The management of hepatic artery complications in liver transplantation

Abstract

11 liver transplant units are acutely aware of their hepatic artery thrombosis rate because this complication can lead to the most devastating of consequences. The reported rates from different series vary between 7%’ and 45%.2 In general, the true incidence of hepatic artery thrombosis is probably higher than is reported because a proportion of cases are silent, being only identified if asymptomatic recipients are subjected to angiography. This was done by Hesselink et al,3 who reported a total incidence of hepatic artery thrombosis of 20%, a quarter of these asymptomatic. Most programmes view hepatic artery thrombosis as a technical failure, but a miriad of different risk factors have been implicated. Not surprisingly, an increased incidence has been reported with paediatric recipients in which the vessel sizes are small’~2~~7 with small being defined as under 3 mm in diameter producing increased risk.7 Some groups, particularly the Japanese, address this problem by using an operating microscope to minimise the risks.* Complex vascular anastomoses are another risk factor, with the lowest risk seen with single arterial supply (5.4%), but the incidence increases to 24% with dual donor arterial supply. I$ The site at which the anastomosis is constructed is also relevant with a distal arterial anastomosis to the native hepatic artery having a higher risk than the more proximal anastomosis to the bifurcation with gastroduodenal artery.g Not surprisingly, another group7 identified the requirement of an arterial anastomosis reconstruction also as a risk factor. Postoperative anticoagulation was also identified, the absence of heparin in postoperative care increasing the relative risk of thromboses by 8.6 times.7 However, not many programmes adopt the Pittsburgh group’s recommendation for anticoagulation prophylaxis against hepatic artery thrombosis.7 This includes dextran 40 starting intra