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USE OF PERCUTANEOUSLY PLACED CATHETERS FOR VENOVENOUS BYPASS IN ORTHOTOPIC LIVER TRANSPLANTATION

1996; Wolters Kluwer; Volume: 62; Issue: 1 Linguagem: Inglês

10.1097/00007890-199607150-00032

1534-6080

D. Manas, Paul Gibbs, D Talbot, Michael Thick, P. Renforth, P. J. M. Bayly, D. R. D. Roberts,

Transplantation: Methods and Outcomes

Despite the lack of prospective randomized data, many centers performing adult orthotopic liver transplantation (OLT) routinely use venovenous bypass(VVB) (1, 2). This involves the placement of two outflow cannulae, one in the portal vein and one in the iliac vein/inferior vena cava (IVC), as originally described by Shaw et al.(3). Positioning of the iliac/IVC outflow cannula required open dissection of the groin, by isolating the sapheno-femoral junction, ligating the distal saphenous vein, and advancing a femoral cannula into the iliac vein/IVC. Venous return by the axillary vein again required open dissection and freeing of the left axillary vein from the adjacent artery and nerves. Consequently, morbidity from these supposedly minor procedures was not insignificant (3, 4). We therefore read with interest recent correspondence in the Journal regarding the use of percutaneous methods of cannulation for VVB during OLT. Benedetti et al. (5) described successful percutaneous cannulation of the right internal jugular (IJ) vein to facilitate venous return in 86 patients undergoing OLT. They reported no adverse sequelae related to this procedure. Ozaki et al. (6) described their method of positioning the iliac/IVC outflow cannula using a percutaneous technique, obviating open groin dissection and the associated complications. Since the inception of our OLT program in Freeman Hospital, 100 transplants in 91 patients have been performed using VVB. All these cases had 15-French gauge-19-French gauge, Medtronic, Biomedicus cannulae placed percutaneously in the right internal jugular vein, using the Seldinger technique, to facilitate venous return. Venous outflow was facilitated in 68 cases (group A) by open dissection of the groin, isolation of the long saphenous vein, and advancement of a 12-French gauge-18-French gauge William Harvey (Bard) cannula into the iliac vein/IVC. In the remaining 32 cases (group B), outflow to the VVB pump was facilitated by placement of a second 15-French gauge Medtronic Biomedicus cannula into the iliac vein/IVC via a left femoral puncture using the Seldinger technique, rather than by open cutdown using a percutaneous technique similar to that described by Ozaki et al.(6). In group A, all patients had successful VVB instituted, except for one patient whose IJ cannula kinked on insertion, causing a neck hematoma to form when bypass commenced. This patient's transplant surgery was successful without bypass. In the same group, seven patients developed complications related to the open groin dissection and iliac/IVC cannula placement. Three patients developed groin seromas, one patient developed wound sepsis, and the remaining three patients developed troublesome lymphoceles, two of which required surgical exploration. In group B, all patients to date have had successful VVB, achieving flows averaging 40% of cardiac output (7). In two patients VVB was temporarily discontinued because of air entrainment at the circuit connection to the femoral cannula. Compared with the conventional technique, the percutaneous method of femoral/iliac cannulation was not associated with any of the usual complications. Overall, percutaneous insertion of both inflow and outflow cannulae offers several advantages. It is less time consuming and easy to insert (Seldinger technique), it avoids open dissection, especially of the axilla, with consequent avoidance of brachial plexus injuries, seromas, and lymphoceles, and the IJ vein cannula can be used as a rapid infusion line before and after commencement of VVB. Unfortunately these cannulae are expensive (£270/cannula), but the less expensive version had problems with air entrainment and kinking. They are not heparin bonded and therefore require careful flushing to ensure that clotting does not occur. Nevertheless, in view of the successful reduction in surgical morbidity, we recommend the routine use of the percutaneous technique for both iliac vein/IVC and IJ vein cannulation to facilitate VVB in OLT. D. M. Manas1,2 P. Gibbs1 D. Talbot1 M. G. Thick1 P. Renforth3 P. Bayly3 D. R. D. Roberts3 Liver Unit and Department of Anaesthetics; Freeman Hospital; Newcastle upon Tyne, NE7 7DN United Kingdom