17. Memon MA, Nicholson CM, Clayton-Smith J. Spontaneous aor- tic rupture in a 22-year-old. Postgrad Med J 1996; 72 (847): 311. 18. Ringe B, Pichlmayr R, Lubbe N, Bornscheuer, Kuse E. Total hepatectomy as temporary approach to acute hepatic or pri- mary graft failure. Transplant Proc 1988; 20 (1): 552. 19. Ringe B, Lubbe N, Kuse E, Frei U, Pichlmayr R. Management of emergencies before and after liver transplantation by early total hepatectomy. Transplant Proc 1993; 25 (1): 1090. 20. Ringe B, Lubbe N, Kuse E, Frei U, Pichlmayr R. Total hepatec- tomy and the liver transplantation as two-stage procedure. Ann Surg 1993; 218 (1): 3. 21. Ringe B, Pichlmayr R. Total hepatectomy and liver transplan- tation: a life-saving procedure in patients with severe hepatic trauma. Br J Surg 1995; 82: 837. 22. Rozga J, Podesta L, Lepage E, et al. Control of cerebral edema by total hepatectomy and extracorporeal liver support in fulmi- nant hepatic failure. Lancet 1993; 2: 898. 23. So SKS, Barteau JA, Perdrizet GA, Marsh JW. Successful re- transplantation after a 48-hour anhepatic state. Transplant Proc 1993; 25 (2): 1962. 24. Henderson A, Webb I, Lynch S, Kerlin P, Strong R. Total hepa- tectomy and liver transplantation as a two-stage procedure in fulminant hepatic failure. Med J Aust 1994; 161: 318. 25. Hammer GB, So SKS, Al-Uzri A, et al. Continuous venovenous hemofiltration with dialysis in combination with total hepatec- tomy and portocaval shunting. Transplantation 1996; 62 (1): 130. 26. Griffith BP, Shaw Jr BW, Hardesty RL, Iwatsuki S, Bahnson HT, Starzl TE. Venovenous bypass without systemic anticoag- ulation for transplantation of the human liver. Obstet Gynecol 1985; 160: 271. 27. Lin PJ, Jeng LB, Chen RJ, Kao CL, Chu JL, Chang CH. Femoro- arterial bypass using Gott shunt in Liver transplantation fol- lowing severe hepatic trauma. Int Surg 1993; 78(4): 295. Received 26 April 1999. Accepted 23 October 1999. EMERGENCY PORTACAVAL SHUNT FOR CONTROL OF HEMORRHAGE FROM A PARENCHYMAL FRACTURE AFTER ADULT-TO-ADULT LIVING DONOR LIVER TRANSPLANTATION AMADEO MARCOS, 1,2 ROBERT A. FISHER, 1 JOHN M. HAM, 1 ANN T. OLZINSKI, 1 MITCHELL L. SHIFFMAN, 3 ARUN J. SANYAL, 3 VELIMIR A.C. LUKETIC, 3 RICHARD K. STERLING, 3 AND MARC P. POSNER 1 Division of Transplantation, Department of Surgery, and Section of Hepatology and Liver Transplantation, Division of Gastroenterology, Department of Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, 23219 As more adults undergo transplantation with partial liver grafts, the unique features of these segments and their clinical significance will become apparent. A pa- tient presented with life-threatening hemorrhage from an iatrogenic laceration to a right lobe graft 11 days after transplantation. The creation of a portaca- val shunt effectively controlled the bleeding, allowing more elective replacement of the organ with another right lobe graft. The regeneration process combined with increased portal blood flow and relative outflow limitation may have set the stage for this complica- tion. Any disruption of the liver parenchyma during transplantation should be securely repaired and fol- lowed cautiously. Portacaval shunting is an option for controlling hemorrhage from the liver in transplant recipients. The timely availability of a second organ was likely the ultimate determinant of survival for this patient. As the organ shortage becomes more critical, adult-to-adult living donor liver transplantation is emerging as a reason- able alternative to conventional cadaveric transplantation, but there are some considerations unique to partial grafts. These grafts are considerably smaller than the native liver and, as a result, a period of rapid regeneration begins imme- diately after surgery (1). Regeneration is necessary for the success of this technique, but the implications for manage- ment of donors and recipients are not yet fully understood. The assurance of adequate outflow from liver grafts has been recognized as critical for as long as these procedures have been performed. The consequences of limited outflow vary in severity and range from mild graft dysfunction to acute hepatic failure (2). Portal blood flow is higher after liver transplantation, and the relative increase is likely fur- ther exaggerated by the comparatively small size of a right lobe graft (3). Outflow limitation may then be of more signif- icance than it would be for a larger graft. Preservation of significant accessory hepatic veins with anastomosis to the inferior vena cava has been recently advocated as a means of augmenting outflow from these grafts (4). Bleeding after whole-organ liver transplantation is a known complication but is generally readily controlled and without serious sequelae. The source is frequently the extra- hepatic vasculature and is rarely from the liver itself. Paren- chymal injuries can be quite impressive and difficult to man- age. Hemorrhage of this type is uncommon after liver transplantation, and its successful management has not been reported. With a partial graft, higher portal venous pressure and flow combined with relative outflow limitation may in- crease the potential for this type of bleeding. Hepatic artery ligation or embolization and partial liver resection are means 1 Division of Transplantation, Department of Surgery. 2 Address correspondence to: Amadeo Marcos, MD, Division of Transplantation, Medical College of Virginia, P.O. Box 980057, Rich- mond, Virginia 23298-0057. 3 Section of Hepatology and Liver Transplantation, Division of Gastroenterology, Department of Medicine. TRANSPLANTATION 2218 Vol. 69, No. 10