Published online Jan 27, 2021. doi: 10.4254/wjh.v13.i1.151
Peer-review started: September 23, 2020
First decision: October 21, 2020
Revised: November 12, 2020
Accepted: November 28, 2020
Article in press: November 28, 2020
Published online: January 27, 2021
Budd-Chiari syndrome (BCS) is a challenging indication for liver transplantation (LT) due to a combination of massive liver, increased bleeding, retroperitoneal fibrosis and frequently presents with stenosis of the inferior vena cava (IVC). Occasionally, it may be totally thrombosed, increasing the complexity of the procedure, as it should also be resected. The challenge is even greater when performing living-donor LT as the graft does not contain the retrohepatic IVC; thus, it may be necessary to reconstruct it.
A 35-year-old male patient with liver cirrhosis due to BCS and hepatocellular carcinoma beyond the Milan criteria underwent living-donor LT with IVC reconstruction. It was necessary to remove the IVC as its retrohepatic portion was completely thrombosed, up to almost the right atrium. A right-lobe graft was retrieved from his sister, with outflow reconstruction including the right hepatic vein and the branches of segment V and VIII to the middle hepatic vein. Owing to massive subcutaneous collaterals in the abdominal wall, venovenous bypass was implemented before incising the skin. The right atrium was reached via a transdiaphragramatic approach. Hepatectomy was performed en bloc with the retrohepatic vena cava. It was reconstructed with an infra-hepatic vena cava graft obtained from a deceased donor. The patient remains well on outpatient clinic follow-up 25 mo after the procedure, under an anticoagulation protocol with warfarin.
Living-donor LT in BCS with IVC thrombosis is feasible using a meticulous surgical technique and tailored strategies.
Core Tip: A right-lobe living-donor liver transplantation (LT) with inferior vena cava (IVC) resection and reconstruction was performed in a patient with liver cirrhosis due to Budd-Chiari syndrome and hepatocellular carcinoma beyond the Milan criteria. It was necessary to remove the IVC because its retrohepatic portion was completely thrombosed, up to almost the right atrium. It was reconstructed with an infra-hepatic vena cava graft obtained from a deceased donor. The patient remains well 25 mo after the procedure. This case highlights the meticulous surgical technique and tailored strategies required for dealing with these challenging procedures in living-donor LT.