We describe a 31-year-old female patient from the Liver Transplant Unit of the University of Sao Paulo School of Medicine who was diagnosed with autoimmune hepatitis in 2002. She progressed to liver cirrhosis, and in July 2010, the patient developed recurrent ascites and edema of the lower limbs with a Model for End-Stage Liver Disease score of 14 and a Child-Pugh score of C11. Preoperative imaging revealed inferior vena cava (IVC) thrombosis and a pulmonary thromboembolism (Fig. 1). A full hematological evaluation did not show any abnormalities.
Surgical thrombectomy of the vena cava was performed during the liver transplantation. The piggyback surgical technique without a venovenous bypass is usually used in our practice. In this case, the piggyback technique was applied until the total hepatectomy, and the integrity of the vena cava was maintained. At the moment of the thrombus approach, we clamped the vena cava at 2 points: a suprahepatic point and an infrahepatic point just above the right renal vein. The ostium of the hepatic veins was joined and extended downward with a longitudinal incision. A vessel loop was applied just above the inferior clamp, and the vena cava was repaired with a double loop. Thus, this maneuver was followed by the removal of the inferior clamp; then, surgical instruments or the surgeon’s finger was introduced to remove the thrombus without bleeding (the finger/double-vessel loop maneuver; Fig. 2). In addition to the incision close to the renal veins, the use of a finger (which could also be pushed to go a little farther) allowed us to reach the beginning of the thrombus, even though the initial position was quite far. The vena cava thrombus was removed completely and safely. After the complete removal of the thrombus, the liver was implanted with a conventional technique. The patient maintained hemodynamic stability while the vena cava was clamped and the thrombus was being removed.
Soyama et al.3 recently performed successful living donor liver transplantation with extensive thrombectomy in a patient with acute-on-chronic Budd-Chiari syndrome and a totally thrombosed retrohepatic IVC. In that procedure, a Fogarty catheter was used to remove the thrombus, the IVC was opened longitudinally and IVC venoplasty was performed. The thrombus in that case was more retrohepatic. In contrast, the thrombus in the present case originated at a lower position just above the iliac vein bifurcation (Fig. 1). With this location, a simple longitudinal incision of the IVC would not have allowed us to perform the thrombectomy. Before the surgery, the placement of a vena cava filter during the procedure was considered, but because we had previous success with thrombectomy, the placement of an IVC filter was not performed.
The surgical technique described here has been proven to be very effective and safe. It maintained the patient’s hemodynamic stability without the use of a bypass. Although the piggyback technique in this case had the potential for a caval embolus, we considered caval manipulation. The use of the piggyback technique reduced the duration of the IVC clamping. The caval thrombus was partial on imaging; however, the patient developed symptoms of thrombosis, so she probably would not have had hemodynamic problems with clamping. On the other hand, we did not know how long the removal of the thrombus would take. The piggyback technique allowed for the possibility of a multistep thrombus removal if complete removal was not possible on the first attempt or if the patient became unstable. Moreover, with the piggyback technique, the remaining IVC itself functioned as a repair for traction and helped with the manipulation of the thrombus inside the vein (Fig. 2).
In this context, the finger/double-vessel loop maneuver dramatically improved the feasibility of the procedure. The large IVC diameter made it possible to use a finger to easily remove the thrombus. This maneuver proved to be very effective for thrombus vein removal. Although it was very easy to perform this procedure in the vena cava, it would most likely be difficult to use the same technique for a portal vein thrombosis because of the smaller vein diameter. Nonetheless, in some cases with large portal veins, this procedure could be attempted with the little finger.
Imaging confirmed the patency of the IVC and the hepatic veins at the 1-year follow-up. Portal vein thrombectomy has been frequently reported in liver transplantation.4 However, this is the first reported case of vena cava thrombectomy during orthotopic liver transplantation without a venovenous bypass. In summary, vena cava thrombectomy is feasible during liver transplantation, even without a bypass, and the finger/double-vessel loop maneuver has been shown to be a good auxiliary maneuver.