Is that the IVC?

Hey everyone,

Here is an interesting POCUS finding to be aware of!

A patient is admitted to you with a PMH of hypertension, NASH cirrhosis s/p deceased donor liver transplant (piggy back surgical approach), and diabetes. You look to perform a POCUS exam. When looking at the inferior vena cava in the subcostal window, you obtain these images.

What do you think each structure is, labeled 1, 2 & 3.

Please post your thoughts/ comments/ answers and I will weigh in next week.

 

Comments (3)

Jason Moore, MD
says:

1) Donor hepatic vein
2) Surgical confluence of donor hepatic veins/IVC, that is connected by a side to side anastomosis of...
3) Recipient IVC

At least I think that's what it is based on piggyback technique. Cool clips! - JM

Clermont
says:

Presumption is that structure #2 is likely the donor IVC with structure #1 a hepatic vein. The side-to-side anastomosis of the donor IVC with the recipient IVC may be compromised with clot of narrowing of the recipient IVC and unclear continuity between the donor and recipient IVC's. Altogether, it would be interesting to know what one was looking for in doing an IVC interrogation. The distorted anatomy will compromise interpretation.

Hey everyone,

Thank you for all the comments on this post! GREAT identification of some post-surgical anatomy.

Here are my thoughts:

Based on the piggyback approach, where a portion of the donor IVC is transplanted with the liver. The caudal portion is ligated, creating a pouch. This approach is an alternative to veno-venous bypass during the procedure. Further details are found in this great article (Note Figure 2 in relation to these images):

Eghtesad B, Kadry Z, Fung J. Technical considerations in liver transplantation: What a hepatologist needs to know (and every surgeon should practice). Liver Transplant. 2005;11(8):861-871. doi:10.1002/lt.20529

Based on what we are seeing in these clips/ images, 1 is a suprahepatic vein, 2 is the donor infrahepatic IVC and 3 is the recipient’s IVC.

Given the challenges of using the IVC for clinical data, combined with these alterations from this surgical approach, it is completely unclear if/ how any information should be used from this for assessing a patient’s CVP/RAP, Collapsibility Index/ Distensibility Index. However, I thought it would be of value to share to be able to recognize what you are seeing in the case of caring for a patient s/p OLTx with a piggy-back surgical approach!

If you have any interesting findings or cases with POCUS you would like to share via this blog, please let me know!

-Christopher

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