The great saphenous vein (GSV) is the longest vein in the human body. The GSV starts from the medial marginal vein of the foot, runs superficially along the length of the lower limb, to finally empty into the femoral vein. It drains the superficial structures of the medial thigh and leg. The autologous GSV has been frequently used as a coronary artery bypass graft (CABG) [1-4]. Because the GSV is long and narrow, its clinical applicability is limited in the field of living donor liver transplantation (LDLT). However, because of the extreme shortage of allograft vessels in Korea, its high availability has expanded its usage for various aspects of LDLT. We have accumulated experience on the use of an autologous GSV for LDLT since its first use for middle hepatic-vein drainage in 1998 [5]. In this study, we present our experience with an autologous GSV used in adult LDLT.

The left GSV has been preferentially approached to allow right femoral vein access for hemodialysis. The left inner thigh is draped for incision. The access point for harvesting the GSV is like that for femoral cannulation as a preparation for bio pump installation (Fig. 1). The GSV has many side branches that should be ligated. A single, long incision (up to 20 cm) is convenient for the surgeons, but less cosmetic for the patient. Skipped tunnel incision and an endoscopic approach are alternative ways to improve the cosmetic aspect [6]. The skin incision should be meticulously repaired with a suction drain because of the risk of lymphocele formation [7]. The harvested GSV is often dilated by hydraulic pressure to increase its diameter.

Figure 1. Gross photographs of the harvesting process of the left great saphenous vein. (A) The proximal insertion into the femoral vein is visible. (B) A poorly developed great saphenous vein is identified.

Use of Autologous Great Saphenous Vein As a Conduit for Middle Hepatic Vein Reconstruction

In our initial experience with LDLT using a modified right liver graft, we used the hydraulically dilated GSV conduit as an interposition graft for middle hepatic vein (MHV) reconstruction (Fig. 2) [5]. Because the GSV had a narrow diameter, it was no longer used for MHV reconstruction.

Figure 2. Gross photographs for application of the hydraulically dilated graft saphenous vein conduit used as an interposition graft for middle hepatic vein reconstruction. Three (A) and two (B) middle hepatic vein branches were reconstructed.

Use of Autologous Great Saphenous Vein As a Patch for Right Hepatic Vein Venoplasty

The right hepatic vein and the retrohepatic inferior vena cava join with an acute angle; thus graft right hepatic vein anastomosis with the recipient right hepatic vein stump is vulnerable to anastomotic stenosis. Removal of the graft hepatic vein that forms an acute angle is effective for making a wide anastomosis [8-10]. All available homologous and autologous vessel grafts have been used for patch venoplasty to widen the diameter of the graft outflow vein. In addition, the acute angle at the recipient right hepatic vein orifice is also removed by application of incision and patch venoplasty (Fig. 3). This combination of venoplasty for the right hepatic vein orifices markedly reduced graft outflow vein obstruction.

Figure 3. Gross photographs for incision-and- patch venoplasty at the graft right hepatic-vein orifice. (A) The caudal wall of the right hepatic vein was incised and a graft saphenous vein segment was attached at the vein wall defect. (B) The acute angle of the wall attached at the recipient right hepatic vein orifice was also removed by application of incision and patch venoplasty.

Use of Autologous Great Saphenous Vein As a Patch for Inferior Right Hepatic Vein Venoplasty

The GSV can be used to unify two separate inferior right hepatic vein branches with or without a central patch, which enables single anastomosis to the recipient vena cava (Fig. 4). Simple attachment of a central patch also can unify two short hepatic veins (Fig. 4) [11,12].

Figure 4. Illustration and gross photographs for unification venoplasty using great saphenous vein patches. Two inferior hepatic veins are unified without (A) and with (B) attachment of a central patch. RHV, right hepatic vein; IRHV, inferior right hepatic vein; MRHV, middle right hepatic vein; V5, segment V hepatic vein; V8, segment VIII hepatic vein.

Use of an Autologous Great Saphenous Vein As a Conduit for Portal Vein Reconstruction

A GSV segment can be attached to the graft portal vein orifice (shaped like an 8) to facilitate portal vein reconstruction (Fig. 5). A stack of two ring-shaped SGV segments can lengthen the recipient portal vein after excision of the damaged proximal portal vein stump (Fig. 6). Two separate graft portal veins can be unified by means of unification patch venoplasty using GSV patches (Fig. 7). A new Y-shaped vein graft can be made by means of a stack of multiple ring-shaped SGV segments (Fig. 8).

Figure 5. Gross photographs for a portal vein conduit to compensate for the figure of 8-shaped orifice. (A) The portal vein orifice appeared to be not suitable for direct anastomosis. (B–D) A graft saphenous vein segment was attached around the periphery of the portal vein stump.

Figure 6. Gross photographs for a portal vein conduit to compensate for the length of the recipient portal vein. (A) A stack of two ring-shaped graft saphenous vein segments was inserted. (B) This procedure provided a significant length for the recipient portal vein.

