Highlights

  • Although not traditionally accepted as a viable central access during liver transplant, this case illustrates that in certain situations femoral central access can be successful

  • When dealing with patients who require constant vascular access from a very early age, potential large vein thromboses should be considered

  • Thromboprophylaxis initiation should be considered at a very early stage

Abstract

Background: This case describes a 23-year-old male who presented for a fifth liver transplant having previously undergone 4 liver transplants as a child. Vascular access had long been a challenge. Liver cirrhosis can result in both hypo- and hypercoagulable states with thrombus formation being a common occurrence. The patient had been subjected to numerous major operations, infections, immunosuppression, and gastrointestinal failure resulting in multiple and prolonged intensive care unit stays. In early adulthood, the patient's fourth liver was failing. This necessitated a fifth liver transplant.

Complications: Liver transplant ideally requires a suprahepatic large-bore catheter for rapid blood loss replacement and in the context of vena cava clamping. In terms of vascular access, the patient had occlusion of both the jugular and subclavian veins, as well as 1 femoral vein. To complicate matters further the suprahepatic vena cava was stenotic and right atrium access had been used in the past.

Method: On the day of the liver transplant, it was necessary to use the right femoral site because it was the only available route of central access. Despite the long and technically complex procedure, the patient recovered rapidly. The patency of the femoral vein was maintained for 2 years after this liver transplant through use of thromboprophylaxis.

Conclusions: This is a rare case report describing a situation in which suprahepatic vascular access for rapid infusion was unavailable. It demonstrates the need to perform a thorough risk-benefit assessment. It also demonstrates that there are times when options are so limited that few or only 1 solution is available. This case showed that although not traditionally accepted as a viable means of central access during liver transplant, in certain situations femoral central access can be successful. It also clearly highlights the need for early and meticulous thromboprophylaxis.

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