Hepatic Artery Dissection Research Articles

Hepatic Artery Thrombectomy after Orthotopic Liver Transplantation: A Stent Retriever and/or Aspiration-Guided Catheter Approach

Retransplantation has been the primary treatment for hepatic artery thrombosis (HAT) in patients with orthotopic liver transplant (OLT); however, because of scarcity of grafts, endovascular revascularization via mechanical thrombectomy offers an alternative to retransplantation should it provide similar long-term benefits. Data regarding a series of 8 patients with hepatic artery thrombectomies across 10 procedures (1 early HAT and 9 late HAT) utilizing stent retriever and/or suction catheter were collected. All had technically successful restoration of flow with stent placement of the anastomotic stenosis in 8 cases. Two patients required reintervention for HAT at 18 and 701 days after primary intervention, with the first dying from liver failure but with a patent hepatic artery on explant. One case had a procedure-related adverse event, hepatic artery dissection, Society of Interventional Radiology (SIR) adverse event classification of 2. Technical success was achieved in all procedures, demonstrating promise in effectively treating HAT in patients with OLT.

Transarterial Bleomycin-Lipiodol Chemoembolization for the Treatment of Giant Hepatic Hemangiomas: An Assessment of Effectiveness.

This study evaluates the effectiveness of superselective transcatheter arterial chemoembolization (TACE) using a bleomycin-lipiodol emulsion in treating giant hepatic hemangiomas. A retrospective review included 31 patients with a mean age of 53 ± 10.42 years who underwent TACE from December 2014 to October 2022, with follow-up imaging examinations to assess outcomes. Technical success was defined as successful embolization of all feeding arteries, and clinical success was defined as a reduction in hemangioma volume by 50% or more on follow-up imaging. This study observed a 100% technical success rate. Post-embolization syndrome was common, and two cases of asymptomatic hepatic artery dissection were noted. Clinical success was achieved in 80.6% of patients, with significant volume reduction observed in the majority. Conclusively, superselective transcatheter arterial chemoembolization with bleomycin-lipiodol emulsions is presented as a viable and effective treatment option for giant hepatic hemangiomas. With no procedure-related mortality and significant volume reduction in most cases, this method offers a promising alternative to surgical intervention. This study's findings suggest a need for further exploration and validation in larger-scale prospective studies.

The clinical outcome of hepatic artery dissection after living donor liver transplantation in a high volume center

The clinical outcome of hepatic artery dissection after living donor liver transplantation in a high volume center

Safety and Feasibility of Transarterial Bleomycin-Lipiodol Embolization in Patients with Giant Hepatic Hemangiomas.

Giant hepatic hemangiomas present a significant clinical challenge, and effective treatment options are warranted. This study aimed to assess the safety and feasibility of transarterial bleomycin-lipiodol embolization in patients with giant hepatic hemangiomas. A retrospective analysis was conducted on patients with giant hepatic hemangiomas (>5 cm). Transarterial chemoembolization (TACE) was performed using 7-20 cc of lipiodol mixed with 1500 IU of bleomycin. Safety outcomes, including post-embolization syndrome (PES), hepatic artery dissection, systemic complications, and access site complications, were evaluated. Radiation doses were also measured. Feasibility was assessed based on the achieved hemangioma coverage. Seventy-three patients (49 female, 24 male) with a mean age of 55.52 years were treated between December 2014 and April 2023. The average hospitalization duration was 3.82 days, and 97.3% of lesions were limited to one liver lobe. The average bleomycin dose per procedure was 1301.5625 IU, while the average lipiodol dose was 11.04 cc. The average radiation dose was 0.56 Gy. PES occurred after 45.7% of TACE procedures, with varying severity. Complications such as hepatic artery dissection (three cases), access site complications (two cases), and other complications (one case) were observed. No treatment-related mortality occurred. Hemangioma coverage exceeding 75% was achieved in 77.5% of cases. The study results suggest that transarterial bleomycin-lipiodol embolization is a safe and feasible treatment option for a heterogeneous group of patients with giant hepatic hemangiomas. This approach may hold promise in improving outcomes for patients with this challenging condition.

Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation: A New Modified Approach

Ensuring optimal arterial flow in solid organ transplantation is very important. Insufficient flow causes important problems such as bile duct problems, intrahepatic abscess formation, and organ loss. Arterial intimal dissection is an important factor that negatively affects organ blood flow. In this study, hepatic artery dissections that we detected in patients who underwent living donor liver transplantation in our clinic were defined, and the microvascular intima-adventitial fixation technique, which can be considered a new approach, was described.

Strategic Approach to Aberrant Hepatic Arterial Anatomy during Laparoscopic Pancreaticoduodenectomy: Technique with Video

It is critical for every pancreatic surgeon to determine how to protect the aberrant hepatic artery intraoperatively in order to safely implement laparoscopic pancreatoduodenectomy (LPD). "Artery-first" approaches to LPD are ideal procedures in selected patients with pancreatic head tumors. Here, we described our surgical procedure and experience of aberrant hepatic arterial anatomy-LPD (AHAA-LPD) in a retrospective case series. In this study, we also sought to confirm the implications of the combined SMA-first approach on the perioperative and oncologic outcomes of AHAA-LPD. From January 2021 to April 2022, the authors completed a total of 106 LPDs, of which 24 patients underwent AHAA-LPD. We evaluated the courses of the hepatic artery via preoperative multi-detector computed tomography (MDCT) and classified several meaningful AHAAs. The clinical data of 106 patients who underwent AHAA-LPD and standard LPD were retrospectively analyzed. We compared the technical and oncological outcomes of the combined SMA-first approach, AHAA-LPD, and the concurrent standard LPD. All the operations were successful. The combined SMA-first approaches were used by the authors to manage 24 resectable AHAA-LPD patients. The mean age of the patients was 58.1 ± 12.1 years; the mean operation time was 362 ± 60.43 min (325-510 min); blood loss was 256 ± 55.72 mL (210-350 mL); the postoperation ALT and AST were 235 ± 25.65 IU/L (184-276 IU/L) and 180 ± 34.43 IU/L (133-245 IU/L); the median postoperative length of stay was 17 days (13.0-26.0 days); the R0 resection rate was 100%. There were no cases of open conversion. The pathology showed free surgical margins. The mean number of dissected lymph nodes was 18 ± 3.5 (14-25); the number of tumor-free margins was 3.43 ± 0.78 mm (2.7-4.3 mm). There were no Clavien-Dindo III-IV classifications or C-grade pancreatic fistulas. The number of lymph node resections was greater in the AHAA-LPD group (18 vs. 15, p < 0.001). Surgical variables (OT) or postoperative complications (POPF, DGE, BL, and PH) showed no significant statistical differences in both groups. In performing AHAA-LPD, the combined SMA-first approach for the periadventitial dissection of the distinct aberrant hepatic artery to avoid hepatic artery injury is feasible and safe when performed by a team experienced in minimally invasive pancreatic surgery. The safety and efficacy of this technique need to be confirmed in large-scale-sized, multicenter, prospective randomized controlled studies in the future.

Preoperative liver arterial conditioning in patients scheduled for a Mayo Clinic class Ia distal pancreatectomy: embolization or ligation?

BackgroundLiver ischemia may occur during intraoperative common hepatic artery ligation in Mayo Clinic class I distal pancreatectomy with en bloc celiac axis resection (DP-CAR). Preoperative liver arterial conditioning could be used to avoid this outcome. This retrospective study compared arterial embolization (AE) or laparoscopic ligation (LL) of the common hepatic artery before class Ia DP-CAR. MethodsFrom 2014 to 2022, 18 patients were scheduled for class Ia DP-CAR after neoadjuvant FOLFIRINOX treatment. Two were excluded due to hepatic artery variation, six underwent AE, ten underwent LL. ResultsTwo procedural complications occurred in the AE group: an incomplete dissection of the proper hepatic artery and a distal migration of coils in the right branch of the hepatic artery. Neither complication prevented surgery. The median delay between conditioning and DP-CAR was 19 days; decreased to five days in the last six patients. None required arterial reconstruction. Morbidity and 90-day mortality rates were 26.7% and 12.5%, respectively. No patient developed postoperative liver insufficiency after LL. ConclusionPreoperative AE and LL seem comparable in averting arterial reconstruction and postoperative liver insufficiency in patients scheduled for class Ia DP-CAR. However, serious complications that may arise during AE led us to prefer the LL technique.

