Hepatic Artery Complications Research Articles

Impact of middle hepatic artery reconstruction after living donor liver transplantation using the left lobe.

The aim of this study was to clarify the impact of middle hepatic artery reconstruction on the outcomes of duct-to-duct biliary anastomosis after living donor liver transplantation (LDLT) using the left lobe. Among 258 patients who underwent LDLT using the left lobe, 216 patients who underwent hepatic artery reconstruction and one hepatic duct reconstruction with duct-to-duct interrupted anastomosis were divided into three groups: Group A (n=123), one arterial stump with left hepatic artery reconstruction; Group B (n=32), two arterial stumps with only left hepatic artery reconstruction; and Group C (n=61), two arterial stumps with reconstruction of the left and middle hepatic arteries. The outcomes after LDLT were compared among the three groups. No hepatic artery complications occurred. Group B had a significantly greater incidence of anastomotic biliary stricture than Group C. A multivariate analysis with Cox regression revealed that being in Group B was the only significant independent risk factor for postoperative anastomotic biliary stricture after LDLT. Middle and left hepatic artery reconstruction is safe in LDLT and may prevent biliary stricture caused by dual hepatic artery reconstruction when the graft has left and middle hepatic artery stumps.

Endovascular Therapy of Arterial Complications Within the First Week After Liver Transplant

BackgroundRecent radiologic advances have made endovascular treatment a very successful option for arterial complications after liver transplant. This article presents our experience of using endovascular treatments during the first week after liver transplant. MethodsThis study is a retrospective, single-center analysis. Liver transplants performed between 2010 and 2018 were analyzed. All patients underwent Doppler ultrasonography on days 1 and 7. Endovascular therapy was indicated in hepatic artery thrombosis diagnosed early after transplant and in stenosis when hepatic narrowing was > 70%. Patients were treated with subcutaneous anticoagulant therapy and with antiplatelet agents after endovascular therapy. ResultsSeven patients (1.1%) were included in the study. Stenosis was the reason in 5 patients while 2 patients had symptoms of thrombosis. The first 2 patients were initially treated with angioplasty; both had restenosis and were treated with angioplasty and stent placement, respectively. The 5 most recent patients received stenting as a primary treatment. Two of these patients developed a new stenosis. No patient developed any hepatic artery complication related to the procedure, and only 1 patient experienced a postprocedure complication (femoral artery pseudoaneurysm), which was managed conservatively. No patient required retransplant. After a median follow-up of 48 months (range, 35-85 months) 1 patient had died, and the rest were alive and asymptomatic. ConclusionsAlthough there is scant experience of the use of endovascular therapy very shortly after liver transplant, recent advances in interventional radiology have made the technique feasible and safe, and it achieves a high success rate.

3:36 PM Abstract No. 302 Effect of bridging locoregional therapy on hepatic arterial complications following liver transplant: 3-year, multicenter, retrospective analysis of 608 patients

Recent studies have suggested a relationship between intra-arterial therapy and the development of HAS following orthotopic liver transplant (OLT). This study evaluates the role of pretransplant locoregional therapies on post-OLT HAS. An IRB-approved, multicenter, retrospective analysis was performed on all patients who underwent liver transplant from January 2, 2016, to December 30, 2018 (n = 608). Patients undergoing locoregional therapy were identified, which was determined based on consensus review of a multidisciplinary liver conference for patients with hepatocellular carcinoma (HCC) and included DEB-TACE (100-300μ LC Beads mixed with doxorubicin), Yttrium radioembolization segmentectomy (TheraSphere), and thermal ablation. Additional treatments were performed as deemed necessary, based on incomplete response, with the majority of patients (n = 96) receiving 1-2 treatments. Patients were surveyed with doppler ultrasound at 1 day, 1 week, 1 month, and 3 months following orthotopic liver transplant (OLT). HAS was suspected based on findings of elevated hepatic artery velocity with downstream intrahepatic artery tardus parvus waveforms and low resistive indices and confirmed angiographically in all patients. Of the 608 patients who were transplanted during the 3-year cohort, 145 patients had HCC, and intra-arterial bridging therapy was performed on 126 patients (115 TACE, 5 Y90, and 6 TACE and Y90). Following OLT, 78 patients (13%) developed HAS. Fewer rates of HAS were noted in patients with HCC (12/145 [8.3%] vs. 66/463 [14.3%], P = 0.05). Similarly, fewer rates of HAS were encountered in patients bridged with intra-arterial therapy (10/126 [8%] vs. 68/482 [14.1%], P = 0.06). Additionally, patients who were treated with thermal ablation prior to liver transplant also had lower rates of HAS (1/24 [4%] vs. 77/584 [13%], P = 0.03). However, MELD scores at the time of liver transplant were associated with the development of HAS (P = 0.001). Intra-arterial therapy is not associated with the development of HAS following OLT; however, underlying liver disease appears to be associated with the development of HAS.

