Evaluation of Plasma Disappearance Rate Indocyanine Green Clearance as a Predictor of Liver Graft Rejection in Donor Brain Death.

INTRODUCTION: There currently exist no quantitative methods to assess graft viability before the donor procurement procedure. In Europe, around 20% of liver grafts evaluated "in situ" by an experienced surgeon are discarded. The aim of this study is to evaluate the use of the plasma disappearance rate indocyanine green (PDR-ICG) clearance in predicting liver graft rejection to avoid this 20% of futile surgeries. OBJECTIVES: To evaluate PDR-ICG as a predictor of liver graft rejection in death brain donors compared with the gold standard evaluation by an experienced surgeon. MATERIAL AND METHODS: Prospective observational single center study. From March 2017 to July 2019, 29 donors were included in the study, 17 were men and 12 women with a median age of 68 years ± 16.9 years. Donors had an intensive care unit stay of 2 days ± 4 days. PDR-ICG was measured with PICCO2 monitor. Indocyanine green clearance dose was 0.25 mg/kg injected intravenously in the operating room just before donor procurement procedure is initiated. The surgeon was unaware of the PDR-ICG measure until the decision of graft acceptance was taken. Data regarding the donors and biopsy results were included in a prospective database. RESULTS: PDR-ICG measure could be obtained in 10 minutes in all of the cases included. The median PDR-ICG obtained was 18%/min (range, 2.4-31%/min). Graft rejection took place in 15 out of the 29 donors. PDR-ICG value was less than 10%/min in 6 of these rejected grafts and less than 15%/min in 10 donors. All donor grafts with PDR-ICG <15% were discarded. The graft had been discarded in 5 donors with a PDR-ICG >15%. CONCLUSIONS: In our study a plasma disappearance rate <10 would have identified the grafts that would be rejected, thus avoiding the displacement work and expense of the surgical team. These results should be confirmed in a multicentric study.

Sengstaken Tube Removal under Direct Hemodynamic Monitoring after Post Transplantation Venous Occlusion.

The surgical procedure for orthotopic liver transplantation (OLT) is well standardized, and most groups use the retrohepatic caval preservation or piggyback technique to improve hemodynamic tolerance. However, when a discrepancy between the site in the right upper quadrant of the liver recipient and a small graft is present, this technique can provoke a rotation on the axis of the vena cava and cause an occlusion of the suprahepatic vein drainage. This problem can be detected intraoperatively, and several methods have been described to resolve it by placing different devices to correct the position. Early withdrawal may cause the development of clinical hepatic congestion with ascites unresponsive to medical treatment. We present three cases of OLT who developed obstruction of the venous drainage solved intraoperatively with the placement of a Sengstaken-Blakemore tube. As a novelty, prior to the withdrawal of the device, a transjugular hemodynamic study was performed to ensure the correct position of the liver with adequate venous drainage.

Donor Risk Index Has an Impact in Intraoperative Measure of Hepatic Artery Flow and in Clearance of Indocyanine Green: An Observational Cohort Study.