S3041 Hepatic Artery Dissection – A Case Report

Introduction: Visceral artery aneurysms are rare pathologies with reported incidence rates between 0.01% to 0.2%; even rarer are hepatic artery dissections (HAD). Most aneurysms rupture or are incidentally found on autopsy, but imaging advancements has enabled earlier identification of aneurysms; in this case, a HAD. Case Description/Methods: A 77-year-old female with medical history pertinent for sickle cell trait, acquired factor VIII inhibitor coagulopathy, history of type 2 thoracic aortic dissection, and hypertension presented to the emergency room with a week of mild fatigue, postprandial epigastric burning pain, and intermittent stabbing right upper quadrant pain. Right upper quadrant ultrasound demonstrated a hypervascularized right hepatic lobe mass with large tortuous internal vessels. CT abdomen & pelvis without contrast showed a large hypodensity in the right liver with curvilinear density. MRI demonstrated large arteriovenous malformation (AVM) within the right hepatic lobe and focal hepatic parenchymal hemorrhage centered within AVM nidus. Gastroenterology was consulted and CT angiogram findings were suspicious for common HAD, proper hepatic & intrahepatic pseudoaneurysms, and intrahepatic rupture. Interventional radiology was consulted. Hepatic angiogram showed a large defect in the proximal hepatic artery with brisk opacification, thought to represent a pseudoaneurysm. This prompted framing coil placement across the large defect and coils extending from the proper hepatic artery to the common hepatic artery with significant reduction in forward flow & pseudoaneurysm opacification. Per hepatobiliary & vascular surgery, no need for additional surgical intervention. Postoperative course was complicated by fever & leukocytosis, worsening kidney injury, and anemia; attributed to the procedure and resolved with supportive care. Patient discharged on postoperative day 8 with outpatient follow-up. (Figure) Discussion: This case highlights the importance of imaging for earlier detection of hepatic artery aneurysms (HAA) in minimizing risk of catastrophic hemorrhage. HAA are rare but clinically important given they are associated with high incidence of rupture and mortality up to 20%. Although surgery is preferred for extrahepatic findings, endovascular interventions are favored for intrahepatic findings depending on size and presence of pseudoaneurysms, such as this case. They have led to more favorable short & longer-term outcomes and lower mortality & morbidity rates, particularly in poor surgical candidates.Figure 1.: Hepatic angiography and embolization was performed. A large defect with brisk opacification of the proper and common hepatic arteries were seen (A), prompting deploy of a framing coil. (B) Embolization was then performed on the hepatic artery with three coils (5mm, 6mm, & 8mm). Coils were examined from proper hepatic artery to the common hepatic artery. (C) Following placement of the coils, significant reduction in flow and opacification of the pseudoaneurysm was seen.

333.2: Vascular Complications in Pediatric Liver Transplants And Their Management

