Venous reconstruction in living donor liver transplantation: lessons learned from a new national program in a resource-limited setting

Complex venous outflow reconstruction in living donor liver transplantation (LDLT) is technically demanding, particularly in resource-limited settings lacking consistent access to synthetic or cryopreserved grafts. We retrospectively analyzed 45 consecutive LDLTs performed during the initiation of a national program. Venous anatomy was evaluated using preoperative CT volumetry and intraoperative findings. Reconstruction strategies included direct anastomosis, unification venoplasty, PTFE grafts, and autologous conduits (falciform ligament, umbilical vein). Outcomes were compared between patients with (n = 17) and without (n = 28) venoplasty. Additional venous reconstruction was required in 37.8% of cases. In 6.7%, anatomically indicated veins could not be reconstructed due to lack of suitable conduits. No early venous thrombosis occurred, and all autologous conduits remained patent during follow-up. Small-for-size physiology developed in 11.1% of recipients, resolved conservatively, and was not associated with unreconstructed major veins. Major morbidity (Clavien-Dindo ≥ IIIb) occurred in 42.2%. The 90-day mortality rate was 11.1%, and 3-year survival was 82.2%, without significant differences between groups. In a newly established program within a resource-limited setting, predominantly autologous venoplasty was feasible and provided satisfactory early and mid-term outcomes.