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Journal saphenous vein reconstruction copy
- 1. Saphenous vein conduits for hepatic arterial reconstruction in living donor liver transplantation
- 2. Introduction • In LDLT, vascular complications are associated with significant morbidity and mortality. • Occasionally, an intraoperative event such as intimal dissection during recipient hepatectomy renders native recipient hepatic artery unsuitable for reconstruction. • Scarring from previous surgery or poor caliber from repeated transarterial chemoembolization (TACE) procedures also increases this risk
- 3. Introduction • Arterial reconstruction in such a situation can be performedwith extra-anatomic conduits • Most frequently used conduits include right gastric artery (RGA), right gastroepiploic artery (RGEA), left gastric artery (LGA), and splenic arteries (SA)
- 4. Introduction • In pure LDLT centers, great saphenous vein (GSV) interposition conduits might be a viable alternative • The objective of this study was to compare outcomes for patients who underwent hepatic arterial reconstruction using native hepatic arteries with patients who had GSV interposition conduits for arterial reconstruction.
- 5. Material and methods Prospective maintained database study was done at Shifa international hospital Islamabad Between April 2012 and September 2017. Inclusion criteria • All adult patient who underwent LDLT Exclusion criteria Pediatric liver transplant • Liver transplant for acute liver failure
- 6. Procedure During recipient hepatectomy High hilar dissection was performed Dissection continued to proper hepatic artery if unsuitable native hepatic artery Common hepatic artery and splenic artery assessed for reconstruction If CHA and SA are also unsuitable
- 7. 18 – 20 cm of left great saphaneous vein was procured
- 8. Aortohepatic conduit created Retrocolic ante pancreatic Proline 6-0 used as suture material
- 9. Intraoperative Doppler study Followed by daily liver Doppler study For conduits they used intravenous heparin For all other patient they used LMWX
- 10. TOTAL PATIENTS (473) GROUP 1 (452) GROUP 2 (21)
- 11. Aim • The two groups were compared for demographics, and graft and operative variables • The outcome was assessed based on the rate of hepatic artery thrombosis (HAT), early allograft dysfunction (EAD) , morbidity, and mortality
- 12. STATISTICS • For interval variables, t test or Mann Whitney U test was used. • For categorical variables, Fisher’s exact test and chi square test were used. • Survival was calculated using Kaplan Meier curves and log-rank test. • A P value < 0.05 was considered statistically significant. • Overall survival was calculated by subtracting date of last follow up/death from date of surgery.
- 13. RESULTS
- 14. RESULTS
- 15. RESULTS
- 16. RESULTS
- 17. RESULTS
- 18. RESULTS
- 19. DISCUSSION • The GSV conduits showed excellent patency rates but were associated with high patient mortality • There was a high rate of failure to rescue (FTR) in patients who had a biliary complication in the GSV group • Postoperative bleeding mandating a laparotomy led to mortality in 25% patients with GSV conduits • In their experience, in presence of hepatic artery dissection, the integrity of nearby arteries is often questionable. • Is one of the conduit of choice in rescue situation.
- 20. Article review • largest experience with the use of GSV conduits in LDLT. • Latest article • Relevant to our center as we are live donor liver transplant center.
- 21. Cons • Small no of patient • Published in journal with impact factor 2.191 • Single institution study • Randomised control trial comparing with other conduit required
Editor's Notes
- Why left because aortic clearance and vein procurement could be done simultaneously from rt and left resp
- Supra celiac pros Shorter length Better alignment But difficult dissection in presence of varices
- Secondary means hepatic artery thrombosis And reimplantation using rt leg gsv done
- NO SIGNIFICANT DIFFERENCE IN CIT,WIT AND INTAOPERATIVE BLOOD LOSS GRWR between 0.6% and 0.8% was also accepted under the following conditions: donor age below 45 years, no sign of any hepatosteatosis, and the MELD score of the recipient not above 20. Usually GRWR should be more than or equal to 0.8% The LAI is the difference between mean hepatic attenuation and mean splenic attenuation (i.e. average density of liver − average density of spleen on non-contrast scan) Grafts below 0.8% of recipient body weight (GW/RW), have been defined as SFS and have traditionally had worse outcomes
- Graft dysfunction was defined by the presence of the following 2 parameters for 3 consecutive days: international normalized ratio (INR) > 2, total bilirubin > 5.8 mg/dL, and encephalopathy grade 3 or 4. Graft dysfunction was defined by the presence of the following 2 parameters for 3 consecutive days: international normalized ratio (INR) > 2, total bilirubin > 5.8 mg/dL, and encephalopathy grade 3 or 4. Uaually done for sfs(small for size syndrome ) done to increase flow to small graft Done by splenectomy or simple splenic artery ligation
- THAT ONE PATIENT UNDERWENT REVASCULARISATION POST OPERATIVE BLEEDING WAS DUE TO COAGULOPATY Graft dysfunction was defined by the presence of the following 2 parameters for 3 consecutive days: international normalized ratio (INR) > 2, total bilirubin > 5.8 mg/dL, and encephalopathy grade 3 or 4
- Ftr might be due to ischemic cholangiopathy aw aortohepatic conduit Bleeding more bcoz more dissection around possible arterial conduits as well para aortic region No bleeders were identified in their cases on exploration Other possible arterial conduit are cryo preserved endotissue or donor iliac arteries