Introduction: Unlike other organs, the blood supply of the liver occurs through two systems. One of these is the hepatic artery, and it supply approximately one-third to one-fifth of the liver. The rest of the liver is supplied with blood via the portal vein. The outflow of blood circulation in the liver is via the hepatic veins. Any disruption in this blood circulation results in deterioration in liver functions. In this study, we aimed to evaluate early vascular complications in pediatric liver transplants. Methods: From 8 November 1988 to 31 December 2021, we performed 701 LT procedures and 334 of them were pediatric.). We reviewed the medical records of these recipients for the following: primary cause of liver failure, age, and weight at the time of transplantation, type of graft, vascular complications and their management. One hundred and seventy six of the recipients were male and 158 were female. Mean age of 7.34 years (0.5 months – 17 years). Nineteen (5.7%) of the LT were deceased donor LT and 315 (94.3%) were living related liver transplant. Most cause of liver failure was biliary atresia (n=169). Mean weight of recipients was 23.3 kg. Most of graft types was left lateral graft (n=204) Results: Hepatic vein complications occurred in 3 patients. In all three patients, stenosis was detected in the portal vein anastomosis region and was successfully treated with interventional radiological methods by placing a stent in the anastomosis region. Portal vein complications occurred in 3 patients. In one of these patients, hemostasis was performed by surgical method due to bleeding from the portal vein anastomosis. In the second patient, the anastomosis was surgically revised due to thrombus formation in the portal vein. In the third patient, due to a stenosis of more than 50% in the portal vein anastomosis, a stent was placed in the anastomosis region after balloon dilation using interventional radiological methods, and blood flow was successfully maintained. Hepatic artery complications occurred in 54 patients. Hepatic artery thrombosis occurred in 31 patients, hepatic artery stenosis in 13 patients, bleeding from hepatic artery anastomosis in 7 patients, hepatic artery dissection in 2 patients, and pseudoaneurysm in the hepatic artery in 1 patient. 43 of these patients were successfully treated with interventional radiological methods and 11 of them surgically. Conclusion: Vascular complications seen in liver transplants can cause deterioration in hepatic functions and acute liver failure. Especially hepatic artery complications are one of the most important causes of biliary tract complications that will develop in the future. Vascular complications can be successfully treated at an early stage in experienced organ transplant centers.

Preoperative liver arterial conditioning in patients scheduled for a mayo clinic class IA distal pancreatectomy: Embolization or ligation?

Patients who undergo intraoperative ligation of the common hepatic artery in Mayo Clinic class I distal pancreatectomy with en bloc celiac axis resection (DP-CAR) might be exposed to liver ischemia. To avoid serious adverse postoperative outcomes related to arterial reconstruction, preoperative liver arterial conditioning by embolization or ligation is used. Here, we report our experience of preoperative liver conditioning by arterial embolization (AE) or laparoscopic ligation (LL) of the common hepatic artery before Class Ia DP-CAR. From 2014 to 2021, 15 patients were scheduled for a Class Ia DP-CAR after neoadjuvant FOLFIRINOX treatment. Six patients underwent AE, while nine underwent LL. Two procedural complications occurred in the AE group: one patient had an incomplete dissection of the proper hepatic artery, and one patient had distal migration of coils in the right branch of the hepatic artery. None of these complications prevented surgery. The median delay between liver conditioning and DP-CAR was 19 days; this delay decreased to 5 days in the last five patients. Arterial reconstruction was not performed. The severe morbidity and 90-days mortality rates were 26.7% and 13.3%, respectively. No patient developed postoperative liver insufficiency. No differences were noted between the groups in terms of the postoperative course. Preoperative AE and LL were comparable in terms of avoiding arterial reconstruction and postoperative liver insufficiency in patients scheduled for class Ia DP-CAR. However, the possible serious complications that may arise during AE led us to prefer the LL technique.

Quality of superior mesenteric and hepatic artery dissection in robotic pancreatoduodenectomy for pancreatic cancer.

This video manuscript by Ikoma and colleagues demonstrates their approach to the superior mesenteric artery and hepatic artery periadventitial dissection. The quality of superior mesenteric artery and hepatic artery dissections should be maintained in robotic pancreatoduodenectomy when performed for pancreatic cancer, to provide the best possible oncological outcomes.

