Technical Solutions for Venous Outflow Reconstruction in Damaged Liver Grafts During Procurement: Case Reports D. Nicolini, F. di Francesco, N. Cautero, S. De Luca, A. Vecchi, P. Garelli, G. Martorelli, P. Vincenzi, M. Gentili, U. Baccarani, G.L. Adani, and A. Risaliti ABSTRACT The incidence and clinical consequences of hepatic injuries (parenchymal, vascular, and biliary) due to surgical handling during multiorgan procurement are still under- estimated. Surgical damage to liver grafts may lead to an increased mortality and graft dysfunction rate; therefore, multiorgan procurements require a high level of expertise and training. We report our experience in two cases of accidental venous outflow damage during liver procurement focusing on our repair strategies. In one case, a short suprahepatic inferior vena cava (IVC) was extended by a venous cuff obtained from a long infrahepatic IVC from the same liver graft. In the second case, we observed a complete transection of the middle hepatic vein during in situ splitting procedure. The damage was reconstructed by cadaveric iliac vein interposition. In both cases, liver transplantation was successfully performed without venous complication. An adequate surgical technique in liver procurement and venous reconstruction during living donor and domino liver transplantation are formidable tools to achieve successful liver transplantation with a damaged graft. T HE INCIDENCE AND CLINICAL consequence of hepatic injures (parencymal, vascular, and biliary) due to surgical handling during multiorgan procurement is still underestimated. Surgical damage to liver grafts may lead to an increased mortality and graft dysfunction rate; therefore, multiorgan procurements require a high level of expertise and training. This problem is particu- larly cogent, since many livers are procured by outside teams including surgeons not routinely involved in trans- plant procedures with a potential risk of unexpected graft injures only discovered during back table or transplant surgery. Herein, we have reported our experience with two cases of accidental venous outflow damage during liver procurement focusing on repair strategies. CASE REPORTS Case 1 During a combined heart-liver procurement, the cardiac team transected the suprahepatic inferior vena cava (IVC) near the confluence of the three suprahepatic veins in the IVC (Fig 1). It was not possible utilize this short vein cuff for direct graft-to- recipient caval anastomosis. A direct closure of the venous defect with a venous patch was considered dangerous due to the high risk of outflow obstruction even with a side-to-side or reverse-type caval reconstruction. Since an adequate iliac vein was unavailable the damaged suprahepatic IVC was extended by means of a circular segment obtained from infrahepatic IVC (Fig 2). Case 2 A complete transection of the middle hepatic vein during an in situ splitting procedure was reconstructed by cadaveric iliac vein interpo- sition (Fig 3). RESULTS In both cases, liver transplantation was successfully per- formed using the piggyback technique without any venous complication. The patients experienced uneventful clinical courses with progressive normalization of liver function From the Chirurgia Epatobiliopancreatica e dei Trapianti di Fegato (D.N., F.d.F., N.C., S.D.L., A.V., P.G., G.M., P.V., M.G., A.R.), Rene e Pancreas, Dipartimento di Scienze Mediche e Chirurgiche, Università Politecnica delle Marche, Ancona, Italy, and Clinica Chirurgica (U.B., G.L.A.), Centro Trapianti di Fegato, Università degli Studi di Udine, Udine, Italy. Address reprint request to Daniele Nicolini, MD, Chirurgia Epatobiliopancreatica e dei Trapianti di Fegato, Rene e Pancreas, Dipartimento di Scienze Mediche e Chirurgiche, Università Politec- nica delle Marche, Ancona, Italy. E-mail: nicolini_daniele@yahoo.it © 2008 by Elsevier Inc. All rights reserved. 0041-1345/08/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2008.06.003 Transplantation Proceedings, 40, 1941–1943 (2008) 1941