Use of a Multilayered Stent for the Treatment of Hepatic Artery Pseudoaneurysm After Liver Transplantation

Abstract

To the Editor: We would like to use this opportunity to share with the wider clinical community our experience in managing a hepatic artery pseudoaneurysm (HAP) of a 59-year-old man after liver transplant using a multilayered stent. HAP is a rare but well-recognised complication occurring after orthotopic liver transplantation (OLT). The reported incidence is 0.3% to 2.6% [1, 2]. The majority of cases of HAP occurring after OLT arise in the context of endovascular intervention or secondary to diathermy injury to the artery during surgery [3]. They have also been reported to complicate other hepato-pancreatico-biliary surgical procedures [4]. With time, the natural history of HAP is of enlargement and an associated risk of rupture, which can be fatal [5]. Patients most commonly present with intraperitoneal bleeding or gastrointestinal haemorrhage secondary to haemobilia; however, incidental and asymptomatic HAP may be recognised [6]. Established management options include surgical ligation and endovascular coil embolisation; however, both of these methods are associated with a significant risk of hepatic ischaemia, which often requires retransplantation [5]. Coronary artery stent-grafts have also been used to treat HAP, often after failure of coil embolisation [7]. The introduction of the Multilayer Aneurysm Repair System (MARS) stent (Cardiatis SA, Belgium) is a recent development in endovascular aneurysm repair. This is an uncovered stent comprised of three-dimensional braided tubing that decreases blood flow velocity in the aneurysmal sac whilst improving laminar blood flow in the main artery and surrounding arterial tributaries [8]. Its use for the treatment of HAP occurring after OLT has not previously been reported. Our case involves a 59 year-old man who underwent OLT for alcoholic cirrhosis in January 2011. The patient’s main indication for OLT was recurrent ascites. A transjugular intrahepatic portosystemic shunt was inserted in November 2010 before emergency surgical repair of a ruptured umbilical hernia. He was transplanted in early January 2011. He received a whole liver from a 74-year-old brainstem-dead donor who was involved in a road-traffic accident. His hepatectomy was performed whilst he was on veno-venous bypass and was uncomplicated. The implantation included a cavocavostomy, end-to-end pulmonary vein anastomosis using 5.0 Prolene (Ethicon, UK) suture material, end-to-end arterial anastomosis to the common hepatic artery using 6.0 Prolene (Ethicon, UK) suture material, and duct-to-duct biliary anastomosis using 5.0 polydioxanone (Ethicon, UK) suture material. The cold ischaemic time was 12 h and 40 min. During surgery, he received 4 U of blood, 1 pool of platelets, and 6 U of fresh frozen plasma. His postoperative recovery was complicated by mild acute cellular rejection on day 10, which required augmentation with intravenous methylprednisolone. He was discharged home on day 16. His immunosuppression medication included tacrolimus, azathioprine, and prednisolone. Because he was a cytomegalovirus mismatch, vanganciclovir was given for 100 days. At 3 months after OLT, the patient was admitted to our hospital for investigation of graft dysfunction. Liver histology showed evidence of perivenular haemorrhage and A. M. Elsharkawy (&) G. Sen M. Hudson S. Masson D. M. Manas Liver Unit, Freeman Hospital, Freeman Road, Newcastle Upon Tyne NE7 7DN, UK e-mail: ahmede@doctors.org.uk