Management of difficult hepatic artery reconstructions to reduce complications through continual technical refinements in living donor liver transplantations

BackgroundHepatic artery reconstruction (HAR) for liver transplantation is crucial for successful outcomes. We evaluated transplantation outcome improvement through continual technical refinements. Materials and methodsHAR was performed in 1448 living donor liver transplants by a single plastic surgeon from 2008 to 2020. Difficult HARs were defined as graft or recipient hepatic artery ≤2 mm, size discrepancy (≥2 to 1), multiple hepatic arteries, suboptimal quality, intimal dissection of graft or recipient hepatic artery (HA), and immediate redo during transplantation. Technique refinements include early vessel injury recognition, precise HA dissection, the use of clips to ligate branches, an oblique cut for all HARs, a modified funneling method for size discrepancy, liberal use of an alternative artery to replace a pathologic HA, and reconstruction of a second HA for grafts with dual hepatic arteries in the graft. ResultsDifficult HARs were small HA (21.35%), size discrepancy (12.57%), multiple hepatic arteries (11.28%), suboptimal quality (31.1%), intimal dissection (20.5%), and immediate redo (5.18%). The overall hepatic artery thrombosis (HAT) rate was 3.04% in this series. The average HAT rate during the last 4 years (2017–2020) was 1.46% (6/408), which was significantly lower than the average HAT rate from 2008 to 2016 (39/1040, 3.8%) with a statistical significance (p = 0.025). Treatment for posttransplant HAT included anastomosis after trim back (9), reconstruction using alternatives (19), and nonsurgical treatment with urokinase (9). ConclusionCareful examination of the HA under surgical microscope and selection of the appropriate recipient HA are key to successful reconstruction. Through continual technical refinements, we can reduce HA complications to the lowest degree.

Vascular Complications in Pediatric Liver Transplants and Their Management.

The blood supply of the liver occurs through the hepatic artery and portal vein. Outflow of blood circulation in the liver is via the hepatic veins. Any disruption in this blood circulation results in deterioration of liver functions. In this study, we evaluated early vascular complications in pediatric liver transplant recipients seen at our center. From November 1988 to December 2021, our team has performed 701 liver transplant procedures, which have included 334 pediatric liver transplants. Among these pediatric liver transplant recipients (mean age of 7.34 y), 176 were male patients. Nineteen patients (5.7%) were recipients of deceased donors. Reason for liver failure was mainly biliary atresia (n = 169). Mean weight of recipients was 23.3 kg. Most graft types were left lateral grafts (n = 204). Three patients had hepatic vein complications. All 3 patients were successfully treated with interventional radiological methods by placing a stent in the anastomosis region. Portal vein complications occurred in 3 patients. One patient had hemostasis performed surgically. The second patient had surgically revision of the anastomosis because of thrombus formation. Because of stenosis of more than 50% in the portal vein anastomosis, the third patient required stent placement in the anastomosis region. Hepatic artery complications occurred in 54 patients: 31 patients had hepatic artery thrombosis, 13 patients had hepatic artery stenosis, 7 patients had bleeding from hepatic artery anastomosis, 2 patients had hepatic artery dissection, and 1 patient had pseudoaneurysm in the hepatic artery. Forty-three of these patients were successfully treated with interventional radiological methods and 11 required surgical treatment. Vascular complications after liver transplant can cause deterioration in hepatic functions and acute liver failure. Vascular complications can be successfully treated in experienced organ transplant centers.

A no-ligation technique to prevent intraoperative hepatic artery dissection in living-donor liver transplantation.

Intrahepatic recipient hepatic artery dissection caused by hepatic artery thrombosis is a lethal complication of living-liver donor liver transplantation (LDLT). We herein report a new surgical technique that avoids the ligation of the recipient hepatic arteries in LDLT. Patients undergoing LDLT between 2009 and 2019 were evaluated. In the second half of this period, a technique involving no ligation of the recipient hepatic artery was initiated and its impact on the incidence of intrahepatic recipient hepatic artery dissection was determined. The middle and left hepatic arteries were ligated in 195 cases (53.4%), and the no-ligation technique was used in 170 (46.6%). The incidence of intraoperative hepatic artery dissection was significantly lower in the no-ligation group (n = 0, 0.0%) than in the ligation group (n = 10, 5.1%) (p = 0.0021). After propensity score matching to evaluate the patient characteristics, the incidence of intraoperative hepatic artery dissection was also significantly lower in the no-ligation group (n = 0, 0.0%) than in the ligation group (n = 6, 4.5%) (p = 0.0295). As a result, this new surgical technique is highly recommended to avoid recipient hepatic artery ligation in LDLT.

