Postreperfusion venovenous bypass for hemodynamic stabilization in liver transplantation with hepatic outflow obstruction: a case report

Chronic inferior vena cava (IVC) stenosis is an uncommon yet serious vascular complication that can significantly impact the success of liver transplantation. We report a case in which postreperfusion venovenous bypass (VVB) was used as a temporizing strategy to achieve hemodynamic stabilization in the setting of severe hepatic venous congestion caused by a fixed suprahepatic IVC obstruction.

A 58-yr-old male with a history of orthotopic liver transplantation complicated by recurrent IVC stenosis and end-stage kidney disease underwent a simultaneous liver and kidney transplant. Intraoperatively, dense fibrosis was encountered proximal to the suprahepatic IVC, preventing resection of the stenotic segment. Although the liver graft was successfully implanted and reperfused, severe hepatic congestion and refractory hemodynamic instability developed. Venovenous bypass was initiated to augment venous return and stabilize systemic hemodynamics. The kidney transplant was aborted owing to the patient's instability. Postoperatively, the patient initially tolerated the procedure, however, he ultimately died in the intensive care unit.

This case illustrates an unconventional postreperfusion application of VVB as a rescue measure for refractory hemodynamic instability. Given the presence of a fixed suprahepatic IVC obstruction, VVB only provided temporary hemodynamic support and did not result in graft recovery. This underscores the physiologic limitations of VVB in the presence of irreversible mechanical outflow obstruction and highlights the importance of early recognition and surgical adaptability in anatomically complex cases.