ORIGINAL ARTICLE Outflow Reconstruction for Right Liver Allograft With Multiple Hepatic Veins: “V-Plasty” of Hepatic Veins to Form a Common Outflow Channel Versus 2 or More Hepatic Vein–to–Inferior Vena Cava Anastomoses in Limited Retrohepatic Space Ashok Thorat, 1 Long-Bin Jeng, 1,2 Horng-Ren Yang, 1,2 Ping-Chun Li, 1,3 Ming-Li Li, 3 Chun-Chieh Yeh, 1,2 Te-Hung Chen, 1,2 Shih-Chao Hsu, 1,2 and Kin-Shing Poon 4 1 Organ Transplantation Center; Departments of 2 Surgery, 3 Cardiovascular Surgery, and 4 Departments of Anaesthesiology, China Medical University Hospital, Taichung, Taiwan Outflow reconstruction in living donor liver transplantation (LDLT) is certainly difficult in limited retrohepatic space with using right liver grafts with venous anomalies. Venoplasty of the inferior right hepatic veins (IRHVs) and middle hepatic vein (MHV) reconstruction using synthetic grafts to form a common outflow channel or a second venocaval anastomosis are available options. We aim to compare outcomes of LDLT recipients who underwent outflow reconstruction with a “V-Plasty” technique and outcomes of patients who underwent a second venocaval anastomosis. Out of 325 recipients who underwent LDLT from March 2011 to September 2014, 45 received right liver allografts that were devoid of MHV with multiple draining IRHVs (2 or more). Group A (n 5 16) comprised the recipients with outflow reconstruction with a V-Plasty, and group B (n 5 29) included the recipients with a second venocaval anastomosis. Group A recipients (male:female, 10:6; median age, 50.5 years) had a mean Model for End-Stage Liver Disease score of 14.7, whereas for group B recipients (male:female, 20:9; median age, 52.0 years) it was 17.2. The mean IRHV diameter for group A and B grafts was 8.3mm each. Mean warm ischemia time for group A was significantly lower (25.2 minutes) as compared to group B recipients (34.6 minutes) with P < 0.001. The 2-month pat- ency rates of vascular grafts were 100% for group A recipients with no evidence of thrombosis. In conclusion, the V-Plasty technique of MHV and IRHV reconstruction to form a common outflow is a new concept that proves to be a safe and feasible alternative for second venocaval anastomosis. Liver Transpl 22:192-200, 2016. V C 2015 AASLD. Received July 6, 2015; accepted September 10, 2015. Short hepatic veins, when present, provide a signifi- cant drainage of the posterior sector of a right liver allograft in living donor liver transplantation (LDLT). Venous variations are present in approximately 40% of donor livers, and presence of single or multiple inferior right hepatic veins (IRHVs) is a common type of short hepatic vein in right liver. 1 Because of deceased donor scarcity, LDLT is a major source of liver allografts in Abbreviations: ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; CT, computed tomog- raphy; ePTFE, expanded polytetrafluoroethylene; ESLD, end-stage liver disease; GRWR, graft-to-recipient weight ratio; HBV, hepati- tis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; INR, international normalized ratio; IRHV, inferior righthepatic vein; IVC, inferior vena cava; LDLT, living donor liver transplantation; MELD, Model for End-Stage Liver Disease; MHV, middle hepatic vein; RHV, right hepatic vein; SD, standard deviation; T-Bil, total bilirubin; V5, segment 5 vein; V8, segment 8 vein. Grants or financial support: Nothing to report. Potential conflict of interest: Nothing to report. Address reprint requests to Long-Bin Jeng, Organ Transplantation Center, China Medical University Hospital, 2, Yuh-Der Road, Taichung, Taiwan, 40447. Telephone: 04-22052121 ext.1765; FAX: 04-22029083; E-mail: otc@mail.cmuh.org.tw DOI 10.1002/lt.24342 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases LIVER TRANSPLANTATION 22:192–200, 2016 V C 2015 American Association for the Study of Liver Diseases.