Caval reconstruction techniques in orthotopic liver transplantation

Table 2 The piggyback technique

Ref.	n	Anastomosis	VVB	TPCS	Complications reported	Conclusion
Fleitas et al[26] single center	44 OLTs 39 patients	LM	No	No	Hepatic artery thrombosis (1), suprahepatic stricture (1), retransplant (5 - hepatic artery thrombosis, suprahepatic stricture, primary nonfunction, rejection), relaparotomy for bleeding (2), splenic steal (1)	Piggyback operation could be done in most OLTs, not restricted to certain anatomic situations. Lateral IVC clamping and unclamping results in good hemodynamic stability. Vascular complications, blood requirements, retransplantation, overall survival similar to that reported with standard technique
Belghiti et al[8] single center	51	LM	No	Yes, 100%	Four postoperative deaths (sepsis and primary nonfunction - 2, nosocomial pneumonitis at 3 and 5 mo - 2), no pulmonary embolism, NO IVC stump thrombosis	Piggyback technique was always technically feasible irrespective of graft size, VVB not required
Levi et al[27] single center	Era I: 945 of 1080 (87.5%)	LMR when possible	177 (18.7%)	No	Outflow obstruction (6)	Increasingly used piggyback technique over time (P < 0.0002). Over time had shorter warm ischemia time (P = 0.0004), less frequent need for VVB (P = 0.001). Hepatic venous outflow obstruction rarely encountered
	Era II: 851 of 920 (92.5%)	LMR when possible	97 (11.4%)	No	Outflow obstruction (3)
Ducerf et al[5]	88 OLTs, 81 patients	LM vs LM+ 3-cm cavotomy	No	No	No outflow obstruction (0)	Preservation of the IVC with recipient caval anastomosis with MHV and LHV is reliable. Associated cavotomy is not necessary
Parrilla et al[13] multi-center	1112	440 LM 672 LMR	No	6 at one center	Abdominal bleeding (2), acute outflow obstruction (9), ascites (3), intraoperative complications (28 - 2 venous tears, 26 congestion), graft failure (11)	Complications inherent to the piggyback technique including intraoperative venous congestion and acute and chronic Budd Chiari syndrome were more common when patients underwent anastomosis with two suprahepatic veins vs three (P < 0.001)
Cescon et al[4]	431	LM, LMR, LM+ 1 cm cavotomy	No	No	Complications related to anastomosis (20, 4.6%)	Increase in complications related to caval anastomosis in patients with two-vein anastomosis (LM vs LM+ P < 0.0001, LM vs LMR P = 0.065, LM+ vs LMR P = 0.4). Orifice formed with two veins is not sufficient. Advocate balloon angiography for dilation of anastomotic narrowing in most cases
Robles et al[17]	171	87 LM 84 LMR	No	No	Hepatic venous outflow obstruction in 7 patients with LM (8%) and in 1 patient with LMR (1.2%)	Increase in hepatic venous outflow obstruction in patients with two-vein anastomosis (P < 0.05)

LM: Anastomosis with left hepatic vein and middle hepatic vein; LMR: Anastomosis with left, middle and right hepatic veins; VVB: Venovenous bypass; TPCS: Temporary portocaval shunt; OLT: Orthotopic liver transplant; MHV: Middle hepatic vein; LHV: Left hepatic vein; IVC: Inferior vena cava.