Effectiveness of Protocol Doppler Ultrasonography in Salvaging Grafts in Post Orthotopic Liver Transplant Patients

Abstract

Background: Hepatic Artery Thrombosis (HAT) is a devastating complication that most commonly arises in post-orthotopic liver transplant (OLT) patients in the first one week after transplantation. But, HAT is also seen after that period. It commonly results in high mortality and graft loss and in many cases requires re-transplantation. Protocol Doppler ultrasonography (DUSG) has been proven to be a sensitive and inexpensive tool in the early detection of HAT and in salvaging grafts; hence, reducing the chance of undergoing a re-transplantation. Methods: Retrospective analysis of 279 cases of OLT both from deceased and living donors performed at a single private institution between March 2008 and October 2013. All the patients underwent DUSG intraoperatively after completion of vascular anastomosis. The first 5 post-operative days was the protocol period when DUSG was performed once every day and it was also performed once on the day of discharge. Further thrombosis detected through DUSG was confirmed by a CT angiography. After thrombectomy revascularization with native vessels or aortic conduit was attempted. This study evaluated the duration for detection of HAT, clinical correlation, surgical procedures, graft salvage and mortality rate. Results: Totally 11 patients out of 279 (4%) were diagnosed with HAT through DUSG. Out of the 11, 5 patients (45%) were diagnosed during the protocol period. Out of the 5 patients, 4 patients underwent revision anastamosis and 1 patient was conservatively managed with anti-coagulants. Six patients developed HAT within a period of 9-34 days after transplantation with a mean of 16 days. Five patients underwent re-exploration and 1 patient who also presented with biliary ischemia underwent re-transplantation. The results for liver function tests were normal or within appropriate levels for all the patients in the protocol period. Also, during that period they were asymptomatic. Nine patients (81%) at the time of discharge had normal liver function and arterial flows. 3 patients 19% who were diagnosed with HAT after the protocol period were critically ill due to sepsis and other issues. They were listed for re-transplantation but succumbed before it was performed. Conclusion: The rate at which HAT was presented in patients who underwent OLT in the specified period at our institute was 4%. It is evidently within the range reported in literatures. DUSG protocol screening was effective in identifying arterial flow abnormalities before clinical or biochemical manifestation and resulted in salvaging 5 out of 5 grafts 100% during the protocol period with good overall outcome.