Deep hypothermia with circulatory arrest to aid in the management of suprahepatic vena cava stenosis after liver transplantation

Liver transplantation is the treatment of choice for many liver diseases in the pediatric population. Complications involving late suprahepatic vena cava obstructions after liver transplantation are not common, but they tend to be more frequently seen in pediatric recipients. When such complications have occurred, approaches involving direct abdominal surgery or interventional radiology guidance have been used with satisfactory results. We present a case report of an alternative approach to a suprahepatic vena cava complication. An 18-year-old man who underwent pediatric liver transplantation for biliary atresia presented with a symptomatic total occlusion of the suprahepatic caval anastomosis that could not be crossed with a wire. We used a right atrial approach and hypothermic circulatory (cardiac) arrest. The anastomotic stricture was easily identified and excised. The postoperative course was uneventful with a rapid resolution of the symptoms. Because the occlusion was not amenable to angioplasty or stenting, a direct surgical approach was necessary. The right atrial approach with hypothermic cardiac arrest gave us direct access to the obliterated cavoatrial anastomosis through a virgin area and allowed us to avoid the difficulties and dangers of the large collaterals in the abdomen.