Living Donor Liver Transplantation for Perihilar Cholangiocarcinoma: Outcomes and Complications

Neoadjuvant therapy and liver transplantation is an effective treatment for perihilar cholangiocarcinoma (pCCA). Living donor liver transplantation (LDLT) addresses the problem of organ shortage, but has higher risk of technical complication that can be aggravated by radiotherapy. We investigated the incidence of vascular and biliary complication in pCCA compared with non-pCCA patients and their impact on patient and graft survival. All consecutive LDLTs (n= 247) performed between 2000 and 2017 were reviewed, including demographics, donor variables, operative details, and postoperative outcomes. Logistic regression models were used to investigate the relationship between variables and outcomes. Seventy-four LDLTs (30.0%) were performed for pCCA and 173 for other indications. Forty-nine patients (66.2%) had primary sclerosing cholangitis-associated pCCA; the remainder had de novo pCCA. LDLT for pCCA was associated with nonstandard arterial (p= 0.001) or portal vein reconstruction (p < 0.001) and Roux-en-Y choledochojejunostomy (p < 0.001). The incidence of early hepatic artery thromboses was similar (5.4% vs 7.6%; p= 0.54). Late hepatic artery (18.9% vs 4.1%; p < 0.001) and portal vein (37.8% vs 8.7%; p < 0.001) complication was more common in the pCCA group. Anastomotic biliary complications occurred in 39.2% vs 54.1% (p= 0.032) of patients. Overall survival for pCCA at 1, 5, and 10 years was 84.9%, 66.5%, and 55.6%, respectively. Cancer recurred in 12.3%. Residual tumor on explant prognosticated inferior survival (hazard ratio 5.69; 95% CI, 1.97 to 16.35) and vascular and biliary complications did not. Late vascular complication is common after LDLT for pCCA, but do not adversely affect long-term survival. LDLT provides excellent survival, particularly for patients with no residual disease at the time of transplantation.

Vascular Complications After Liver Transplantation.

Vascular complications after liver transplant can be lethal. High levels of suspicion and aggressive use of diagnostic tools may help with early diagnosis and treatment. Here, we share our experiences regarding this topic. Adult and pediatric patients who had liver transplant between February 1997 and June 2018 in our clinic were included in the study. Patients were grouped according to age (pediatric patients were those under 18 years old), male versus female, indication for transplant, type of liver transplant, type of vascular complication, treatment, and survival aftertreatment.We analyzed the statistical incidence of vascular complications according to age, male versus female, and type of liver transplant. Our analyses included 607 liver transplant procedures, including 7 retransplants, with 349 (57.4%) from living donors and 258 (42.6%) from deceased donors. Of total patients, 539 were adults (89.8%) and 61 were children (10.2%). Vascular complications occurred in 25 patients (4.1%), with hepatic artery complications seen in 13 patients (2.1%) (10 adults [1.8%] and 3 children [4.9%]), portal vein complications seen in 9 patients (1.5%) (6 adults [1.1%] and 3 children [4.9%]), and hepatic vein complications seen in 3 patients (0.5%) (2 adults [0.36%] and 1 child [1.6%]). Rate of vascular complications was statistically higher in pediatric patients (11.4% vs 3.3%; P = .007) and higher but not statistically in recipients of livers from living donors (5.2% vs 2.7%; P = .19). Twelve patients (48.8%) were treated with endovascular approach, and 11 (0.44%)required surgicaltreatment. Two patients underwent immediate retransplant due to hepatic artery thrombosis. Because vascular complications are the most severe complications afterlivertransplant,there must be close follow-up of vascular anastomoses, particularly early postoperatively, with radiologic methods. In cases of vascular complications, emergent treatment, including endovascular interventions, surgery, and retransplant, must be performed.

