Post reperfusion syndrome during liver transplantation: From pathophysiology to therapy and preventive strategies

Table 3 Surgical prevention/treatment strategies

Year	Ref.	Title	Type of study	Rationale	No. subjects	Definition of PRS	Effects	Jadad score
1992	Jugan et al[50]	The failure of venovenous bypass to prevent graft liver postreperfusion syndrome	Prospective interventional	VVBP should grant a better hemodynamic stability during reperfusion	58 (29 VVBP vs 29 NBP)	30% drop in MAP within 5' lasting for 1'	No differences in PRS incidence	1
1997	Millis et al[54]	Randomized controlled trial to evaluate flush and reperfusion techniques in liver transplantation	Randomized Controlled Trial	The techniques used to flush and reperfuse the graft could have an impact on PRS	88 (4 groups: hepatic arterial or portal vein flush with or without vena caval venting)	Three criteria: MAP < 60 mmHg at 1'; MAP < 60 mmHg at 5'; and a decrease of 30% or more for the MAP percent area under the curve (%AUC) during the first 5'	↓ PRS incidence in patients transplanted with a portal vein flush without vena caval venting versus arterial flush with/without vena caval venting	5
1999	Acosta et al[49]	Influence of surgical technique on postreperfusion syndrome during liver transplantation	Prospective interventional	The stability granted by the piggy-back (PGB) technique during the anhepatic phase without the need for VVBP could be extended to the initial minutes of reperfusion	71 (8 VVBP vs 43 NBP vs 20 PGB)	30% drop in MAP within 5' lasting for 1'	The greatest percent decrease in SVRI, and incidence of PRS, occurred in the VVBP group	1
2000	Durcef et al[52]	Hemodynamic profiles during piggyback liver grafts using arterial or portal revascularization	Prospective, randomized	The techniques used to flush and reperfuse the graft could have an impact on PRS	59 (29 HA vs 30 PV)	20% drop in MAP within the first 10' lasting for 5'	Initial arterial revascularization of the liver graft leads to a more stable hemodynamic profile. The time lag between arterial revascularization and the following portal anastomosis allows venous mesenteric pressure release	3
2006	Moreno et al[53]	Hemodynamic profile and tissular oxygenation in orthotopic liver transplantation: Influence of hepatic artery or portal vein revascularization of the graft	Randomized Controlled Trial	Simultaneous arterial and portal anastomosisis feasible due to the hemodynamic improvement offered by the piggy-back technique with temporary portacaval shunt	60 (30 IAR vs 30 IPR)	30% drop in MAP within 5' lasting for 1'	IPR leads to ↑ values of preload parameters, ↑ CO and MAP values than IAR. This increase in pulmonary pressure was lower in the artery group so that IAR of the graft may be indicated in case of poor pulmonary and cardiac reserve	3
2006	Gruttadauria et al[55]	Comparison of two different techniques of reperfusion in adult orthotopic liver transplantation	Retrospective	Better hemodynamic stability of caval venting than flushing with cold Ringer Lactate solution	50 (25 portal vein flush, no caval venting vs 25 caval venting, no portal vein flush)	30% drop in MAP within 5' lasting for 1'	↑ hemodynamic and metabolic stability in the group with portal vein flush	1
2008	Ko et al[46]	Greater hemodynamic instability with histidine-tryptophan-ketoglutarate solution than University of Wisconsin solution during the reperfusion period in living donor liver transplantation	Retrospective	Different vasoactive substances concentration in the two solutions	87 (28 UW vs 59 HTK)	30% drop in MAP within 5' lasting for at least 1' and up to more than 1 h	↑ PRS incidence in non flushed HTK group, flushing the solution ↓ PRS incidence similar to UW	1
2010	Ghafaripour et al[47]	Hypotension after reperfusion in liver transplantation: histidine-tryptophan-ketoglutarate versus University of Wisconsin solution	Randomized Controlled Trial	Different vasoactive substances concentration in the two solutions	89	30% drop in MAP within 5' lasting for at least 1' and up to more than 1 h	↑ PRS incidence in both flushed and non flushed HTK groups, flushing the solution ↓ PRS incidence	3
2011	Garcìa-Gil et al[48]	Celsior versus University of Wisconsin preserving solutions for liver transplantation: postreperfusion syndrome and outcome of a 5-year prospective randomized controlled study	Randomized Controlled Trial	Different potassium concentrations in the two solutions may imply different PRS outcomes as the outcome is closely related to hyperkalemia	102 (51 CS vs 51 UW)	30% drop in MAP within 5' lasting for 1'	Significant ↓ of PRS incidence in CS group; greater control over magnesium, potassium and glucose levels, no differences in long term outcomes	4
2012	Hong et al[56]	Regulated hepatic reperfusion mitigates ischemia-reperfusion injury and improves survival after prolonged liver warm ischemia: a pilot study on a novel concept of organ resuscitation in a large animal model	A pilot study in a animal model	The modification of reperfusion perfusate and cellular environment after warm ischemia would reverse the metabolic deficit and facilitate recovery of organ function	12 (6 RHR vs 6 control)	30% drop in MAP within 5' lasting for 1'	Regulated hepatic reperfusion (RHR) by using an energetic substrate-enriched, oxygen-saturated, and leukocyte-depleted perfusate delivered under regulated reperfusion pressure, temperature, and pH mitigates ischemia-reperfusio injury, facilitates liver function recovery, and improves survival after prolonged WI	1
2013	Fukazawa et al[51]	Crystalloid flush with backward unclamping may decrease postreperfusion cardiac arrest and improve short-term graft function when compared to portal blood flush with forward unclamping during liver transplantation	Retrospective	CB flush grants a lower blood loss during reperfusion, a gradual rewarming wich could foster systemic hemodynamics and graft survival	478 (313 CB vs 165 PF)	30% drop in MAP within 5' lasting for 1'	No differences in PRS incidence, ↓ PNF and cardiac arrest incidence; ↑ 30-d graft survival in CB group	1

PRS: Post reperfusion syndrome; VVBP: Veno-venous bypass; NBP: Without veno-venous bypass; MAP: Mean arterial pressure; PGB: Piggy-back; SVRI: Systemic vascular resistance index; HA: Hepatic artery revascularization; PV: Portal vein revascularization; IAR: Initial arterial revascularization; IPR: Initial portal revascularization; CO: Cardiac output; UW: University of wisconsin solution; HTK: Histidine-tryptophan-ketoglutarate solution; CS: Celsior solution; RHR: Regulated hepatic reperfusion; WI: Warm ischemia; CB: Crystalloid flush with backward unclamping; PF: Portal blood flush with forward unclamping; PNF: Primary non function.