Re-appropriation of a right anterior thoracotomy approach to portal-systemic bypass for liver transplantation in a patient with complete superior vena cava occlusion

The utilization of venovenous bypass in liver transplantation (LT) has become less frequent and more center dependent over time. Unfortunately, this has left many transplant surgeons, particularly younger trainees, unfamiliar with the techniques and indications for its utilization. We present a case of LT in a patient with complete superior vena cava (SVC) occlusion prohibiting direct vascular access. A multi-disciplinary approach involving interventional radiology, anesthesiology, cardiac surgery, and transplant surgery, was used to diagnose, evaluate, and develop an operative plan for successful LT. In doing so, a novel approach to portosystemic bypass was utilized involving a right mini-thoracotomy with direct cannulation of the right atrium to gain central venous access and optimize venous return during LT. As a center that does not routinely use venovenous bypass, this multidisciplinary approach was crucial identifying the need for a rarely used technique for vascular access and performance of a successful LT.