Hepatic artery stenosis after liver transplant: Donation after cardiac death donor vs donation after brain death donor grafts.

Hepatic artery stenosis (HAS) after liver transplant (LT) is a source of significant morbidity. Some reports have suggested higher arterial complications in patients who receive donation after cardiac death (DCD) livers. A total of 2860 consecutive LT were reviewed from a prospectively collected database. All angiograms performed in LT recipients were reviewed and primary patency rates determined by need for further intervention or graft loss due to HAT. Hepatic artery stenosis was seen in 4.6% of DCD and donation after brain death (DBD) recipients. Recipient male gender, age at transplant, complex donor hepatic artery anatomy, and prolonged operative time were all associated with HAS, but not DCD status. While HAS in recipients of DCD grafts required more stents (1.7% vs 0.6%, P=0.04) and had worse primary patency rates (logrank, P=0.02), outcomes as defined by HAT, patient and graft survival were not significantly different between the recipients of DCD or DBD grafts. We observed no significant difference in the incidence of hepatic artery complications, patient survival, or graft survival in recipients of DCD or DBD grafts. However, HAS in DCD recipients had worse primary patency and a higher need for stent placement.

Primary Stent Placement for Hepatic Artery Stenosis After Liver Transplantation: Improving Primary Patency and Reintervention Rates.

Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow-up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow-up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24-68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow-up period (median, 41 months; interquartile range [IQR], 25-86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4-11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow-up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.

Early Diagnosis and Management of Hepatic Artery Complications Following Living Donor Liver Transplantation

AbstractBackground: Liver Transplantation (LT) has become the treatment of choice for patients with end-stage liver disease. However vascular problems are considered the most serious complications reported after LT. These complications can lead to increased morbidity, graft loss, and patient death. Hepatic Artery Thrombosis (HAT) represents a major cause of graft loss and mortality after liver transplantation.Aim of Study: To assess hepatic artery complications after Living-Donor Liver Transplantation (LDLT) and to make an early diagnosis with different ways of management, with clinical follow-up.Design: Historical cohort study.Patients and Methods: Between March 2008 and February 2018, 323 adult to adult LDLT were performed at Ain Shams Organ Transplant Center (ASCOT) in Ain Shams Specialized Hospital. The overall male/female ratio was 280/43. We retrospectively identified and analyzed hepatic artery compli-cations in recipients.Results: The overall incidence of hepatic artery compli-cations was 4.3% (n=14) and early HA thrombosis 1.8% (n=6); all treated surgically, two patients were retransplanted, late HAT 1.2% (n=4); treated medically and HA stenosis 0.6% (n=2) treated with stenting by interventional radiology.Conclusion: Prevention and proper treatment of hepatic artery complications is required to achieve better survival among patients undergoing LDLT.

Bridging transarterial embolisation therapy is not associated with increased hepatic artery complications following liver transplantation

Bridging transarterial embolisation therapy is not associated with increased hepatic artery complications following liver transplantation

A systematic review and meta-analysis of rescue revascularization with arterial conduits in liver transplantation.