BACKGROUND: The increase in indications for liver transplantation has led to acceptance of donors with expanded criteria. The donor risk index (DRI) was validated with the aim of being a predictive model of graft survival based on donor characteristics. Intraoperative arterial hepatic flow and indocyanine green clearance (plasma clearance rate of indocyanine green [ICG-PDR]) are easily measurable variables in the intraoperative period that may be influenced by graft quality. Our aim was to analyze the influence of DRI on intraoperative liver hemodynamic alterations and on intraoperative dynamic liver function testing (ICG-PDR). METHODS: This investigation was an observational study of a single-center cohort (n = 228) with prospective data collection and retrospective data analysis. Measurement of intraoperative flow was made with a VeriQ flowmeter based on measurement of transit time (MFTT). The ICG-PDR was obtained from all patients with a LiMON monitor (Pulsion Medical Systems AG, Munich, Germany). DRI was calculated using a previously validated formula. Normally distributed variables were compared using Student's t test. Otherwise, the Mann-Whitney U test or Kruskal-Wallis test was applied, depending on whether there were 2 or more comparable groups. The qualitative variables and risk measurements were analyzed using the chi-square test. P < .05 was considered statistically significant. RESULTS: DRI score (mean ± SD) was 1.58 ± 0.31. The group with DRI >1.7 (poor quality) had an intraoperative arterial flow of 234.2 ± 121.35 mL/min compared with the group having DRI < 1.7 (high quality), with an intraoperative arterial flow of 287.24 ± 156.84 mL/min (P = .02). The group with DRI >1.70 had an ICG-PDR of 14.75 ± 6.52%/min at 60 minutes after reperfusion compared to the group with DRI <1.70, with an ICG-PDR of 16.68 ± 6.47%/min at 60 minutes after reperfusion (P = .09). CONCLUSION: Poor quality grafts have greater susceptibility to ischemia-reperfusion damage. Decreased intraoperative hepatic arterial flow may represent an increase in intrahepatic resistance early in the intraoperative period.

Management of liver transplantation waiting list for decompensated cirrhosis in a Spanish tertiary hospital: differences between hepatitis C virus recipients and other etiologies.

BACKGROUND: Decompensated cirrhosis due to hepatitis C virus (HCV) is one of the main indications for liver transplantation (LT) in Spain. Recurrence of HCV after LT is the main cause of graft loss and death in HCV-positive recipients. Advanced donor age determines a more aggressive recurrence of HCV and a shorter survival. In this setting, in our liver unit, grafts from younger donors are allocated to HCV-positive recipients. The aim of this study was a comparative analysis of allocation of grafts in HCV-positive recipients versus other etiologies and the impact on waiting list time, Model for End-Stage Liver Disease (MELD) score progression until LT, need of admission in a hospital, survival until LT. METHODS: This was a retrospective study from the cohort of patients included in the waiting list for LT owing to decompensated cirrhosis in the Hospital Gregorio Marañón from January 2008 to June 2013. RESULTS: A total of 91 patients were included; 63 patients (69.23%) received LT; 19 (20.88%) retired from the waiting list: 6 because of improvement, 11 (12.08%) because of death. In both groups, the age of recipients was similar (HCV 52 y vs other 53 y; P = .549). HCV patients were included in the waiting list with lower MELD score than other etiologies (HCV 16.1 vs other 19.4; P = .010); nevertheless, MELD score was similar at the time of LT in both groups (HCV 18.9 vs other 19.4; P = .675). Time on waiting list was significantly longer in HCV patients (198 d vs 86 d; P = .002) and they were admitted in hospital more days (30 d vs 12 d; P = .03). Donor age in the HCV group was significantly lower (64.3 y vs 54.7 y; P = .006). The intention-to-treat survival analysis did not show differences between the groups (log rank = 0.504). CONCLUSIONS: HCV patients with decompensated cirrhosis receive grafts from younger donors. HCV patients remain waiting longer for an optimal organ and suffer MELD deterioration and more days admitted in hospital. These differences in allocation of grafts did not affect final survival. In our experience, designating younger organs to HCV-positive patients does not penalize neither HCV recipients nor recipients with other etiologies.

Brachial-jugular expanded PTFE grafts for dialysis.

The objective of this study was to analyze the long-term outcome of 51 patients with brachial-jugular grafts for dialysis. Age, presence of diabetic nephropathy, complications of the angio-access, and therapeutic methods of treating complications were analyzed. All surgical procedures were performed under local anesthesia in an ambulatory surgical setting. The duration of angio-access was analyzed using the life-table method. Our results showed that brachial-jugular grafts can be performed under local anesthesia and in an ambulatory surgical setting. This procedure can be an alternative to complex intrathoracic procedures, Dacron cuff catheters, or lower limb grafts, in cases of stenosis or occlusion of the subclavian vein.

