Hepatic Artery Rupture Research Articles

Transplant Hepatic Artery Rupture.

A case of transplant hepatic artery thrombosis treated with thrombolysis and vascular stenting is presented. Stenting was complicated by hepatic artery rupture necessitating emergent stent graft placement. Hepatic artery occlusion in a liver transplant often leads to biliary complications such as ischemic cholangiopathy, biliary necrosis, cholangitis, biloma formation, intrahepatic abscesses, and liver failure. Prompt recognition and appropriate treatment of hepatic artery thrombosis are necessary to avoid graft failure and possible death.

中結腸動脈瘤破裂に続発して肝動脈後区域枝の切迫破裂を認めたsegmental arterial mediolysisの1例

中結腸動脈瘤破裂に続発して肝動脈後区域枝の切迫破裂を認めたsegmental arterial mediolysisの1例

Endoscopic Removal of Migrated Vascular Embolic Material from the Common Bile Duct: A Multimodality Approach

Figure: No Caption available.Purpose: A 74-year-old man underwent percutaneous trans-hepatic cholangiography (PTC) for a distal non-malignant common bile duct (CBD) stricture with internal and external drain placement in 2009. At a subsequent drain exchange, he developed significant bleeding from the drain, which necessitated coil embolization of the hepatic artery. He did well afterwards and drains were removed. Three years later, he developed jaundice and cholangitis. ERCP done at an outside facility revealed a foreign body, which was assumed to be jag wires from a prior ERCP. A plastic stent was placed for biliary drainage, and he was referred to us for further management. A CT scan noted hardware within the porta-hepatis that caused streak artifact, along with dilation of intra-hepatic bile ducts. Review of the case suggested endovascular coils in the bile duct. It was assumed that some of the embolic material from the hepatic artery had eroded into CBD. It was decided to remove this embolic material by ERCP. Due to concern of hepatic artery rupture during retrieval, a catheter was positioned in the hepatic artery by interventional radiology (IR) to facilitate rapid re-embolization, should uncontrolled bleeding occur. During ERCP balloon extraction of a vascular plug with sludge was performed, followed by removal of filamentous wires in distal CBD with rat-tooth forceps. The duct was then accessed with spyglass to extract the more proximal wires using spybite. A fluoroscopic video obtained at the end of the procedure demonstrated remaining coils in a different plane from the biliary system, most likely in the hepatic artery. There was a thin sliver of embolic material remaining in the CBD that will probably epithelialize. There was no GI bleeding during the procedure. The patient has been event-free for over seven months now. Post-cholecystectomy clips, suture material and displaced stents are commonly discussed foreign bodies in CBD. There are limited reports on migration of vascular embolic material into duodenum; however, erosion of vascular coils into CBD is an extremely rare situation. Our case demonstrates successful use of various endoscopic techniques to manage this otherwise high-risk and presumably surgical condition. Adopting a multi-modality approach with IR backup may prevent need for surgical exploration of CBD in such intricate cases. Our method of management may serve as a teaching tool for endoscopists who may encounter a similar situation.

GW24-e1752 Animal study of application of kelp micro gelation embolisation for hepatic artery rupture

ObjectivesEffective treatment of patients with vascular disease during war or natural disasters is a worldwide problem. We aimed to develop a novel field injuries surgical treatment cabin to provide emergency...

Hepatic Artery Ligation for Arterial Rupture Following Liver Transplantation: A Reasonable Option

Hepatic artery (HA) rupture after liver transplantation is a rare complication with high mortality. This study aimed to review the different managements of HA rupture and their results. From 1997 to 2007, data from six transplant centers were reviewed. Of 2649 recipients, 17 (0.64%) presented with HA rupture 29 days (2-92) after transplantation. Initial management was HA ligation in 10 patients, reanastomosis in three, aorto-hepatic grafting in two and percutaneous arterial embolization in one. One patient died before any treatment could be initiated. Concomitant biliary leak was present in seven patients and could be subsequently treated by percutaneous and/or endoscopic approaches in four patients. Early mortality was not observed in patients with HA ligation and occurred in 83% of patients receiving any other treatment. After a median follow-up of 70 months, 10 patients died (4 after retransplantation), and 7 patients were alive without retransplantation (including 6 with HA ligation). HA ligation was associated with better 3-year survival (80% vs. 14%; p=0.002). Despite its potential consequences on the biliary tract, HA ligation should be considered as a reasonable option in the initial management for HA rupture after liver transplantation. Unexpectedly, retransplantation was not always necessary after HA ligation in this series.