Although aortohepatic conduits (AHCs) provide an effective technique for arterialization in liver transplantation (LT) when the native recipient artery is unusable, various publications report higher occlusion rates and impaired outcome compared to conventional anastomoses. This systematic review and meta-analysis investigates the published evidence of outcome and risk of AHCs in LT using bibliographic databases and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Primary and secondary outcome were artery occlusion as well as graft and patient survival. Twenty-three retrospective studies were identified with a total of 22113 patients with LT, of whom 1900 patients (9%) received an AHC. An AHC was used in 33% of retransplantations. Early artery occlusion occurred in 7% (3%-16%) of patients with AHCs, compared to 2% (1%-3%) without conduit (OR 3.70; 1.63-8.38; P=.001). The retransplantation rate after occlusion was not significantly different in both groups (OR 1.46; 0.67-3.18; P=.35). Graft (HR 1.38; 1.17-1.63; P<.001) and patient (HR 1.57; 1.12-2.20; P=.009) survival was significantly lower in the AHC compared to the nonconduit group. In contrast, graft survival in retransplantations was comparable (HR 1.00; 0.82-1.22; P=.986). Although AHCs provide an important rescue option, when regular revascularization is not feasible during LT, transplant surgeons should be alert of the potential risk of inferior outcome.

Interventional radiology treatment for vascular and biliary complications following pediatric living donor liver transplantation - a retrospective study.

There are few long-term outcome reports for interventional radiology (IVR) treatments for vascular and biliary complications following pediatric living donor liver transplantation (LDLT). Herein, we presented our institution's experience and investigated the efficacy and issues of long-term outcome with IVR treatments. Between May 2001 and September 2016, 279 pediatric LDLTs were performed. The median age at LDLT was 1.4 years old, and the median observation period was 8.2 years. All the biliary reconstructions at LDLT were hepaticojejunostomy. The IVR treatments were selected as endovascular, radiological, or endoscopic interventions. Post-transplant hepatic vein, portal vein, hepatic artery, and biliary complications were present in 7.9%, 14.0%, 5.4%, and 18.3%, respectively. IVR treatment was the first treatment option in 81.8%, 94.9%, 46.7%, and 94.1%, respectively. The recurrence and cure rates following IVR treatment were 42.1%, 21.1%, 44.4%, and 34.0% and 84.2%, 97.4%, 100%, and 88.0%, respectively. The graft survival rates in patients with and without post-transplant vascular and biliary complications were 94.4% and 90.6%, respectively (P = 0.522). The IVR treatments for vascular and biliary complications following pediatric LDLT are the first choice option. Although the recurrence following IVR treatment is a major problem and it is necessary to carefully perform long-term follow-up, IVR treatments have good treatment outcomes.

Predictive Value of Indocyanine Green Plasma Disappearance Rate on Liver Function and Complications After Liver Transplantation.

BackgroundThe aim of this study was to investigate the correlation between indocyanine green plasma disappearance rate (ICG-PDR) and allograft function as well as postoperative complications after liver transplantation.Material/MethodsIn this prospective study, 115 cases of adult liver transplantation performed from 1 June 2016 to 1 December 2016 were enrolled. These 115 patients were divided into a group of PDR <18%/min (50 cases) and a group of PDR ≥18%/min (65 cases). The rates of liver recovery, postoperative complications, and survival were compared between these 2 groups.ResultAmong the total of 115 patients, 111 patients recovered well and were discharged, whereas 4 patients died during the first month after the operation. Between the 2 groups, significant differences were observed in terms of the model for end-stage liver disease (MELD) score, intraoperative bleeding volume, and the level of hemoglobin (Hb), pre-albumin (PA) and total bilirubin (TB) the first week after the operation. Overall, the incidence of hepatic arterial complications and pneumonia was much higher in the PDR<18%/min group (P<0.05).ConclusionsThe early postoperative value of ICG-PDR was closely related to graft function and could act as a good predictor for the incidence of postoperative arterial complications.

