PORTOFEMORO-SUBCLAVIAN VENOVENOUS BYPASS AND RAPID INFUSION TECHNIQUE DURING HUMAN ORTHOTOPIC LIVER-TRANSPLANTATION

Veno-venous bypass during orthotopic liver transplantation is commonly performed as a portofemoro-axillary bypass. Right-angle positioning of one patient's arm and surgical preparation of the femoral and axillary veins are necessary. In 17 patients and 20 consecutive orthotopic liver transplant procedures the common portofemoro-axillary veno-venous bypass was substituted by portofemoro-subclavian bypass with a percutaneous 20 F cannulation set (LAUB catheter, Cook). The 20 F catheter was introduced into the left subclavian vein by Seldinger's technique before the operation and was connected intraoperatively to the outflow tube of the biopump. Surgical preparation of the axillary vein was not performed. In 10 patients a Y-connector was used to connect up the Rapid Infusion System in addition. Postoperatively the catheter was left in place for 2-4 days. Introduction and removal of the catheter were uneventful in all cases. High blood flow through the catheter could be maintained by a low driving pressure of the pump (4000 ml/min; 100 mmHg). No intraoperative complications were observed. Shunt flows remained stable throughout the surgical procedure during the anhepatic stage. There was no bleeding from the puncture site, especially after removal of the catheter, though several patients had a poor coagulatory status in the early postoperative period. Two postoperative complications were observed: air embolism due to disconnection and formation of a thrombus at the catheter tip, which it was possible to remove together with the catheter itself. Installation of an irrigation infusion in the postoperative period and well-tightened connections help avoid such complications as thrombus formation, bleeding or air embolism. The veno-venous bypass can be installed easily and rapidly by using the percutaneous cannulation technique with a 20 F catheter. Introduction, shunting and removal can be performed safely. The necessity of veno-venous bypass may be considered intraoperatively. A porto-subclavian bypass can be installed without further surgical preparation. The anaesthesiologist can take advantage of the large-bore lumen of the catheter for rapid transfusion and infusion.