Figure 7. Gross photographs for unification of two graft portal veins. (A) Three small vein segments were attached. (B) Their three-dimensional suturing provided unification of two portal vein orifices.

Figure 8. Gross photographs for making a new Y-shaped vein graft. (A) Graft saphenous vein segments were sliced. (B, C) Multiple ring segments were made and combined to make a Y-shape. (D) This conduit was anastomosed to the recipient portal vein.

Making a Paneled Patch or Spirally Winded Conduit Using Great Saphenous Vein

Parallel longitudinal suturing makes two GSV patches twice as large, which can be used for quilt venoplasty (Fig. 9) [13]. Spiral winding of a long, narrow GSV segment converts it to a large-caliber vein conduit, which can used for MHV reconstruction. A GSV segment is wrapped around 1 to 10 mL plastic disposable syringe. A continuous running suture is applied until the first turn, and then the suture material should be transfixed to prevent a purse-string effect. The same suture material is used for next-turn suturing, and the transfixation suture is repeated. The spirally wound conduit is shortened depending on the original diameter of the GSV segment. Such an enlarged conduit can be used for LDLT as well as for hepatobiliary and pancreatic surgery [14].

Figure 9. Gross photographs for making a spirally winded conduit (A) and paneled patch (B) using a graft saphenous vein.

We have preferentially used the right gastroepiploic artery as an alternative for the recipient hepatic artery inflow during LDLT, but it was not always available. We reported a case of LDLT with hepatic artery reconstruction using an autologous GSV conduit because the right gastroepiploic artery had been transected by prior subtotal gastrectomy. We harvested a 6-cm-long GSV segment from the left ankle and interposed it between the recipient common hepatic artery and the graft hepatic artery (Fig. 10) [15].

Figure 10. Fig. 10 . Gross photograph for hepatic artery reconstruction using an autologous graft saphenous vein conduit (arrow).

The GSV is formed by the dorsal venous arch of the foot and the dorsal vein of the great toe. It ascends the medial side of the leg, passing anteriorly to the medial malleolus at the ankle and posteriorly to the medial condyle at the knee. As the vein moves up the leg, it receives tributaries from other small, superficial veins. The GSV terminates by draining into the femoral vein immediately inferior to the inguinal ligament. The GSV allows its harvest because the deep vein system can replace its role.

The autologous GSV has been frequently used for CABG [1-4]. It is harvested from the patients themselves, thus it is fresh and healthy. We have had extensive experience with the use of an autologous GSV for LDLT since its first use for MHV drainage in 1998 [5]. The clinically important problems of the autologous GSV are its small diameter and wound problem at the harvest site [16,17]. Deprivation of the superficial vein drainage at the inner thigh can result in local edema and lymphocele formation, which is often a serious surgical complication requiring treatment over 1–2 months. The skin incision of the donor GSV site should be meticulously repaired with a suction drain because of the risk of lymphocele formation.

The GSV has a small caliber, but its wall is thick and strong, and thus useful for CABG. We also reported a case of a GSV conduit as a hepatic artery replacement when other arterial sources, including the right gastroepiploic artery, were unavailable [15]. Unlike the rarity of a GSV conduit in our experience, a study from Pakistan reported 21 cases of LDLT using a GSV conduit; in these, hepatic artery thrombosis occurred in only one case (4.7%) [18]. This result was comparable to that in 452 cases using the native recipient HAs. The fact that GSV conduits were used in 4.4% of the LDLT cases indicates that the authors preferentially used GSV conduits instead of the right gastroepiploic artery. We think that such a preference for GSV conduits does not appear reasonable, although they have achieved good outcomes.

Endoscopic GSV harvesting has been also reported, because it can reduce the leg wound complications [16,17,19]. However, for LDLT, we have used the conventional open harvesting method, because GSV harvesting is a small part in the whole surgical procedure of LDLT and because the endoscopic method requires more time and effort.

To our knowledge, this study is the first collective review of autologous GSV usage in LDLT. Recently, the Korean Public Tissue Bank started to harvest the GSVs from deceased donors. Such availability of GSV must be beneficial to the patients, because it can avoid inguinal incision for GSV harvest. However, until now, its supply has been too limited to meet the demand for GSVs; so the autologous GSV is still the main source of vein patches used for adult LDLT in our institution. An autologous GSV cannot be used for pediatric patients, because they cannot provide GSVs of the right size.

In conclusion, the autologous GSV is a useful vascular material for LDLT in the forms of the vein segment itself, a paneled vein patch, a ring-shaped or spirally winded vein conduit.

There was no funding related to this study.

All authors have no conflicts of interest to declare.

Conceptualization: TYH, SH, DHJ. Data curation: SH, CSA, DBM, DHJ, GCP. Methodology: All. Visualization: SH. Writing - original draft: TYH, SH, CSA, DBM, DHJ, GCP. Writing - review & editing: TYH, SH.