Conventional hepatic arterial anatomy? Novel findings and insights of a multi-disciplinary hepatic arterial infusion pump program

IntroductionVariant hepatic arterial anatomy (vHAA) is thought to occur in 20–30% of patients. Hepatic arterial infusion (HAI) pump placement for liver cancers requires thorough hepatic artery dissection; we sought to compare vHAA identified during pump placement with established dogma. MethodsBetween 2016 and 2020, n = 30 patients received a HAI pump. Intra-operatively identified vHAA was characterized and compared with published data. ResultsvHAA was identified in 60% (n = 18) of patients, significantly higher than 19% (3671 of 19013) in the largest published series (P < 0.001). The most common variations were accessory left (n = 12; 40%) and replaced right (n = 6; 20%) hepatic arteries; six (20%) had ≥2 variants. Pre-operative imaging correctly identified 67% of variant hepatic arteries. DiscussionMeticulous operative dissection of the hepatic arterial tree reveals vHAA not captured by imaging or cadaveric dissection. vHAA likely has a higher prevalence than previously reported and should be addressed to optimize therapeutic efficacy of HAI pump therapy.

Providing Arterial Supply to the Liver Graft with Recipient Splenic Artery in Living Donor Liver Transplantation: Case Report

Hepatic arterial reconstruction is an important step in graft implantation in liver transplant procedure. Hepatic arterial anastomosis always demands meticulous and highly skilled surgical techniques to provide adequate blood supply to the graft. Hepatic arterial intimal dissection in liver transplantation is although a rare but documented complication, with incidence of less than 5%, but having dreadful complications. To overcome this complication of Recipient hepatic artery dissection, various techniques have been described by different authors. Here, in this case report we are describing technique of utilization of transposed recipient splenic artery for graft arterial inflow where native hepatic artery was dissected up to common hepatic artery. Post-operative recovery was uneventful and on follow up, patient was absolutely fine. So, recipient splenic artery is a safe alternative option in such complex situations for providing arterial blood flow to the graft and moreover it avoids the burden of extra anastomosis which is required in conduit technique.

Endovascular Stenting of Large Hepatic Artery Aneurysm: Case Report

Background: Large hepatic artery aneurysms are rare, especially spontaneous ones without history of hepatopancreatobiliary surgery or trauma. They are serious and need attention due to risk of spontaneous rupture. Management depends on local expertise with endovascular management being the preferred option, and surgical repair usually reserved to ruptured aneurysms in hemodynamically unstable patients. Methods: A 54-year-old female patient was referred to our hospital for treatment of incidentally discovered large hepatic artery aneurysm without obvious etiology. The decision was made to attempt percutaneous endovascular management at the interventional radiology unit. Result: The aneurysm sac was successfully excluded using covered stents. This was complicated by right hepatic artery occlusion and clinically insignificant contrast extravasation. These complications did not have any clinical sequel in terms of hemodynamic stability or impaired liver function. The patient was safely discharged few days after the procedure. Conclusion: Endovascular management of spontaneous large hepatic artery aneurysms is effective. Potential complications include hepatic artery occlusion and dissection, which may or may not have serious clinical consequences. This offers a less invasive treatment option compared to surgery.