The rate of hepatic artery complications is higher in pediatric liver transplant recipients with metabolic liver diseases than with biliary atresia

BackgroundLiver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA. Basic proceduresData from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed. Main findingsCompared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P < 0.001), and had lower Child–Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014). Principal conclusionDespite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications. Type of submissionOriginal article, Case control study, Retrospective. Evidence levelIII.

Systematic Review and Meta-Analysis of Posttransplant Hepatic Artery and Biliary Complications in Patients Treated With Transarterial Chemoembolization Before Liver Transplantation.

Hepatic artery complications are feared complications after liver transplantation and may compromise the biliary tract, graft, and patient survival. The objective of this systematic review and meta-analysis was to compare risk of hepatic artery and biliary complications after liver transplantation in patients who underwent neoadjuvant transarterial chemoembolization (TACE) versus no TACE. Comprehensive searches were performed in Embase, MEDLINE OvidSP, Web of Science, Google Scholar, and Cochrane databases to identify studies concerning hepatocellular cancer patients undergoing preliver transplantation TACE. Quality assessment of studies was done by the validated checklist of Downs and Black. Meta-analyses were performed to evaluate the incidence of all hepatic artery complications, hepatic artery thrombosis, and biliary tract complications, using binary random-effect models. Fourteen retrospective studies, representing 1122 TACE patients, met the inclusion criteria. Postoperative hepatic artery complications consisted of hepatic artery thrombosis, stenosis, and (pseudo)-aneurysms. Preliver transplantation TACE was significantly associated with occurrence of posttransplant hepatic artery complications (odds ratio, 1.57; 95% confidence interval, 1.09-2.26; P = 0.02). No significant association between neoadjuvant TACE and hepatic artery thrombosis alone or biliary tract complications was found. Patients treated with TACE before liver transplantation may be at increased risk for development of hepatic artery complications after liver transplantation.

Hepatic Artery Pseudoaneurysm Eroding into Common Bile Duct in a Liver Transplant Recipient

Hepatic artery pseudoaneurysm is an uncommon but serious complication that can occur after liver transplantation. Overall incidence is estimated to be around 2% but risk factors remain poorly defined. We present the case of a patient who presented with hemobilia due to hepatic artery pseudoaneurysm eroding into the bile duct within a few weeks of liver transplantation. The patient is a 65 year old male who underwent orthotopic liver transplantation (LT) for Hepatitis C cirrhosis and hepatocellular carcinoma. Post-transplant immunosuppression consisted of tacrolimus and mycophenolate mofetil. Medical co-morbidities included hypertension and type 2 diabetes. Duplex Ultrasonogram in immediate post-transplant period revealed mild parvus et tardus hepatic artery waveforms that remained stable. One week post-LT, patient underwent endoscopic retrograde cholangiopancreatography (ERCP) for evaluation of abnormal liver tests (aspartate aminotransferase (AST) 294 IU/L, alanine aminotransferase (ALT) 263 IU/L, Alkaline phosphatase 757 IU/L, total bilirubin 2.4 mg/dl, direct bilirubin 1.4 mg/dl). A tight anastomotic stricture was found, and biliary sphincterotomy was performed with placement of 2 biliary stents. Post-procedural course was complicated by mild pancreatitis, which resolved with conservative measures. Liver enzymes remained persistently elevated, and a percutaneous liver biopsy was performed 2 weeks after ERCP. Histologic findings were consistent with large duct obstruction. A week later, patient presented with abdominal pain and hematochezia. Computed tomographic angiogram was suggestive of hepatic artery pseudoaneurysm as well as occlusion of right portal vein. Repeat ERCP was performed that showed hemobilia and a pseudoaneurysm with hepatic artery to common bile duct fistula. The patient underwent surgical resection of pseudoaneurysm and bile duct, hepaticojejunostomy and revascularization of hepatic artery. Patient is alive and doing well after a 2 week follow up. Extension of a pseudoaneurysm into the common bile duct is a rare but potentially fatal complication. Although surgical technique is the most cited etiology for hepatic artery complications, percutaneous liver biopsy might have contributed in our case. This case demonstrates the criticality of early detection and appropriate management.