Unilateral breast enlargement secondary to right brachiocephalic vein occlusion.

We describe a 56-year-old woman who received dialysis through a right jugular catheter and developed a progressive right breast enlargement 1 year after arteriovenous graft shunt construction in the right forearm. Arm edema was not observed. A fistulography showed retrograde long thoracic and lateral thoracic veins flow secondary to a right brachiocephalic vein occlusion. Breast enlargement disappeared completely 2 weeks after a transfemoral balloon angioplasty and stent placement.

[Proximal vein by-pass in the treatment of venous stenosis in expanded polytetrafluoroethylene prosthesis for hemodialysis]. / By-pass a vena proximal para el tratamiento de estenosis venosas en prótesis de politetrafluoroetileno expandido para hemodiálisis.

OBJECTIVE: To show the long-term results of 97 politetraflouroethylene dialysis grafts submitted to a graft by-pass to treat graft-vein stenosis. MATERIALS AND METHODS: Venous stenoses were studied and diagnosed by means of fistulography in cases with fistula dysfunction or during surgery for graft thrombectomy. Both early and late complication rates were studied, as well as primary and secondary patency rates. RESULTS: Number of cases, 97. Mean age, 58 years (7-79). Diabetic nephropathy: 19.5%. Types of grafts in which stenoses developed: straight forearms 13; loop forearm 9; 6 mm upper arm 36; 6-8 mm upper arm 34; brachio-jugular 4; femoro-femoral 1. Overall follow-up time: 2,427 graft-months. Mean follow-up time: 21 +/- 5 months. Late complication rate: 0.30 episodes per graft-year of follow-up. Re-stenosis rate: 0.12 graft-year of follow-up. Primary cumulative patency rate: 70%, 62%, 51%, 45% at one, two, three and four years, respectively. Secondary cumulative patency rate: 87%, 79%, 74% and 71% at one, two, three and four years, respectively (p < 0.0016). No differences were observed between secondary patency observed after by-pass to treat dysfunction or thrombosis (p = 0.09259). DISCUSSION: In our experience, by-pass to proximal vein is associated with good results both at short and long term, probably because the intimal hyperplasia area is excluded and because by-pass is performed on an already dilated vein. The procedure can be performed under local anesthesia and in an outpatient basis between dialysis, with little discomfort for the patient.

Brachiocephalic jump graft fistula: an alternative for dialysis use of elbow crease veins.

Elbow crease fistula can be an alternative for autologous vascular access. Either brachiocephalic or brachiobasilic fistulas could be chosen according to the venous anatomy at the elbow crease. When a median antecubital vein is not present, the cephalic vein is usually too far away from the brachial artery. Thus, a end-to-side fistula must usually be performed after an extensive dissection of the distal part of the vein. In this way, only the proximal cephalic vein can be used for dialysis. To overcome this drawback, a brachiocephalic jump graft fistula was designed. A short segment of polytetrafluoroethylene graft, 6 mm in diameter, is tunneled under the skin and anastomosed to the artery and vein through two short longitudinal skin incisions. From 1981 to 1995, 222 brachiocephalic graft jump fistulas were constructed. The mean age of the patients was 56.1 years, 20% had diabetic nephropathy, and 61.7% had a previously failed angioaccess. Follow-up was obtained in 92.4% of the patients, and overall follow-up was 6,665 fistula-months. Early failure was observed in 4% of the cases. The complication rate was two episodes per 100 fistula-months of follow-up. Primary patency rates (event-free patency) were 85%, 67%, 48%, and 34% at 1, 3, 5, and 7 years. Secondary patency rates (overall patency) were 85%, 72%, 56%, and 43% at 1,3, 5, and 7 years. There were no differences between primary and secondary curves. Brachiocephalic graft jump fistula is a reliable technical variation of elbow crease fistulas for dialysis and can be another alternative to graft access when the cephalic vein is dominant at the elbow crease.