Vena cava and hepatic vein clamping during orthotopic liver transplantation: instrumentation and technical approaches

During liver transplantation complete occlusion of the hepatic veins or vena cava is a critical step prior to removal of the diseased liver in preparation for implantation of the donor liver. There are several technical approaches utilized to remove the diseased liver and implant the donor graft. Generally, following complete mobilization of the liver, the hilum is dissected and inflow can be selectively ligated. Next, the vena cava is approached. In ‘classic’ or bicaval technique the retrohepatic vena cava is replaced in its entirety and thus requires mobilization, encircling, and clamping of both the suprahepatic and infrahepatic vena cava for control1,2. This is followed by removal of the diseased liver with vena cava and subsequent anastomosis of both the suprahepatic and infrahepatic vena cava to the donor graft (Fig. 1a). Vena cava clamping techniques with specific clamps in place Copyright Richard Gilbert/Albert Fung/Peter Kim. In piggyback and ligation of the short hepatic veins and often the right hepatic vein as the liver is mobilized off the vena cava3. Most commonly the middle and left hepatic veins are encircled and clamped in preparation for implantation. The diseased liver is then removed and the donor graft is anastomosed to a common orifice of the left and middle hepatic vein (Fig. 1b). A variation on this technique involves ligation of all three hepatic veins followed by a side-to-side caval anastomosis between donor and recipient vena cava4 (Fig. 1c). These technical approaches are felt to be equivalent in their safety and efficacy, but there may be anatomical or physiological situations and even various pathologies which favour a particular approach over the other5,6. Regardless of technical approach, the ability to clamp the recipient vena cava or hepatic veins is of the utmost importance and numerous vascular clamps have been utilized to facilitate this process. Below we will highlight three of the most commonly used vascular clamps during liver transplantation, their initial development, and their respective advantages and disadvantages. The Satinsky vascular clamp (Fig. 2) was designed by American cardiac surgeon Victor Satinsky (1912–1997)7. The clamp was initially designed by Satinsky in 1948 to facilitate the surgical management of portal hypertension by creation of a portocaval shunt through a thoracoabdominal approach8. The clamp is specifically designed to approach the cava tangentially and provide partial caval occlusion in order to facilitate the creation of the portocaval anastomosis. The clamp’s most notable feature is the angled tip. Because the clamp was designed for use on the vena cava, it initially had a criss-cross jaw pattern that suited the thickness of the vein9. In 1950, Pilling equipped the clamp with its patented Atraugrip jaw pattern, which featured a single row of serrated teeth opposing a double row, a pattern that has been felt to be better suited to arteries than veins. This pattern is the most commonly found jaw pattern today9. Clamp profiles The clamp provides good control of the vena cava and often comes in a variety of sizes to facilitate both bicaval and piggyback clamping. It is often the most universally available clamp at surgical centres. The clamp does, however, have several notable disadvantages. First, owing to the tip angulation, injury to liver parenchyma or even right hepatic vein is a possibility with this clamp. Specifically, during sewing of the infrahepatic caval anastomosis during a classic liver transplant when the liver is rotated cephalad, the pointed tip of the clamp can injure these structures. Several modifications can be made to the clamp to avoid this, including placement of a red-rubber catheter over the tip and the placement of sponges between the clamp tip and liver. Second, the clamp can struggle on thicker tissue and clamp slippage has been experienced with the Satinsky clamp when it is used for suprahepatic control. This may relate to the teeth modification by Pilling in the 1950s. Finally, the specific design of the clamp is likely best suited for tangential clamping such as in the side-to-side caval anastomosis. The ‘German’ clamp (Fig. 2), as it is most commonly referred to in North America, is a large version of the Potts vascular clamp designed by Willis J. Potts and Bruno Richter in 1948. Potts, an American paediatric surgeon, designed the clamp with his neighbour and craftsman Bruno Richter specifically for surgical interruption of patent ductus arteriosus in children10. The clamp has fine, interlocking teeth that were designed to penetrate the wall of a vessel without crushing and without slipping. In addition to this, there is a bevel near the teeth that is designed to facilitate sewing the vascular anastomosis11. The ‘German’ nomenclature colloquially used in North America likely stems from American surgeons trained by the early German transplanters who then returned to North America to practice. In the first reported attempt at liver transplant by Starzl in 1963, a Potts clamp is described in the operative note. The German/Potts clamp has several advantages. The large, gently curved jaw facilitates excellent presentation of the tissue for sewing, particularly in the piggy back transplant where it is generally the clamp of choice. Its teeth also provide excellent tissue control and prevention of slippage (numerous fine teeth). Its unique curve can be suboptimal for control of the lower cava during a bicaval transplant where a Satinsky or straight vascular clamp is generally preferred. In addition, if sewing a side-to-side cavo-cavostomy the clamp is ill suited due to its curve and a large Satinsky performs better. The Klintmalm ‘GK’ clamp (Fig. 2), was designed by