Severe Outflow Obstruction After Liver Transplantation: Rescue Stapled Cavo-Cavostomy Via The Right Atrial Approach And Hypothermic Circulatory Arrest

Late vena cava/hepatic outflow obstruction after orthotopic liver transplantation (OLT), while rare, is among the most challenging complications. The cause may be an organized thrombus, reactive edema, fibrosis/scarring with calcification, or neointimal hyperplasia. Moreover, the obstruction can involve different anatomical parts of the vena cava. Surgical approaches have classically included anastomotic revision, hepatopexy, thrombectomy, cavoatrial shunt, and retransplantation. We present a case report of an innovative approach to combined inferior vena cava (IVC)/hepatic outflow obstruction in a 62-year-old female who underwent OLT using a piggyback technique for end-stage liver disease secondary to hepatitis C virus and alcohol, approximately 10 months post-transplant. A right atrial approach and hypothermic circulatory (cardiac) arrest were employed. The IVC stricture was easily resolved by performing a side to side cavo-cavostomy using an endovascular stapler (endo-GIA). In conclusion, this innovative approach is safe and effective in resolving severe outflow obstruction after liver transplantation.