A new method of veno‐venous bypass during human orthotopic liver transplantation

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Abstract
Summary: Veno‐venous bypass is commonly used during orthotopic liver transplantation, but there is some controversy as to whether it contributes to a better outcome. Low shunt flows frequently reduce the efficacy of portofemoro‐axillary systems and so a percutaneous cannulation technique for the subclavian and femoral vein with large bore catheters was developed in order to facilitate bypass management. This study reports the performance and complications of a portofemoro‐subclavian bypass system during the anhepatic phase of human orthotopic liver transplantation in 85 patients. A percutaneous cannulation technique and two 7 mm (subclavian and femoral) catheters, inserted pre‐operatively, were used in a pump driven portofemoro‐subclavian bypass system. Coagulation profiles, shunt flows, haemodynamic parameters, and peri‐operative complications associated with bypass were recorded for each patient. Percutaneous cannulation of the left femoral and subclavian vein was successful in 78 patients (91.8%). Mean femoro‐subclavian shunt flow was 1.45 1.min‐1 (SD 0.37), and mean portofemoro‐subclavian flow was 4.28 1.min‐1 (SD 1.03). Although oxygen delivery was not maintained at pre‐shunt levels (559.7 (SD 147) vs 506 (SD 107) ml.min‐1.m‐2, p < 0.05) renal perfusion pressure stayed above 50 mmHg (during shunt it was 56 (SD 9) mmHg). One intra‐operative air embolism was observed (1.2%), and in one patient a myocardial infarction occurred during the anhepatic phase; neither complication was considered to be related to the percutaneous cannulation technique. There were no bleeding complications. After operation, all chest X rays were normal and clinical examination revealed no adverse effects of portofemoro‐subclavian bypass. Percutaneous cannulation for portofemoro‐subclavian bypass using 7 mm catheters for the femoral and subclavian vein is a rapid, simple, effective, and safe method for management of adverse haemodynamic effects during the anhepatic phase of orthtopic liver transplantation.