Hepatic artery and biliary complications in liver transplant recipients with radioembolization bridging treatment for hepatocellular carcinoma.

Locoregional bridging treatments are commonly applied in patients with hepatocellular carcinoma (HCC) prior to liver transplantation to prevent tumor progression during waiting time. It remains unknown whether pre-transplant radioembolization treatment may increase the prevalence of hepatic artery and biliary complications post-transplant. We performed a retrospective review of 173 consecutive patients with HCC who underwent liver transplantation at our transplant center between January 2007 and December 2016. Radioembolization bridging treatment was applied in 42 patients while 131 patients received other or no forms of bridging treatment. The overall prevalence of intra-operative and early post-operative hepatic artery complications was 9.5% in the radioembolization group and 9.2% in the control group (P=1.000). Biliary complications were significantly less frequent in the radioembolization group (4.8% vs 17.6%, P=.0442). In multivariable analysis, radioembolization was not significantly associated with an increased risk of arterial complications. Considering biliary complications, radioembolization bridging treatment was the only factor significantly associated with decreased odds (OR 0.187 (0.039, 0.892), P=.036). Radioembolization is not associated with higher odds of hepatic artery complications following liver transplantation. There may even be a protective effect regarding biliary complications. Radioembolization as a bridge to transplantation may effectively be applied without compromising successful liver transplantation.

Pretransplant Intra-arterial Liver-Directed Therapy Does Not Increase the Risk of Hepatic Arterial Complications in Liver Transplantation: A Single-Center 10-Year Experience.

To investigate the association between pretransplant intra-arterial liver-directed therapy (IAT) for hepatocellular carcinoma (HCC) and hepatic arterial complications (HAC) in orthotopic liver transplantation (OLT) [namely hepatic artery thrombosis (HAT) and/or the need for hepatic arterial conduit]. A total of 175 HCC patients (mean age: 60years) underwent IAT with either transarterial chemoembolization or yttrium-90 (90Y) transarterial radioembolization prior to OLT between 2003 and 2013. A matched control cohort of 159 HCC patients who underwent OLT without prior IAT was selected. Incidence of HAC in both cohorts was investigated. The categorical differences between both cohorts were calculated by chi-square test. Among the 175 patients (chemoembolization, n=82; radioembolization, n=93), 8 (5%) required conduits due to HA disease (chemoembolization, n=6; radioembolization, n=2), 3 (2%) developed HAT (chemoembolization, n=2; radioembolization, n=1). Eleven of 175 patients (6.7%) had HAC. Of the 159 control patients, 6 (4%) needed conduits for HA disease and 3 (2%) developed HAT. Nine of 159 patients (5.7%) had HAC. Chi-square analysis between the IAT cohort and the control group yielded a p value of 0.810. When comparing chemoembolization to radioembolization, p=0.076 (not significant at p<0.05). Although aggressive pretransplant radioembolization and chemoembolization are both utilized in most liver transplant centers, neither appears to increase the risk of peri-transplant hepatic arterial complications in HCC patients.

Rescue Arterial Revascularization Using Cryopreserved Iliac Artery Allograft in Liver Transplant Patients.

