Children who require liver transplantation far outnumber the available deceased-donor livers each year. This shortage leads to prolonged wait times and, particularly among infants younger than one year, a waitlist mortality rate more than twice as high as that of older pediatric patients.
Offering technically variant grafts (TVGs) – partial liver grafts – instead of whole-liver grafts alone helps close this mortality gap by expanding use of the thousands of adult donor livers available annually. However, TVG procedures demand specialized surgical expertise, and only about 10 pediatric liver transplant centers in the United States routinely perform them.
In October 2024, Children’s Medical Center Dallas, part of Children’s HealthSM, began offering TVG, primarily through in-situ split liver procurement whenever feasible. Since then, the team has completed eight such transplants. Prior to this capability, many patients would have had to travel out of state or continue waiting. One child, for example, spent more than a year awaiting a whole liver but received a partial graft almost immediately once the TVG option became available.
“TVG enables our program to transplant more patients, more quickly, by a very wide margin,” says Yong Kwon, M.D., Chief of Pediatric Abdominal Transplantation and Pediatric Transplant Surgeon at Children’s Health, and Associate Professor at UT Southwestern. “If more centers were able to provide this option, waitlist times could be significantly reduced, leading to fewer children dying while awaiting transplant.”
TVG is rare because it’s complex
Of the roughly 500-550 pediatric liver transplants performed annually nationwide, only about 20% involve TVGs. The primary barrier is surgical complexity. The small size and triangle shape of the left lateral segment of the donor liver, which is commonly used for small pediatric recipients, requires carefully securing the liver to allow blood vessels in very particular ways among many others. These technical challenges contributed to inferior outcomes in the early days of TVG compared to whole-liver transplantation.
“Now, with greater experience, research shows that outcomes for TVG are comparable to whole-liver grafts – provided the procedure is performed by centers that routinely practice it,” says Dr. Kwon.
Offering TVG had an immediate impact in Dallas
Dr. Kwon previously trained and practiced at two other high-volume TVG centers before joining Children’s Health. When he arrived, the Pediatric Liver Transplant Program averaged seven transplants per year, using only whole-liver grafts.
In his first 10 months, the program performed 20 transplants – 40% of them TVGs, double the national average. During that time, the number of patients on the transplant waitlist decreased from 19 to six.
One unique advantage of split liver procurement is its dual impact: a single donor liver can save two lives – typically one child and one adult. “Our program is integrated with the adult transplant program at UT Southwestern, allowing us to maximize each gift of life and ensure no part of the organ goes unused,” says Amal Aqul, M.D., Medical Director of the Pediatric Liver Disease Center and Liver Transplant Program at Children’s Health, and Associate Professor at UT Southwestern.
Case study: Life-saving TVG after delayed biliary atresia diagnosis
A four-month-old infant was referred to Children’s Health with hyperbilirubinemia, pale stools, and other concerning symptoms. She was diagnosed with biliary atresia, and the team promptly performed a Kasai procedure. Unfortunately, bile flow was not adequately restored, and she was subsequently listed for liver transplantation.
She waited a year and a half for a whole-liver graft, developing complications such as ascites during that time. In October 2024, Children’s Health began offering TVG, and just one month later – shortly before her second birthday – a partial graft became available.
Dr. Kwon traveled 250 miles to the donor hospital to perform the in-situ split liver procurement.
“Occasionally, we see unexpected findings – such as anomalous vascular anatomy or fatty liver – that make a split surgery unfeasible,” he explains. “The success of any liver transplant begins with meticulous donor liver selection and precise procurement.”
Upon his return to Dallas, the child underwent transplantation with a 30% portion of the donor liver, while the remaining segment was transplanted into an adult patient at UT Southwestern. The surgery was uneventful, and her parents noticed she was more verbal and energetic immediately after awakening – “as if a switch had been flipped.”
The child experienced an early rejection episode, which is no more common with TVG than with whole-liver grafts. After adjustments to her immunosuppressive regimen, she has had no further complications.
“Today she is a vibrant and happy toddler – as she should be,” says Dr. Aqul.
Training and policy can make TVG more available
The first in-situ split liver procurement in the U.S. occurred in 1997, yet the technique remains underutilized. With only about 100 split-liver procedures performed annually in the U.S. –concentrated at a small number of centers – trainee surgeons often lack the exposure and experience needed to develop proficiency.
“We must expand training opportunities so that more pediatric centers can offer this life-saving procedure,” says Dr. Kwon.
Policy changes could also accelerate adoption. Italy and the United Kingdom, for example, prioritize splitting healthy deceased-donor livers and favor pediatric recipients in allocation. In Italy, these changes reduced median pediatric waitlist time from over 200 days to about 80 days, with a corresponding decline in mortality.
“TVG has transformed the paradigm for our program,” says Dr. Aqul. “Children everywhere deserve the same opportunity.”
Learn more about advancements in pediatric gastroenterology at Children’s Health.
