Caval Cross-Clamping, Piggyback and Veno-Venous Bypass

  • David Hovord
  • Ruairi Moulding
  • Paul Picton


Liver transplantation has historically been associated with massive blood transfusion and major hemorrhage was considered routine. Surgical techniques have evolved in an attempt to reduce blood loss and reduce transfusion requirements. In this chapter we review the physiologic effects of caval cross-clamping and explore surgical options to safely establish hepatectomy and transplantation including piggyback technique and venovenous bypass (VVB).

Caval Cross-Clamping

The aim of caval cross-clamping is to eliminate hepatic outflow prior to hepatectomy. Traditionally two inferior vena cava (IVC) cross clamps are placed with one below the diaphragm and one above the renal veins. Resection of the recipient’s vena cava is achieved by dividing both the infra- and supra-hepatic vena cava. Transplantation of the donor organ therefore requires both supra and infra-hepatic caval anastomoses and complete caval occlusion occurs during the vast majority of the anhepatic phase.



Caval clamp Bypass circuit Piggyback Blood flow Anhepatic phase Reperfusion 


  1. 1.
    Costa MG, Chiarandini P, Della Rocca G. Hemodynamics during liver transplantation. Transplant Proc. 2007;39(6):1871–3.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Henriksen JH, et al. Reduced central blood volume in cirrhosis. Gastroenterology. 1989;97(6):1506–13.CrossRefPubMedGoogle Scholar
  3. 3.
    Carmichael FJ, Lindop MJ, Farman JV. Anesthesia for hepatic transplantation: cardiovascular and metabolic alterations and their management. Anesth Analg. 1985;64(2):108–16.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Lhuillier F, et al. Spontaneous baroreflex cardiac sensitivity in end-stage liver disease: effect of liver transplantation. Eur J Anaesthesiol. 2006;23(5):426–32.CrossRefPubMedGoogle Scholar
  5. 5.
    Schwarz B, et al. Liver transplantation without venovenous bypass: morbidity and mortality in patients with greater than 50% reduction in cardiac output after vena cava clamping. J Cardiothorac Vasc Anesth. 2001;15(4):460–2.CrossRefPubMedGoogle Scholar
  6. 6.
    Reich DL, et al. Association of intraoperative hypotension and pulmonary hypertension with adverse outcomes after orthotopic liver transplantation. J Cardiothorac Vasc Anesth. 2003;17(6):699–702.CrossRefPubMedGoogle Scholar
  7. 7.
    Valta P, et al. Pulmonary effects of caval clamping during liver transplantation without venovenous bypass in acute or chronic liver failure. Transplant Proc. 2001;33(4):2521–2.CrossRefPubMedGoogle Scholar
  8. 8.
    Schroeder RA, et al. Intraoperative fluid management during orthotopic liver transplantation. J Cardiothorac Vasc Anesth. 2004;18(4):438–41.CrossRefPubMedGoogle Scholar
  9. 9.
    O'Riordan A, et al. Acute renal disease, as defined by the RIFLE criteria, post-liver transplantation. Am J Transplant. 2007;7(1):168–76.CrossRefGoogle Scholar
  10. 10.
    Pham PTT, Pharn PCT, Wilkinson AH. Renal function outcomes following liver transplantation and combined liver-kidney transplantation. Nat Clin Pract Nephrol. 2007;3(9):507–14.CrossRefPubMedGoogle Scholar
  11. 11.
    Niemann CU, et al. Acute kidney injury during liver transplantation as determined by neutrophil gelatinase-associated lipocalin. Liver Transpl. 2009;15(12):1852–60.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Massicotte L, et al. Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations. Liver Transpl. 2006;12(1):117–23.CrossRefGoogle Scholar
  13. 13.
    Abdala E, et al. Bacterial translocation during liver transplantation: a randomized trial comparing conventional with venovenous bypass vs. piggyback methods. Liver Transpl. 2007;13(4):488–96.CrossRefGoogle Scholar
  14. 14.
    Reddy K, Mallett S, Peachey T. Venovenous bypass in orthotopic liver transplantation: time for a rethink? Liver Transpl. 2005;11(7):741–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Marcos A, et al. Functional venous anatomy for right-lobe grafting and techniques to optimize outflow. Liver Transpl. 2001;7(10):845–52.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Giglio MT, et al. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2009;103(5):637–46.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Karvellas CJ, et al. Outcomes and complications of intracranial pressure monitoring in acute liver failure: a retrospective cohort study. Crit Care Med. 2014;42(5):1157–67.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg. 1989;210(5):649–52.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Lerut J, et al. Cavocaval adult liver transplantation and retransplantation without venovenous bypass and without portocaval shunting: a prospective feasibility study in adult liver transplantation. Transplantation. 2003;75(10):1740–5.CrossRefGoogle Scholar
  20. 20.
    Mehrabi A, et al. A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti. Liver Transpl. 2009;15(5):466–74.CrossRefPubMedGoogle Scholar
  21. 21.
    Belghiti J, et al. Feasibility and limits of caval-flow preservation during liver transplantation. Liver Transpl. 2001;7(11):983–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Khan S, et al. Conventional versus piggyback technique of caval implantation; without extra-corporeal veno-venous bypass. A comparative study. Transpl Int. 2006;19(10):795–801.CrossRefPubMedGoogle Scholar
  23. 23.
    Nishida S, et al. Piggyback technique in adult orthotopic liver transplantation: an analysis of 1067 liver transplants at a single center. HPB (Oxford). 2006;8(3):182–8.CrossRefGoogle Scholar
  24. 24.
    Fonouni H, et al. The need for venovenous bypass in liver transplantation. Hpb. 2008;10(3):196–203.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Polak WG, Peeters PMJG, Slooff MJH. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant. 2009;23(4):546–64.CrossRefPubMedGoogle Scholar
  26. 26.
    Gurusamy KS, Pamecha V, Davidson BR. Piggy-back graft for liver transplantation. Cochrane Database Syst Rev. 2011;1:CD008258.Google Scholar
  27. 27.
    Belghiti J, et al. A new technique of side to side caval anastomosis during orthotopic hepatic transplantation without inferior vena caval occlusion. Surg Gynecol Obstet. 1992;175(3):270–2.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Shaw BW, et al. Venous bypass in clinical liver-transplantation. Ann Surg. 1984;200(4):524–34.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Shaw BW, et al. Advantages of venous bypass during orthotopic transplantation of the liver. Semin Liver Dis. 1985;5(4):344–8.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Grande L, et al. Effect of venovenous bypass on perioperative renal function in liver transplantation: results of a randomized, controlled trial. Hepatology. 1996;23(6):1418–28.CrossRefPubMedGoogle Scholar
  31. 31.
    Hilmi IA, Planinsic RM. Con: venovenous bypass should not be used in orthotopic liver transplantation. J Cardiothorac Vasc Anesth. 2006;20(5):744–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Barnett R. Pro: veno-veno bypass should routinely be used during liver transplantation. J Cardiothorac Vasc Anesth. 2006;20(5):742–3.CrossRefPubMedGoogle Scholar
  33. 33.
    Hoffmann K, et al. Is veno-venous bypass still needed during liver transplantation? A review of the literature. Clin Transplant. 2009;23(1):1–8.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of Michigan Medical SchoolAnn ArborUSA
  2. 2.Department of AnaesthesiaMusgrove Park HospitalXXXUK

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