Living donor liver transplantation for Budd‒Chiari syndrome with right posterior segment graft and patch plasty using the superficial femoral vein: a case report

Abstract

Background: In living donor liver transplantation (LDLT) for patients with Budd‒Chiari syndrome (BCS), there are several concerns about reconstruction of the inferior vena cava (IVC) and hepatic veins. Herein, we report the case of a patient with BCS who underwent LDLT with right posterior segment graft (RPSG) and patch plasty for reconstruction of the hepatic venous outflow, using the patient's own superficial femoral vein (SFV).

Case presentation: A 19-year-old man, who was diagnosed with primary BCS, underwent LDLT. His main hepatic veins were totally obstructed, and membranous stenosis was seen in the IVC. The LDLT donor was his mother; however, liver volumetric analysis showed that only her RPSG was appropriate. In the recipient surgery, 16 cm of the left SFV was harvested and was cut longitudinally and opened. The right hepatic vein (RHV) of the RPSG was anastomosed to the sidewall of the SFV graft. After explantation of native diseased liver was completed, the stenotic and thickened wall of the IVC was widely resected, and a large anastomotic orifice was created. Patch cavoplasty was performed with the RHV‒SFV graft patch. After portal reperfusion started, hepatic venous outflow was satisfactory, and there was no venous graft congestion. Both his postoperative course and his long-term course after discharge were uneventful.

Conclusions: In LDLT for BCS patients, ingenuity is required for the reconstruction of venous outflow. The SFV patch can be safely harvested from liver transplant recipients and is suitable for venous reconstruction. In addition, RPSG is an alternative type of liver graft for LDLT if a conventional right- or left-lobe graft cannot be used.

Keywords: Budd‒Chiari syndrome; Living donor liver transplantation; Right posterior segment graft; Superficial femoral vein.

Fig. 1

Preoperative abdominal computed tomography (CT) showing the membranous-like stenosis (yellow arrowhead) and non-perfusion of the main hepatic veins (a coronal section, b axial section)

Fig. 2

Preoperative abdominal magnetic resonance imaging (MRI) showing obstructed and scarred main hepatic veins. Abbreviations: IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein

Fig. 3

Right posterior segment graft before (a) and after (b) anastomosis to the SFV graft. Abbreviations: B-post, posterior branch of right hepatic bile duct; IRHV, inferior right hepatic vein; PV-post, posterior branch of right portal vein; RHA, right hepatic artery; RHV, right hepatic vein; SFV, superficial femoral vein

Fig. 4

Resection of the membranous web in the suprahepatic inferior vena cava (IVC) and creation of the orifice for patch cavoplasty. a Severe stenosis is seen when the suprahepatic IVC was opened. b The membranous web in the IVC. c Resection of the membranous web. d Creation of the anastomotic orifice for patch cavoplasty

Fig. 5

Postoperative enhanced computed tomography showing the right hepatic vein graft (asterisk) and no stenosis in the inferior vena cava (a coronal section, b axial section)