Asymptomatic hepatic artery dissection early after living-donor liver transplantation with simultaneous splenectomy: two case reports

BackgroundHepatic artery dissection after liver transplantation is an uncommon morbidity. The onset mechanism and management for this disorder remain unclear. The present report describes the cases of two patients with hepatic artery dissection after living-donor liver transplantation (LDLT) with simultaneous splenectomy and provides new insight into the onset mechanism of this disorder.Case presentation: Case 1A 51-year-old man with liver cirrhosis caused by hepatitis B virus underwent LDLT with a right lobe graft and splenectomy simultaneously. The recipient’s right hepatic artery had partial dissection at the anastomosis site; therefore, his left hepatic artery was anastomosed. Contrast-enhanced computed tomography (CT) on postoperative day (POD) 27 showed dissection from his celiac artery to his left hepatic artery with bleeding in the false lumen. There was a risk of rupture of the false lumen; therefore, emergency interventional radiology and coil embolization of the false lumen were performed. The patient was doing well at 6 months after LDLT.Case 2A 58-year-old woman with liver cirrhosis caused by primary biliary cholangitis underwent LDLT with a left lobe graft and splenectomy simultaneously. Her hepatic artery had a dissection that extended from her left hepatic artery to the proper hepatic artery. The gastroduodenal artery was anastomosed. Contrast-enhanced CT on POD 8 revealed dissection from the celiac artery to the common hepatic artery as well as a pseudoaneurysm at the celiac artery. We managed the patient with conservative treatment and performed daily follow-ups with Doppler ultrasonography examination and serial contrast-enhanced CT. At the time of writing this report, the patient was doing well at 34 months after LDLT.ConclusionsPatients who have an intimal dissection at the anastomosis site and/or simultaneous splenectomy are at a higher risk of hepatic artery dissection. Most patients with asymptomatic hepatic artery dissections can be treated conservatively. Blood flow in the intrahepatic artery should be checked frequently using Doppler ultrasonography or contrast-enhanced CT soon after diagnosis.

S0991 Hepatic Artery Complications Post Liver Transplantation in Patients Treated With Pretransplant Transarterial Chemoembolization

INTRODUCTION: The use of locoregional therapy, such as transarterial chemoembolization (TACE), minimizes the risk of hepatocellular carcinoma (HCC) progression in patients with cirrhosis listed for liver transplantation (LT). Previous studies have shown the association of TACE with a higher prevalence of hepatic artery stenosis post LT. In this study, we aimed to compare the prevalence of post-operative hepatic artery complications in LT patients with HCC who received TACE pretransplant versus LT patients with HCC without TACE. METHODS: We conducted a retrospective single-center cohort study of all adult patients who underwent LT at our institute between 2013 and 2018. We collected data on the presence of HCC, receipt of TACE, donor and recipient demographics, graft characteristics, and perioperative variables (Tables 1 and 2). The primary outcome was the development of HAT and HAS. Secondary outcomes were graft failure and mortality. We used univariate and multivariate logistic regression to ascertain the odds of binary outcomes relative to the utilization of TACE. Kaplan Meier estimates were used to compare graft survival and overall survival. RESULTS: We included 145 HCC patients with cirrhosis, out of a total of 341 patients who underwent LT. We compared 91 patients (75.9% males, 61.4 years median age) who received pre-LT TACE with 54 patients (70.3% males, 61 years median age) who did not. The prevalence of HAS was 23.1% in the TACE group and 22.1% in the no TACE group (P = 0.9). The prevalence of HAT was 7.69% in the TACE group and 3.70% in the no TACE group (P = 0.25) (Table 3). Although statistically not significant, the rates of complications after endovascular therapy (EVT) for the treatment of HAS, was higher in the TACE group compared to the no TACE group (5.49% vs. 1.85%, P = 0.41). Four complications were noted in the TACE group (hepatic artery dissections in 3, and one case of stent erosion and extravasation). There was no difference in graft failure and overall mortality between the two groups. CONCLUSION: We found that TACE before LT, did not increase the rate of HAS or HAT post LT. However, we noted higher rates of EVT for HAS related complications in the TACE recipient group. The trauma of arterial instrumentation and arterial wall injury from chemotherapeutic agents may make the patients treated with TACE more prone to vascular complications, particularly after EVT for HAS. Further studies are needed to understand the impact of TACE on post LT vascular complications.Table 1Table 2Table 3

Intraoperative Challenge for Vascular Reconstruction in Orthotopic Liver Transplantation Because of Extensive Portal Thrombosis and Intimal Dissection of the Hepatic Artery.

