2019 FSA Posters

P024: BLOODLESS LIVER TRANSPLANTATION IN CHRONIC BUDD CHIARI SYNDROME AND COMPLETE VENA CAVA OBSTRUCTION
Bhavna P Singh, MD, Fouad G Souki, MD, Yehuda Raveh, MD, Tiago Beduschi, MD, Vadim B Shatz, MD, Ramona E Nicolau-Raducu, MD; Jackson Memorial Hospital

Introduction:

Describe implications of chronic Budd Chiari syndrome with complete vena cava obstruction

Discuss use of Veno-Venous bypass (VVBP) during liver transplantation

Discuss the cannulae placement: types, locations

Thromboelastogram (TEG) directed heparin treatment in recipients with hypercoagulable state

Review use of Organox prior to liver transplantation              

Case:

58-year old AA woman with a 5-year history of Budd Chiari syndrome with intrahepatic vena cava thrombosis and a MELD score of 15 presented for liver transplantation. On examination, extensive collaterals were present over the neck, chest and abdominal wall (Figure 1), without signs of SVC obstruction. Under general anesthesia, using ultrasound guidance, a 16F outflow bypass cannula was inserted in the left femoral vein, and a 16F inflow bypass cannula plus a 12F TL catheter were placed in the RIJ vein, under TEE guidance (Figure 2). VVBP was started prior to skin incision. Upon commencement of VVBP (2 L/min), a dramatic decrease in engorgement of the superficial abdominal collateral veins was achieved. An hourly 1000 U Heparin bolus was administered via VVBP circuit, and an additional 2000 U were given just prior to IVC clamping. Heparin effect was monitored with kaolin/heparinase TEG (Figure 3). After extensive dissection, the portal vein was deemed too small for bypass cannulation.  Hepatectomy with IVC resection was followed by a conventional orthotropic liver transplant.  VVBP was discontinued after uneventful reperfusion. Patient was extubated the next day, and discharged home 10 days later.

Discussion:

By effectively decompressing the extensive venous collaterals VVBP turned a potentially massively hemorrhagic procedure into a bloodless transplant. While Organox trial mainly aims to improve organ preservation and graft function, it could be used as a practical clinical strategy for surgically challenging cases, with expected prolonged dissection and cold storage.