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Not All Piggybacks Are Equal: A Retrospective Cohort Analysis of Variation in Anhepatic Transcaval Pressure Gradient and Acute Kidney Injury During Liver Transplant

Oliver, CM; Fabes, J; Ingram, N; Rahman, S; Krzanicki, D; Spiro, M; (2021) Not All Piggybacks Are Equal: A Retrospective Cohort Analysis of Variation in Anhepatic Transcaval Pressure Gradient and Acute Kidney Injury During Liver Transplant. Experimental and Clinical Transplantation , 19 (6) pp. 539-544. 10.6002/ect.2021.0050. Green open access

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Abstract

Objectives: Complete inferior vena cava clamping in caval replacement during liver transplant is associated with substantial physiological derangement and postoperative morbidity. Partial clamping in the piggyback technique may be relatively protective, but evidence is lacking. Having observed substantial variation in transhepatic inferior vena cava pressure gradient with piggyback, we hypothesized that the causative mechanism is the extent of caval clamping rather than the surgical approach. Materials and Methods: We used internal jugular and femoral catheters to estimate suprahepatic and infrahepatic inferior vena cava pressures during clamping. Pressure gradients were calculated, and distributions were compared by surgical technique. We estimated adjusted odds ratios for pressure gradient on acute kidney injury at 72 hours. Results: In 115 case records, we observed substantial variation in maximum pressure gradient; median values were 18.0 mm Hg (interquartile range, 8.0-25.0 mm Hg) with the piggyback technique and 24.0 mm Hg (interquartile range, 19.5-27.0 mm Hg) with caval replacement. Incidence of acute kidney injury was 25% (29 patients). Pressure gradient was linearly associated with probability of acute kidney injury (odds ratio, 1.06; 95% CI, 1.01-1.13). Conclusions: We report 2 novel findings. (1) Anhepatic inferior vena cava pressure gradient varied substantially in individuals undergoing piggyback, and (2) gradient was positively associated with early acute kidney injury. We hypothesize that this (unmeasured) variation explains the conflicting findings of previous studies that compared surgical techniques. Also, we propose that caval pressure gradient could be routinely assessed to optimize real-time piggyback clamp position during liver transplant surgery.

Type: Article
Title: Not All Piggybacks Are Equal: A Retrospective Cohort Analysis of Variation in Anhepatic Transcaval Pressure Gradient and Acute Kidney Injury During Liver Transplant
Open access status: An open access version is available from UCL Discovery
DOI: 10.6002/ect.2021.0050
Publisher version: http://dx.doi.org/10.6002/ect.2021.0050
Language: English
Additional information: This version is the author accepted manuscript. For information on re-use, please refer to the publisher’s terms and conditions.
Keywords: Anhepatic inferior vena cava pressure gradient, Caval replacement, Clamp position, VENA-CAVA, COMPLICATIONS, PRESERVATION, FREQUENCY, BYPASS
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences > Div of Surgery and Interventional Sci
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences > Div of Surgery and Interventional Sci > Department of Surgical Biotechnology
URI: https://discovery.ucl.ac.uk/id/eprint/10131012
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