A new percutaneous technique for establishing venous bypass access in orthotopic liver transplantation

Partial veno-venous bypass (VVB) is commonly used in orthotopic liver transplantation (OLT). Venous access for blood return during VVB classically uses a surgical cutdown on the left axillary vein (LAV), which may prolong operating time and can be associated with significant complications. The authors have developed an alternative means of establishing venous access whereby the anesthesia team places 8.5F venous cannulae preoperatively in one or two vessels (internal jugular, antecubital, or subclavian) percutaneously using the Seldinger technique. These cannulae then serve to accept venous return from below the diaphragm via a centrifugal pump. The aim of the present study was to compare the hemodynamic profiles obtained during the anhepatic phase of OLT in patients in whom either a conventional LAV catheter (group 1) or percutaneous catheters (group 2) were used for return flow from a centrifugal pump. There were no identifiable complications related to venous access in either group of patients. Total operating room time was 800 ± 30 minutes in group 1 and 720 ± 40 minutes in group 2 (P = 0.17). Hemodynamic parameters were determined from continuous strip chart recordings of arterial, right atrial, and inferior vena caval (IVCP) pressures. Cardiac output (CO) was measured by thermodilution whereas pump flow was determined by an electromagnetic probe. Renal perfusion pressure (RPP) was calculated as the difference between mean arterial pressure (MAP) and IVCP. Bypass pump flow was greater, but not significantly different between group 1 (3.0 ± 0.2 L/min) and group 2 (2.4 ± 0.2 L/min) (P = 0.09). IVCP was lower in group 1 (19 ± 1) than in group 2 (25 = 2 mmHg) (P = 0.02). These differences did not prevent the achievement of comparable hemodynamic profiles between groups. Groups 1 and 2, respectively, did not differ with regard to CO 7.1 ± 0.5 versus 6.9 ± 0.6 (P = 0.81), MAP 79 ± 2 versus 83 ± 3 (P = 0.30), or RPP 60 ± 3 versus 58 ± 3 (P = 0.72). Average blood transfused was similar between groups. The authors conclude, based on hemodynamic profiles and the low incidence of complications, that percutaneous placement of 8.5F venous cannulae for VVB return flow is an acceptable alternative to surgical cutdown of the LAV during OLT.