Feasibility and limits of caval-flow preservation during liver transplantation

As promoters of orthotopic liver transplantation (OLT) with preservation of caval flow, we reviewed our 8-year experience to assess the feasibility an d limits of this technique. Preservation of caval flow during OLT, which im proves intraoperative hemodynamic stability, was not considered feasible in a significant proportion of transplant recipients. When transient clamping of caval flow is required, causes and consequences of this clamping during all phases of the procedure were not reported. Between, 1991 and 1998, a t otal of 275 OLTs using a whole graft were performed in 259 patients with a policy consisting of a systematic attempt to preserve inferior vena cava (I VC) and caval flow. Preservation of IVC flow was possible in all cases, and no procedure was converted to the conventional technique. Caval flow was m aintained throughout the procedure in 246 procedures (90%). Temporary IVC c ross-clamping was required in 24 cases during hepatectomy because of diffic ult dissection and in 5 cases after graft reperfusion because of outflow ob struction; none required the use of a venovenous shunt. IVC cross-clamping during hepatectomy was required more frequently in cases of a large liver, with a mean duration of 11 +/- 4 minutes, but without significant influence on early postoperative risk, including one graft failure (4%) and one, pos toperative death (4%). Conversely, IVC cross-clamping after reperfusion, wi th a mean duration of 23 +/- 5 minutes, was associated with four graft fail ures (80%) and four deaths (80%). We conclude that IVC preservation is feas ible in almost all candidates, allowing the use of split livers from cadave ric or living donors independently from their underlying disease. Although preservation of caval flow was possible in the large majority of cases, tra nsient IVC cross-damping during hepatectomy was well tolerated in contrast to caval damping after graft reperfusion. Therefore, if necessary, we recom mend transient IVC cross-clamping to perform a large cavocaval anastomosis.