Swedish born liver transplant surgeon Goran Klintmalm (1950–) while he was working at Baylor University in Dallas Texas. The clamp was specifically designed to overcome some of the aforementioned limitations of the Satinsky clamp. Specifically, clamp slippage events had occurred at times with use of the Satinsky clamp (Goran Klintmalm, personal communication). This clamp is also one of the few vascular clamps specifically designed for liver transplantation. The clamp has several features to facilitate sewing of the suprahepatic vena cava during classic liver transplantation. The jaw is straight from the middle to the tip to be parallel with the liver surface and to prevent injury to the right hepatic lobe or right hepatic vein, which can happen while using the Satinsky clamp. The clamp features wings to retract the diaphragmatic tissue while sewing and to prevent the suture being caught by the proximal end of the jaws. The proximal and distal tips close at the same time, then the jaws close parallel, which provides equal pressure over the length of the clamp jaw to prevent slippage (Fig. 3). Its teeth are designed with a single row of interlocking teeth on one jaw and two rows on the opposing jaw. Due to its design, specifically the retraction wings, the clamp can struggle in piggyback transplantation. Smaller sizes of the clamp were made for paediatric transplantation and they can be used for infrahepatic cava control. Clamp compression profiles Copyright Richard Gilbert/Albert Fung/Peter Kim. Not infrequently, technical problems can pose challenges to clamping the vena cava or hepatic veins during liver transplant. Transjugular intrahepatic portosystemic shunt (TIPS) is used relatively frequently in patients with refractory ascites or medically refractory variceal bleeding. These shunts involve the placement of a partially covered metal stent from the portal system to the suprahepatic vein cava—most frequently through the right hepatic vein—as a way to decompress the portal system. In patients who then go on to be transplanted following TIPS the catheter can pose a physical restriction to clamping of the suprahepatic vena cava or right hepatic vein. To manage this issue, preoperative imaging can be helpful to determine the location of the stent. Often, if the stent is ‘high’ it can be gently retracted caudally to facilitate clamping above the stent. In cases where this is not possible more cephalad clamping may be necessary, often requiring a ‘classic’ surgical approach. Clamp slippage is a feared complication during liver transplantation and most surgeons have developed strategies to avoid this complication. Slippage or accidental clamp opening will lead to significant haemorrhage as the right atrium is usually just 1–2 cm from the suprahepatic clamp. The avoidance of clamp slippage involves appropriate sizing of clamp and positioning. This can be achieved by ensuring the suprahepatic cava or hepatic veins are appropriately cleared and encircled. Next, clamp positioning to maximize cuff size is imperative to ensure enough tissue remains to easily sew too. Finally, cutting the vena cava or hepatic veins accurately while again maintaining an appropriate cuff of vein is of critical importance. We will often ‘scratch’ down the hepatic tissue with scissors on the hepatic veins to gain extra vein cuff length. Should the clamp be felt to be too low, or the vein cuff inappropriately small, a second clamp will often need to be placed above the original clamp to facilitate repositioning. This is often best performed with the same size and design of clamp to ensure the clamps match curves. Finally, should a clamp be felt to be slipping, the most appropriate course of action is to place a series of long Allis clamps across the vein cuff to ensure that if slippage were to occur some control of haemorrhage would be possible. With Allis clamps in place an additional clamp can be placed above the slipping clamp to ensure appropriate safe repositioning. During liver trauma, total vascular exclusion of liver may be required to control haemorrhage and address specific injuries. These situations can be challenging, and are best approached as if it were a classic liver transplant. The suggested steps for this are mobilization of the left lobe, opening of the paracaval tissue below the caudate, and then placement of a small sponge below the cava from the left. Next, the cava can be approached from the right with full right lobe mobilization, ligation of the right adrenal vein and then visualization of the sponge from the right side; sometimes phrenic veins may need to be ligated. After this mobilization, control can be achieved with a GK or German clamp from the patients left and a straight or Satinsky clamp from the right. Following this, a Pringle manoeuvre can complete the exclusion. In situations where this level of dissection cannot be safely achieved, a Debakey aortic clamp can be applied in a vertical orientation to both the infra- and suprahepatic vena cava. Often hypovolaemic patients who undergo total hepatic vascular exclusion will require significant vasopressor support to tolerate this loss of preload. Above we have outlined three of the most common vascular clamps used to obtain caval control during liver transplantation. Institutional or surgeon specific approaches to caval occlusion vary widely. Regardless, the ability to control the vena cava is a critical skill during liver transplantation and occasionally during emergency situations that should be within a surgeon’s armamentarium. Knowledge of the various advantages and disadvantages to different clamps is critical to their safe and effective usage. The authors have no funding to declare. The authors declare no conflict of interest. There are no data to make publicly available.

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