Modulation of graft vascular inflow guided by flowmetry and manometry in liver transplantation

BackgroundSurvival of the partial graft after living donor liver transplantation owes much to its tremendous regenerative ability. With excellent venous outfow capacity, a graft within a wide range of graft-to-standard-liver-volume ratios can cope with portal hypertension that is common in liver transplant recipients. However, when the ratio range is exceeded, modulation of graft vascular infow becomes necessary for graft survival. The interplay between graft-to-standard-liver-volume ratio and portal pressure, in the presence of portosystemic shunt or otherwise, requires individualized modulation of graft portal and arterial infows. Boosting of portal infow by shunt ligation can be guided by transonic fowmetry, whereas muting of portal infow by splenic artery ligation can be monitored by portal electronic manometryMethodWe describe four cases to illustrate the above.ResultsOne patient had hepatic artery thrombosis resulting from splenic artery steal syndrome which was the sequela of small-for-size syndrome. Emergency splenic artery ligation and re-anastomosis of the hepatic artery successfully muted the portal infow and boosted the hepatic arterial infow. Another patient with portal vein thrombosis underwent thrombendvenectomy. Portal infow was boosted with ligation of portosystemic shunt, which is often present in these patients with portal hypertension. The coexistence of splenic aneurysm and splenorenal shunt required ligation of both in the third patient. The fourth patient, with portal pressure and fow monitoring, avoided ligation of a coronary vein which became a main portal infow after portal thrombendvenectomy.ConclusionsManagement of graft infow modulation guided selectively by transonic fowmetry or portal manometry was described.