Refined surgical techniques to improve the patency of cryopreserved iliac artery homografts for middle hepatic vein reconstruction during living donor liver transplantation

PURPOSE: A cryopreserved iliac artery homograft (IAH) has not been considered suitable for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT), primarily due to the low patency from its small diameter. We revised our surgical techniques for MHV reconstruction using an IAH to improve its patency. METHODS: This study analyzed the causes of early conduit occlusion and developed revised techniques to address this that had clinical application. RESULTS: The potential risk factors for early conduit occlusion were the small IAH size, small graft in the segment V vein (V5) and segment VIII vein (V8) opening, and small recipient MHV-left hepatic vein stump. These factors were reflected to our revised surgical methods which included endarterectomy of the atherosclerotic plaque, unification of the internal and external iliac artery branches for large V5, and branch-patch arterioplasty for large V8. IAH endarterectomy, branch unification technique, and branch-patch arterioplasty were applied to 8, 5, and 5 patients, respectively and resulted in 1-month occlusion rates of 37.5%, 20.0%, and 40.0%, respectively. The overall patency rates of the IAH-MHV conduits in our 18 patients were 66.7% at 1 month, 38.9% at 3 months, and 33.3% at 1 year. CONCLUSION: Our refined MHV reconstruction using an IAH improved short-term MHV conduit patency, but did not effectively prevent early conduit occlusion, particularly with a small- or medium-sized IAH. Individualized reconstruction designs during LDLT operation are needed when an IAH is used for a modified right liver graft.