title: Triple-phase computed tomography and intraoperative flow measurements improve the management of portosystemic shunts during liver transplantation.
abstract: Ligation of portosystemic shunts in patients with cirrhosis undergoing liver transplantation has been recommended to avoid insufficient portal vein (PV) flow. Shunts are not always recognized pretransplantation because intraoperative PV flow assessment is not routinely attempted. As a result of a posttransplantation PV thrombosis in a recipient with a large portosystemic shunt and a PV flow <1 L/minute, we employed triple-phase computed tomography with vascular reconstruction and intraoperative graft flow measurement to determine the need for inflow modification in our next 16 patients with large portosystemic shunts. Subsequently, 6 patients with large portosystemic shunts and PV flows <or=1 L/minute underwent inflow modification at the time of transplantation to improve venous graft inflow. One patient with PV thrombosis had PV replacement without shunt ligation. Two patients with large splenorenal shunts and extensive PV thrombosis had left renoportal bypass. In 7 patients with large portosystemic shunts and PV flow greater than 1 L/minute, inflow modification was not attempted, to avoid excessive venous inflow that could jeopardize hepatic artery flow via the hepatic artery buffer response. In conclusion, sustained good graft function and inflow were achieved in all 16 patients.
authors.affiliation: Departments of General Surgery and Radiology, Cleveland Clinic, Cleveland, OH 44195, USA. faucejo@hotmail.com
authors.forename: Federico N
authors.initials: FN
authors.lastname: Aucejo
authors.forename: Koji
authors.initials: K
authors.lastname: Hashimoto
authors.forename: Cristiano
authors.initials: C
authors.lastname: Quintini
authors.forename: Dympna
authors.initials: D
authors.lastname: Kelly
authors.forename: David
authors.initials: D
authors.lastname: Vogt
authors.forename: Charles
authors.initials: C
authors.lastname: Winans
authors.forename: Bijan
authors.initials: B
authors.lastname: Eghtesad
authors.forename: Mark
authors.initials: M
authors.lastname: Baker
authors.forename: John
authors.initials: J
authors.lastname: Fung
authors.forename: Charles
authors.initials: C
authors.lastname: Miller
mesh_terms: D005260:Female; D006085:Graft Survival; D006801:Humans; D008102:Liver Circulation / Q000502:physiology; D008103:Liver Cirrhosis / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D011170:Portasystemic Shunt, Surgical / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000379:methods*; D016896:Treatment Outcome