Anomalous hepatic vein anatomy of left lateral section grafts and customized unification venoplasty for pediatric living donor liver transplantation

Abstract

In liver transplantation, a left lateral section (LLS) graft may have an unusual variant left hepatic vein (LHV) anatomy. This study was designed to analyze the incidence of unusual LHV variants and to determine technical methods for effective reconstruction in infant recipients weighing approximately 10 kg or less. The study comprised 3 parts: an LHV variation analysis, a simulation-based design for the technical modification of graft LHV venoplasty, and its clinical application. The LHV anatomy of 300 potential LLS graft donors was classified into 4 types according to the number and location of the hepatic vein openings: (1) a single opening (n ¼ 218 or 72.7%); (2) 2 large adjacent openings (n ¼ 29 or 9.7%); (3) 2 adjacent openings, 1 large and 1 small (n ¼ 34 or 11.3%); and (4) 2 widely spaced openings (n ¼ 19 or 6.3%). Types 2 and 3 required wedged unification venoplasty, and type 4 required additional vein interposition. In a series of 49 cases using LLS grafts, the graft hepatic vein complication rate was 4.5% at 3 years; stenting was necessary for 1 of the 36 type 1 LHV grafts (2.8%) and for 1 of the 13 type 2-4 LHV grafts (7.7%, P ¼ 0.46). A customized interposition-wedged unification venoplasty technique for coping with type 4 vein variations was developed with a simulation-based approach, and it was successfully applied to a 10-month-old male infant receiving an LLS graft with a type 4 LHV. In conclusion, nearly all LHV variations can be effectively managed with customized unification venoplasty. These venoplasty techniques represent beneficial surgical options as part of graft standardization for hepatic vein reconstruction in pediatric living donor liver transplantation.

Reconstruction of a rare variant of the left hepatic vein in a left lateral segment liver graft from a living donor: Technical notes

“…Securing a wide orifice for venous anastomosis is beneficial for accommodating potential graft remodeling-associated distortion of the hepatic vein anastomosis and is the most important strategy to prevent hepatic venous stenosis (HVS). [ 2 3 ] The obstruction of hepatic vein outflow could potentially result in cut surface bleeding, graft congestion, and graft failure, thereby increasing the morbidity and indeed the mortality. Outflow obstruction can result from anastomotic narrowing, twisting, or inadequate drainage of accessory veins in partial liver transplantation and cause severe graft dysfunction resulting either in retransplantation or mortality, especially in those regions where DDLT is seldom practiced.…”

Better innovate than compromise: A novel hepatic outflow reconstruction technique in pediatric living donor liver transplantation

“…Hwang et al. classified anatomy of LL graft venous openings and described various venoplasty techniques for anastomosis including the so‐called quilt venoplasty technique.…”

Complex outflow anatomy in left lateral lobe graft and modified venous reconstruction in pediatric living donor liver transplantation

“…Although successful treatment with radiological stents has been reported , failed management almost invariably leads to re‐transplantation. Different techniques of reconstruction of hepatic vein tributaries , in distinct variants in LLL venous anatomy , have been described to avoid graft congestion. The surgical difficulty in these anatomical variations depends on the cutting distance of the LLL veins from the MHV and IVC, from the vessel diameter, and from the extraparenchymal length of the LLL veins .…”

“…Although successful treatment with radiological stents has been reported [10], failed management almost invariably leads to re-transplantation. Different techniques of reconstruction of hepatic vein tributaries [1,3,8,9,11,12], in Because of the small diameter of the LHV orifice, a venoplasty was performed to maximize the caliber and to be able to suture it directly to the inferior vena cava using the triangulation technique. On the right, a schematic view of the "U"-shaped venous graft.…”

“…e106 distinct variants in LLL venous anatomy [4][5][6], have been described to avoid graft congestion. The surgical difficulty in these anatomical variations depends on the cutting distance of the LLL veins from the MHV and IVC, from the vessel diameter, and from the extraparenchymal length of the LLL veins [3,5,7].…”