries (n = 43), aortas (n = 13), and PTFE (n = 84), and these reconstructions yielded 6-month patency rates of 75.3%, 35.2%, 92.3%, and 76.6%, respectively. The overall 6-month patency rates for the iliac vein and PTFE grafts were similar (P = 0.92), but the 6-month patency rates with vein segment 5 were 51.0% and 34.7%, respectively (P = 0.001). The overall graft and patient survival rates did not differ among these 4 groups. In conclusion, ringed PTFE grafts combined with small vessel patches showed high patency rates comparable to those of iliac vein grafts; thus, they can be used for MHV reconstruction when other sizable vessel allografts are not available.

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    • "Luminal thrombus formation is uncommon when an ePTFE graft is used for IVC reconstruction because the IVC can be classified as a high-flow vessel. By contrast, the MHV may be a low-flow vessel, resulting in the possibility of luminal thrombus formation [22]. Although a short period of graft patency may be acceptable in a case of HV reconstruction, warfarin should be used for long patency for cases of chronic hepatitis and liver cirrhosis, in order to secure liver volume. "
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    ABSTRACT: The purpose of this study was to evaluate the results of hepatectomy with inferior vena cava or hepatic vein resection, followed by vessel reconstruction with an artificial vascular graft. From 2000 to 2011, 1,434 patients underwent several types of hepatectomy at our institution. Of these, we reviewed the cases of eight patients (0.56%) who underwent hepatectomy with inferior vena cava or hepatic vein resection and subsequent reconstruction using an expanded polytetrafluoroethylene (PTFE) graft. We resected the inferior vena cava in six patients and the hepatic vein in two patients. All eight patients underwent subsequent reconstruction using an expanded PTFE graft. The median operative time was 443 minutes and the median blood loss was 2,017 mL. The median postoperative hospital stay period was 18.5 days and the in-hospital mortality rate was 0%. Complications occurred in four patients: two patients experienced bile leakage, one experienced a wound infection, and one experienced pleural effusion. The two patients who experienced bile leakage had undergone reoperation on postoperative day 1. No complication with the artificial vascular graft occurred in these eight cases. Histological invasion to the replaced inferior vena cava or hepatic vein was confirmed in four cases. All artificial vascular grafts remained patent during the observation period. Hepatectomy combined with inferior vena cava or hepatic vein resection, followed by reconstruction with an expanded PTFE graft can be performed safely in selected patients.
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    ABSTRACT: Background: With the popularization of living donor liver transplantation (LDLT), it has been discovered that adequate venous outflow from the transplanted liver is crucial for proper graft function. Recently, the harvesting of the LDLT recipient's autologous great saphenous vein (GSV) has been increasingly adopted as a solution to the shortage of cadaveric vascular grafts. Minimally invasive GSV harvesting for coronary artery bypass grafting was shown to improve the cosmetic result and reduce leg wound pain and other complications. For immunosuppressed patients such as LDLT recipients, these benefits could be especially valuable. Materials and methods: From April to August 2012, eleven LDLT recipients underwent either minimally invasive or short-incision harvesting of GSV. The patient profiles, operative and postoperative information regarding operation time, estimated blood loss, harvested GSV graft length, serum tacrolimus (FK506) levels and postoperative complications were recorded prospectively. Results: The only wound complication was a subcutaneous hematoma, in our fourth patient. The mean operation time and the mean estimated blood loss were 33.9 min and 7.3 ml respectively. The mean incision length divided by the mean vein graft length was 31.6%. Two patients had poorly controlled diabetes mellitus. The mean serum FK506 level during the first postoperative week was 6.4 ng/ml (therapeutic range 5-10 ng/ml according to our protocol). No patient had surgical site infection in this series. Conclusions: GSV harvesting from LDLT recipients for hepatic venous outflow reconstruction is feasible without the need for expensive endoscopic systems, and an adequate length of vein can be obtained through a single 3 cm incision.
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