Venous-right atrial bypass for superior vena cava thrombosis during orthotopic liver transplantation.

The introduction of veno-venous bypass during orthotopic liver transplantation (OLT*) in 1984 avoided venous stagnation and hemodynamic instability during the anhepatic phase (1). In patients with superior vena cava (SVC) thrombosis or stenosis, the use of veno-venous bypass with the standard technique should be avoided because it can precipitate the onset of severe SVC syndrome (2). We describe here the use of a veno-right atrial bypass in a patient with SVC thrombosis who underwent simultaneous OLT and ltidney transplantation. A 51-year-old man with the diagnosis of cryptogenic cirrhosis and chronic renal failure underwent simultaneous OLT and renal transplantation at our institution on February 5, 1995. A LeVeen shunt had been implanted elsewhere in October 1994 for refractory ascites and was subsequently removed 4 weeks later due to infection and occlusion. At the time of transplantation, insertion of an oxymetric pulmonary artery catheter was attempted through both the right and left internal jugular veins, but it could not be advanced on either side. An intraoperative venogram showed thrombosis of the SVC with several small collaterals draining caudally (Fig. 1). An oximetric pulmonary artery catheter was subsequently inserted through the right femoral vein and positioned in the pulmonary artery. In order to infuse volume during the transplant, a Biomedicus venous cannula with a side port was inserted through the left femoral vein. This cannula also served as the outflow catheter for the inferior vena cava (IVC) during the subsequent bypass. After a median sternotomy, a single straight Bard cannula (no. 32), modified in order to have a side port for volume infusion, was placed in the right atrium and secured with two 2-0 Ethibond pledgeted purse-string sutures (Fig. 2). After transection of the bile duct and the hepatic artery, the portal vein was cannulated with a Gott shunt cannula (no. 9) and connected with the other cannulas to a centrifugal force pump.