Simultaneous Arterial and Portal Revascularization in Liver Transplantation P.C.B. Massarollo, S. Mies, and S. Raia I N THE usual liver transplant (Tx) technique, the graft is initially revascularized only with the portal venous blood flow, as soon as the anastomoses of the inferior vena cava and the portal vein are completed and the reconstruction of the hepatic artery is subsequently performed. This order of revas- cularization is chosen to minimize the duration of cold storage preservation and the graft implantation time. This method, however, implies a period during which the liver, although already revascularized, is deprived of arterial blood supply. This approach dates from an era when the total ischemia time was limited to 8 hours by the available preservation solutions. With the advent of the University of Wisconsin (UW)-Belzer solution, it is now possible to extend cold storage for up to 24 hours. 1 Despite this, most groups have not altered the procedure, fearing that the prolonged suture time required for performing arterial anastomosis before revascularization may allow progressive rewarming and increase graft ischemic injury. The method of initial portal revascularization (IPR) is based on the ability of the portal blood flow alone to maintain the normal liver. However, this statement con- trasts with the severe consequences of hepatic artery throm- bosis in the transplanted liver, like biliary strictures and leaks, multiple hepatic abscesses, and fulminant liver fail- ure. 2 Thus, it is possible that IPR may result in an insuffi- cient blood supply to the graft and a warm ischemia time that will last until the end of the arterial anastomosis. It is worth pointing out that those consequences may be more severe in the biliary tract, which has only arterial blood supply. One must also consider that in view of the relatively frequent occurrence of severe coagulopathy after graft revascularization, arterial anastomosis may be delayed until appropriate hemostasis is achieved or may be accomplished under unfavorable technical conditions. In 1992, a group of surgeons of the Liver Unit of the Faculdade de Medicina da Universidade de Sa ˜o Paulo (Medical School of the University of Sa ˜o Paulo) decided to revascularize the liver simultaneously with hepatic arterial and portal venous blood flow. The aim of this study is to compare the result of this method with that of IPR. MATERIALS AND METHODS Seventy-six consecutive Tx performed in 63 patients between July 1992 and June 1995 were retrospectively studied. Recipient oper- ations were accomplished by two different teams: one adopted simultaneous arterial and portal revascularization (SR) and the other chose IPR. All other steps of the procedure, including donor surgery, anesthesia, and postoperative care, were common to all patients. All grafts were preserved with UW-Belzer solution. The transplants were conducted using the standard technique with venovenous bypass. When SR was chosen, the recipient’s hepatic artery was mobilized and the anastomotic site was prepared during hilum dissection, before the anhepatic phase. Patients were given triple immunosuppression consisting of prednisone, cyclosporine (CyA), and azathioprine. SR was used in 50 Tx (group I) and IPR in 26 (group II). Both groups were similar with regard to sex, age, and total ischemia time (Table 1). Biliary reconstruction was performed by choledochocho- ledochostomy in 39 Tx in group I (78.0%) and in 22 Tx in group II (84.6%). In those cases, a T-tube was used in all but two Tx in group I (94.9%) and in just eight cases in group II (36.4%). Recorded variables include the incidence of primary graft non- function, 1-month patient and graft survival rates, and biliary complication rate considering both graft biliary tract and bile duct anastomosis, assessed as of July 1997. Alterations in the recipient’s biliary tree, like T-tube exit site leakage and sphincter of Oddi dysfunction, were excluded. All biliary complications were clinically suspected (increased billirubin or hepatic enzymes, septic episodes, or histologic alterations in liver biopsy) and confirmed with chol- angiograms performed using the T-tube, when present, or endo- From the Liver Unit, Faculdade de Medicina da Universidade de Sa˜ o Paulo, Sa˜ o Paulo, Brazil. Address reprint requests to Dr Paulo Massarollo, Rua Ernesto de Oliveira 130, Apto 24, Sa˜ o Paulo, Brazil; CEP:04116-170; e-mail: massaro @usp.br. Table 1. Patient’s Characteristics, Incidence of Primary Nonfunction, Patient and Graft Survival Rates, and Biliary Complication Rate IPR SR n 26 50 — Sex (M/F) 16/10 36/14 ns Age (y) 40.3 6 13.0 39.7 6 13.6 ns Cold ischemia time (h) 14.2 6 3.2 13.3 6 2.8 ns Primary nonfunction 3 (11.5%) 5 (10.0%) ns Patient survival 19 (73.1%) 43 (86.0%) ns Graft survival 18 (69.2%) 38 (76.0%) ns Biliary complications 9 (34.6%) 1 (2.0%) P , .001 Abbreviations: ns, not significant. © 1998 by Elsevier Science Inc. 0041-1345/98/$19.00 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(98)00854-9 Transplantation Proceedings, 30, 2883–2884 (1998) 2883