Human acellular dermal matrix for middle hepatic vein reconstruction in living donor liver transplantation: a prospective feasibility and safety study

Background: During living donor liver transplantation (LDLT), middle hepatic vein (MHV) reconstruction requires a conduit that preserves early venous outflow while avoiding late device-related complications typical of synthetic grafts. We evaluated human acellular dermal matrix (ADM) as an off-the-shelf biological conduit. Methods: In a prospective single-center cohort (2022–2025), adults undergoing LDLT with MHV reconstruction using ADM ( n = 40) were followed. Outcomes were benchmarked against historical controls using Hemashield ( n = 40) or polytetrafluoroethylene (PTFE; n = 20). Primary endpoints were early-phase patency (≤6 months) and major structural complications. Two blinded radiologists independently reviewed serial Doppler ultrasonography and contrast-enhanced computed tomography with consensus adjudication. Patency was estimated by Kaplan–Meier and compared with the log-rank test. Results: ADM achieved excellent early patency [95.0% (83.5–98.6) at 3 months; 85.0% (70.9–92.9) at 6 months]. At 18 months, patency was 62.5% for ADM versus 50.0% (PTFE) and 47.5% (Hemashield) (log-rank P = 0.785). No ADM graft required re-intervention, and no graft infection or duodenal invasion occurred (0/40 vs 2/60 [3.3%] in synthetic cohorts). Baseline characteristics were comparable. Case review showed that several ADM occlusions were associated with large bilomas, where secondary infection rather than intrinsic graft failure likely triggered thrombosis. Conclusions: ADM is a feasible and safe biological conduit for MHV reconstruction, delivering robust patency throughout the critical period of graft regeneration while avoiding catastrophic complications observed with synthetic materials. These hypothesis-generating results support a randomized trial and introduce the concept of ADM as a temporary biological scaffold. Given its excellent early patency and safety profile, ADM should be considered a valuable addition to the surgical armamentarium with potential to redefine success in venous reconstruction.