Autologous Saphenous By-Pass as Treatement of the Hepatic Artery Pseudoaneurym in Liver Transplant Recipients

Abstract

Background: The incidence of hepatic artery pseudoaneurysm (HAP) is 1 to 2% of liver transplantation (LT) patients. The mortality associated with pseudoaneurysm formation following LT been reported to be as high as 69%. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. This article discusses the presentation, etiology, treatment indications, and the vascular procedure used to manage these complications. Patients and methods: From 2003 to 2011, 454 LTs were performed in our institution. Of these, 8 (1,7%) patients underwent vascular procedure to treat HAP after LT, 7 male and 1 female with a median age of 59.5 years (range, 46-68). Three patients underwent TACE before LT for HCC. In all cases a revascularization with autologous saphenous patches was performed. Results: Three patients revealed the pseudoanuryms as a rupture with bleeding, in others 5, the HAP were diagnosed during the normal followup. The diagnosis was made with a CT-scan in all cases, confirmed with a standard angiography in 3 cases. The median delay between the LT and the HAP diagnosis was 36 days (range, 28-125). All were extraepatic located. All patients had a T-Tube. The median diameter of the HAP was 1.2 mm (range, 1.0-1.4). In 6 cases a bile leakage was associated and in the remnants 2 a candidiasis (Candida Glabrata) was founded at the histologic analisys. One patient was re-transplanted due to ischemic cholangitis. At 5-years follow-up 4 patients had a normal arterial anatomy, the others 3 patients had a by-pass stenosis but with a normal liver function. One patients died 3-yrs after LT due to HCC recurrence. Discussion: Limited and debated literature suggests that stenting of HAP during acute hemorrhage can be successfully performed. Surgical intervention near the hepatic vessels at long-term posttransplantation is a major procedure and can be complicated due to the presence of a large number of intraabdominal adhesions related to the previous transplant. The revascularization of the artery also presupposes a brief period of ischemia. Our results suggest a high succeful rate of the surgical procedure as a saphenous by-pass. In conclusion, our experience strongly support the surgical revascularization as treatment of choice in case of extrahepatic HAP at high risk of rupture or ruptured.