CASE REPORT The presence of the portal vein (PV) thrombosis in cirrhotic patients is not considered an absolute contraindication for liver transplantation, despite being technically challenging and associated with longer operative time and poor outcomes.1 We aim to present a patient with an extensive portal thrombosis who underwent a deceased donor liver transplantation. A 41-year-old man presented with a diagnosis of alcoholic cirrhosis (Model for End-Stage Liver Disease score = 28) and a history of multiple upper gastrointestinal bleeding and refractory ascites. Computed tomography revealed revascularized PV cavernous transformation with signs of left segmental portal hypertension in the splenic, gastric, and esophagic territories, without low-pressure signs in the superior mesenteric vein system (Figure 1). The patient underwent a successful nonanatomical liver transplantation with an implantation of the donor PV into the recipient's left gastric vein (LGV) in an end-to-side fashion. To increase the flow in the liver graft, a distal ligation of LGV was performed to avoid vascular steal phenomenon toward the esophagus or gastric territories (Figure 2). Intraoperatively, a complete intimal dissection of the recipient common hepatic artery was confirmed and thus, the donor hepatic artery flow was reconstructed using an iliac artery interposition graft from the infrarenal aorta (Figure 3). The postoperative outcome was uneventful, and the patient was discharged under anticoagulation therapy on the seventh postoperative day (Video 1; watch the video at https://links.lww.com/ACGCR/A20).Figure 1.: Computed tomography showing signs of segmental portal hypertension in the splenic, gastric, and esophagic areas due to portal vein cavernous transformation.Figure 2.: Nonanatomical reconstruction of the graft portal flow with an implantation of the donor PV into the recipient left gastric vein (distal ligation to increase PV flow). PV, portal vein.Figure 3.: The final aspect of the liver graft vascular reconstruction. The arterial anastomosis of the donor common hepatic artery and iliac artery interposition graft from the infrarenal aorta. PV reconstruction of the donor PV and the recipient left gastric vein. PV, portal vein.The presence of PV thrombosis is a complex scenario in patients on a waiting list for liver transplantation, and it is observed in 10% of preoperative imaging in cirrhotic patients.2 The cause of the occurrence of PV thrombosis is multifactorial, and it is probably related to the presence of extensive fibrosis of the hepatic parenchyma, a procoagulant state, and periportal lymphangitis. Other risk factors have been described including male sex, alcoholic liver disease, previous splenectomy, and the coexistence of a hepatocellular carcinoma. Unfortunately, the presence of PV thrombosis has been associated with poor patient survival after a liver transplantation.3,4 Despite being a challenging situation, it does not represent a contraindication for liver transplantation.1 There are several options to manage portal reconstruction including anatomical reconstruction with portal-portal anastomosis after portal thrombectomy or nonanatomical reconstruction including the implantation of the donor PV in the recipient superior mesenteric vein, LGV, vena cava with or without the use of interposition iliac vein grafts.5 From the surgical point of view, PV flow reconstruction in this setting represents a technical challenge and usually increases operative time, bleeding risk, graft failure rate, and finally, the risk of postoperative PV rethrombosis.6 In our case, it was performed for a nonanatomic PV reconstruction using the recipient LGV with an end-to-lateral anastomosis and distal ligation of the LGV to redirect the portal flow to the liver graft. DISCLOSURES Author contributions: F. Laxague wrote the manuscript and is the article guarantor. V. Agustin provided the video. R. Dario and Q. Emilio edited the manuscript. C. M. Agustina provided the video and images. L. McCormack wrote and revised the manuscript for intellectual content. Financial disclosure: None to report. Informed consent was obtained for this case report.