Technical alternative with mixed arterial and venous patch in the reconstruction of the hepatic veins in the domino liver transplantation

Domino liver transplantation is an accepted strategy to increase the pool of donors, implanting the liver of a patient affected by Amyloid Polyneuropathy to an elderly patient with a terminal liver disease. The most important technical peculiarity is obtaining a good outflow to avoid a budd-chiari syndrome. When carrying out the hepatectomy in the donor, the section of the hepatic veins to be short in length and since we must preserve the stump for the subsequent suture, is performed practically at the level of the entrance of the veins in the hepatic parenchyma. This flush section causes the hepatic veins to be independent and may cause a venous drainage obstruction. To avoid this situation, different technical resources have been described, from a classical technique with vena-venous bypass resection and cava, to reconstruction with a vena cava vein patch, with an inverted Y-shaped iliac bifurcation, venous patches and reconstruction with arterial patch. We expose an alternative for the reconstruction of the outflow when we do not have the necessary graft for this type of reconstructions described. We present a case with a segment of short iliac vein and segment of common iliac artery with moderate atheromatosis as the only available grafts with which we made a new wide cuff that encompasses the area of the 3 ostiums of the hepatic veins and that we anastomose in bank surgery performing an end-to-end anastomosis on the anterior and posterior faces of the hepatic veins of the graft, thus ensuring the drainage.