Management of hepatic arterial complications after liver transplant remains challenging. The aim of our study was to assess the efficacy of rescue arterial revascularization using cryopreserved iliac artery allografts in this setting. Medical records of patients with liver transplants who underwent rescue arterial revascularization using cryopreserved iliac artery allografts at a single institution were reviewed. From 1992 to 2015, 7 patients underwent rescue arterial revascularization using cryopreserved iliac artery allografts for hepatic artery pseudoaneurysm (3 patients), thrombosis (2 patients), aneurysm (1 patient), or stenosis (1 patient). Two patients developed severe complications, comprising one biliary leakage treated percutaneously, and one acute necrotizing pancreatitis causing death on postoperative day 29. After a median follow-up of 75 months (range, 1-269 mo), 2 patients had an uneventful long-term course, whereas 4 patients developed graft thrombosis after a median period of 120 days (range, 2-488 d). Among the 4 patients who developed graft thrombosis, 1 patient developed ischemic cholangitis, 1 developed acute ischemic hepatic necrosis and was retransplanted, and 2 patients did not develop any further complications. Despite a high rate of allograft thrombosis, rescue arterial revascularization using cryopreserved iliac artery allografts after liver transplant is an effective and readily available approach, with a limited risk of infection and satisfactory long-term graft and patient survival.

Hepatic Artery Reconstruction With Autologous Inferior Mesenteric Artery Graft in Living Donor Liver Transplant Recipients

IntroductionIn living donor liver transplantation (LDLT), hepatic arterial continuity is crucial to avoid biliary leakage, biliary stricture, cholangitis, and graft and patient loss. Sometimes there exist factors making anastomosis difficult or even impossible. In these cases, a vascular graft may be needed to bridge the two arteries for revascularization. MethodMedical records of 297 patients who underwent LDLT between June 2000 and July 2016 at the Hepatopancreatobiliary Surgery and Liver Transplantation Unit of Dokuz Eylul University Hospital were reviewed retrospectively. Twenty-eight (9%) patients younger than the age of 18 were excluded from the study. The remaining 269 patients were included in the study. We analyzed data of patients who developed hepatic arterial complications during or after LDLT and underwent revascularization using autologous interposed inferior mesenteric artery (IMA) grafts. ResultsIn 8 (2.9%) of the 269 patients who underwent LDLT and were included in the study, autologous interposed IMA grafts were used for the hepatic artery revascularization. All of the patients were males. Their mean age was 42 (range, 25–57). The mean duration of follow-up was 83.25 months (range, 3–144 months). One patient developed intraoperative hepatic arterial thrombosis (HAT) after autologus IMA reconstruction and this patient needed retransplantation. No arterial complications developed in the other 7 patients. ConclusionAutologous interposed IMA graft could be used as an alternative vascular graft in hepatic artery revascularization to provide tension-free hepatic arterial continuity.

Effect of Right Posterior Bile Duct Anatomy on Biliary Complications in Patients Undergoing Right Lobe Living Donor Liver Transplant.

Our aim was to evaluate the influence of the localization of right posterior bile duct anatomy relative to portal vein of the donors on posttransplant bile duct complications. We retrospectively investigated 141 patients who had undergone living donor liver transplant using right hemiliver grafts. The patients were classified based on the pattern of the right posterior bile duct and divided into infraportal and supraportal types. Clinical donor and recipient risk factors and surgical outcomes were compared for their relationship with biliary complications using logistic regression analyses. The 2 groups were similar according to demographic and clinical features. The biliary complication rate was 23.7% (9/38) in the infraportal group and 47.4% (37/78) in the supraportal group (P = .014). An analysis of risk factors for the development of anastomotic bile leak using logistic regression showed that a supraportal right posterior bile duct anatomy was a statistically significant positive predictor, with odds ratio of 18.905 (P = .012; confidence interval, 1.922-185.967). The distance of the right posterior bile duct from confluence was significantly lower in patients with biliary complications than in those without (mean of 7.66 vs 0.40 mm; P = .044). According to receiver operating characteristic analyses, the cut-off point for the length of right bile duct to right posterior bile duct from the hepatic confluence was 9.5 mm regarding presence of complications. Factors influencing bile duct anastomosis leakage were supraportal-type donor bile duct anatomy and length of the right main bile duct from biliary confluence. Hepatic arterial complications were similarly a risk factor for biliary strictures. Because of the multiple factors leading to complications in living donor liver transplant, it is challenging to group these patients by operative risk; however, establishing risk models may facilitate the prediction of complications.