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Remodeled saphenous vein as interposition graft for portal vein reconstruction in living donor liver transplantation

In this report, we describe a surgical innovation in reconstructing the portal vein (PV) in a recipient with portal vein thrombosis (PVT) using a remodeled triplesheet great saphenous vein (GSV) from the recipient as a vascular interposition graft. A 36-year-old Taiwanese male diagnosed with endstage alcoholic cirrhosis and hepatocellular carcinoma was referred for possible liver transplantation. He had profound hypoalbuminemia (albumin, 1.2 g/dL) and massive ascites (Child-Pugh B, Model for End-Stage Liver Disease 12, and United Network for Organ Sharing status 2B). Preoperative imaging modalities showed a 3-cm hepatocellular carcinoma in segment 8. The computed tomography angiography demonstrated a narrowed distal (hilar) PV. However, the proximal PV at the splenomesenteric junction measured 10 mm. There were prominent, engorged mesenteric collateral veins (Fig. 1). The patient underwent living donor liver transplantation (LDLT) with a right lobe graft without the middle hepatic vein (graft weight, 632 g; graft-to-recipient weight ratio, 0.99) coming from his wife. The segment 5 and 8 veins were reconstructed with a cryopreserved deceased donor iliac vein graft. For PV reconstruction, the measured length of interposition graft required was 5 cm. A 20-cm GSV was harvested from the recipient’s thigh with the conventional open technique for vein harvest in vascular surgery. The distal and proximal portions being noted, the vein was hydrostatically distended by hand injection with a normal saline solution and was checked for leaks. The vein was opened longitudinally. After being opened, the vein was divided into 3 sheets with an equal length of 6 cm each. The sheets of GSV were fashioned and sewn side by side with a polypropylene 6-0 continuous suture along their longitudinal axes. Upon completion of this side-by-side anastomosis, the vein was remodeled to form a hollow tube by sewing together from the farthest ends of the sheets using polypropylene 6-0 continuous suture along their longitudinal axes (Fig. 2). The diameter of the remodeled GSV measured 1.3 cm. This remodeled GSV was used as an interposition graft connecting the graft PV to the recipient’s native splenomesenteric junction (Fig. 3). The narrowed PV segment was resected without an attempt at PV thrombectomy because of circumferential subintimal thrombosis noted intraoperatively. Intraoperative Doppler ultrasound showed that the remodeled GSV interposition graft diameter measured 8.3 mm and the PV flow velocity was 31 cm/second after reconstruction. The PV flow volume was 161 mL/min/100 g of liver tissue. Routine daily postoperative Doppler ultrasound to check vascular patency showed that the mean PV size measured 8.4 mm (range, 7.5-9.5) with a mean PV flow velocity of 28.5 cm/second (range, 12.7-46) during the first week. At 1 month post transplant, the remodeled GSV-PV measured 12 mm with a flow velocity of 16.8 cm/second. The remodeled GSV-PV remained patent to the latest follow-up. Postoperative antithrombosis management included heparin infusion (200 units/kg of body