Selective use of veno-venous bypass in orthotopic liver transplantation

The use of veno-venous bypass (VVB) during the anhepatic phase of orthotopic liver transplantation (OLT) remains controversial. We employ VVB on a selective basis: patients who tolerate intra-operative supra-hepatic IVC test cross-clamping undergo OLT without VVB while patients who, despite maximal volume resuscitation, develop hemodynamic instability during test cross-clamping, undergo OLT with VVB. The records of 150 adult orthotopic liver allograft recipients transplanted at the Massachusetts General Hospital from January 1984 to December 1994 were reviewed to identify any potential adverse affects on peri-operative, 6 months, 1 year outcomes in recipients foregoing VVB during liver transplantation. Thirty-eight patients (25%) underwent OLT without VVB with actuarial survivals of 78.4% and 69% at 6 months and 1 year. 112 patients (75%) underwent OLT with VVB with actuarial survivals at 6 months and 1 year of 73% and 72%. Demographic data, UNOS status, and diagnoses were similar in each group. There were no significant differences in intra-operative PRBC requirements; lengths of hospital stay; retransplantation rates; or 30 day, 6 months and 1 year survivals between these two groups. There was no significant difference in renal function as determined by preoperative, peak post-operative, discharge serum creatinine levels, or number of patients requiring HD between these two groups. There were two major complications (1.8%) possibly resulting from VVB. In conclusion, patients who tolerate IVC test cross-clamping can safely undergo orthotopic liver transplantation without veno-venous bypass. In our experience, there were no significant differences in peri-operative parameters, post-operative renal function, or short-term survival when compared to patients who, due to hemodynamic instability during IVC cross-clamping, underwent OLT with VVB. Given the potential complications associated with VVB, we feel that in those patients who tolerate intra-operative IVC cross-clamping, it is better to proceed without the use of VVB.