Background: It has been reported that ex vivo benching and prolonged ischemia time may endanger liver graft viability.This is a case of orthotopic liver transplantation (OLTx) of an ex situ hepatectomized liver graft and the successful point-of-care haemostatic management with rotational thromboelastometry (ROTEM). 
Case report: A 45y old man with alcoholic cirrhosis (MELD score 16, conventional haemostatic profile ΙΝR 1.8, PT 19.9s, APTT 50.7s, Fib 1.94 g/L and PLTs 105000 µ/l), underwent a successful OLTx. The peculiarity of the case lies at the fact that during graft removal from the donor, an exceptional left liver lobe perfusion was noted through a separate ectopic hepatic artery rising directly from the aorta (rare anatomic variation, 1.6%). The endothelium of this specific vessel being “fractured” led to an extended graft hepatectomy of the depended liver segments (I, II and III) performed on the bench, just before transplantation. This excision produced an extended surface where no surgical haemostasis was feasible ex vivo. Baseline Hbg was 10.5g/dl and by the end of the operation 9.3g/dl after 2 PRBCs transfusion. Cold ischemia time was 10 hrs, anhepatic phase lasted 2,5 hours, reperfusion was uneventful, total OLTx duration was 6 hrs. Early graft function was relatively sufficient with mild cholestasis but no signs of “small-for-size syndrome”. After prolonged ICU stay due to difficult weaning he was discharged to the ward tracheostomized, but in good general state. Intraoperative haemostatic management was accomplished with ROTEM following a published algorithm (Goerlinger K,2006). 
Discussion: Platelet transfusion has been related to hypercoagulative danger and increased mortality in OLTx patients. In late anhepatic phase insignificant mild diffuse bleeding was noted (CTEXTEM 176s, A5EXTEM7mm, MCFEXTEM14mm). No platelets were transfused, although this should be considered. Fibrin substrate enhancement was chosen instead (1500U PCC). In neohepatic phase, without bleeding, ROTEM showed CTEXTEM 97s & A5EXTEM23mm. Again, no platelets were transfused while 1g Fibrinogen concentrate was given to enhance clot strength. No sign of hyperfibrinolysis was noted (LI30EXTEM100%).
Learning points: This is the first case of ex situ hepatectomy just before OLTx in our centre. Point-of-care haemostatic management combined with close clinical evaluation of surgical bleeding nature contributed successfully to safe decision making in the management in this rare case.

Point-of-care haemostatic management in orthotopic liver transplantation of an ex situ hepatectomized liver graft