Ligamentum teres hepatis as a graft for portal and/or superior mesenteric vein reconstruction: From bench to bedside

Figure 1 Ligamentum teres hepatis recanalization. A and B: The remnant lumen of the ligamentum teres hepatis was identified and recanalized using a mosquito clamp (A) and a 3 mm probe (B); C: A bolus of normal saline was injected into the lumen from the proximal end to further enlarge the lumen.

Figure 2 Vascular reconstruction. A: Tangential resection of the involved vein with the preservation of portal vein (PV)-splenic vein (SV)-superior mesenteric vein (SMV) confluence; B: Vein reconstruction with ligamentum teres hepatis (LTH) patch; C: PV reconstruction with an interposition LTH graft with the preservation of SV-SMV confluence; D: Repair of the SMV with an interposition LTH graft with the preservation of PV-SV confluence. The white arrows indicate the anastomosis line. LTH: Ligamentum teres hepatis; PV: Portal vein; SMV: Superior mesenteric vein; SV: Splenic vein; P: Pancreas; HA: Hepatic artery.

Figure 3 Images of the reconstructed portal vein and/or superior mesenteric vein. A: Doppler ultrasound showed a patent vascular lumen; B: Enhanced computed tomography scan revealed a patent vascular lumen (orange arrow). PV: Portal vein; SMV: Superior mesenteric vein.

Figure 4 Distribution and function of endothelial cells and relative content of collagen fibers, elastic fibers and smooth muscle in ligamentum teres hepatis. A: The ligamentum teres hepatis (LTH) lumen (× 100 magnification); B: Endothelial cells (black arrow, × 400 magnification); C: LTH after Verhoeff-Van Gieson (VVG) staining (× 400 magnification); D: The portal vein (PV) after VVG staining. Elastic fibers (red), collagen fibers (black) and smooth muscle (yellow) (× 400 magnification); E: CD34 expression in LTH endothelial cells (× 400 magnification); F: CD34 expression in PV endothelial cells (× 400 magnification); G: Factor VIII-related antigen (FVIIIAg) expression in LTH endothelial cells (× 400 magnification); H: FVIIIAg expression in PV endothelial cells (× 400 magnification); I: Endothelial nitric oxide synthase (eNOS) expression in LTH endothelial cells (× 400 magnification); J: eNOS expression in PV endothelial cells (× 400 magnification); K: Tissue type plasminogen activator (t-PA) expression in LTH endothelial cells (× 400 magnification); L: Tissue type plasminogen activator expression in PV endothelial cells (× 400 magnification).

Figure 5 Postoperative cumulative survival and vascular stenosis rate curve. A: The cumulative survival curve of the 26 patients undergoing pancreatoduodenectomy with venous resection and reconstruction; B: The vascular stenosis rate curve of the 26 patients undergoing portal vein and/or superior mesenteric vein reconstruction with ligamentum teres hepatis.