ASSA13-03-48 Animal Study of Application of Kelp Micro Gelation Embolization For Hepatic Artery Rupture

BackgroundEffective treatment of patients with vascular disease during war or natural disasters is a worldwide problem. We aimed to develop a novel field injuries surgical treatment cabin to provide emergency...

Early Experience of the Use of Ringed PTFE Graft for Middle Hepatic Vein Reconstruction for Living Donor Liver Transplantation

Introduction: We present the initial experience of use of ringed PTFE graft for middle hepatic vein (MHV) reconstruction for living donor liver transplantation (LDLT) at Haeundae Paik hospital during two years from the hospital opening. Large vein allograft, especially cryopreserved vein, is suitable for MHV reconstruction, but its supply is often limited in a newly opened hospital. For this reason, ringed PTFE (GORE-TEX®) grafts (10-12 mm in diameter) were used to reconstruct MHV branches for the modified right lobe grafts in our institution. Method: From March 2010 to December 2011, 10 LDLTs and 1 deceased donor LT were performed at our hospital. There were 8 cases of modified right lobe graft (MRL) and 2 cases of dual grafts. 7 ringed PTFE grafts were used in 8 MRL. In one MRL, ringed PTFE did not need due to MHV branches were less than 5 mm in diameter. 6 of 7 cases were analyzed. One case was excluded because retransplantation was performed 3 weeks later of LDLT due to hepatic artery rupture. Results: The patency of the ringed PTFE graft was checked with computed tomography scan of the liver. The 1-month, 4-month and 6-month patency rates of the ringed PTFE grafts were 100% (6/6), 50% (3/6) and 16.6% (1/6) respectively. All showing late obstruction (over 4 months) were asymptomatic (no elevated liver enzyme) and did not have congestion of the liver on CT scans. There were no specific complications related using ringed PTFE graft and no patient death, chronic graft dysfunction or graft loss during follow up period. Conclusion: Although small cases, the early ringed PTFE graft function was excellent and late obstruction of ringed PTFE graft had no specific clinical problems on graft function or patient survival. Ringed PTFE graft seems to be a good alternative material for MHV reconstruction.

Sudden Death after Pancreatic Head Resection: Rupture of Hepatic Artery Caused by Clostridial Infection

Rupture of the hepatic artery caused by clostridial infection has not been reported before. Case report and literature review. A 75 year-old man was admitted to the hospital for resection of a cystic tumor of the head of the pancreas. A pylorus-preserving radical pancreaticoduodenectomy was performed. On the fifth postoperative day, he developed fever (38.2 degrees C), and computed tomography scanning revealed free air in the subhepatic area near the pancreaticojejunal anastomosis. On the ninth postoperative day, the patient died suddenly. Autopsy revealed a ruptured hepatic artery secondary to clostridial infection. Close monitoring and early recourse to invasive diagnostic and therapeutic procedures may be advisable in the presence of suspect findings after pancreatic surgery to prevent this fatal complication.

Stent-Graft for the Management of Hepatic Artery Rupture Subsequent to Transcatheter Thrombolysis and Angioplasty in a Liver Transplant Recipient

Arterial rupture subsequent to angioplasty occurs in about 5% of cases. Thrombolysis with re-establishment of flow without resolving underlying anatomic defects such as hepatic arterial stenosis leads to re-thrombosis. We present a case of arterial anastomotic rupture after thrombolysis and angioplasty of an underlying anastomotic hepatic arterial stenosis. Both the underlying anatomic defect and the rupture were resolved successfully with placement of a stent-graft, with a resultant patent artery for 1 year after the procedure.

Liver Transplantation From a Donor Affected by Marfan's Syndrome

Marfan's Syndrome (MS) is a systemic inheritable connective tissue (CT) disease related to fibrillin-1 genetic mutation, which gives an abnormal consistency to the CT. This compromised structure of the CT is related to cardiovascular, skeletal, and ocular system complications (1, 2). A 49-year-old patient underwent liver transplantation (LT) for hepatitis C virus-related end-stage liver disease and hepatocellular carcinoma. The donor was a 17-year-old female with MS pronounced brain dead from postanoxic brain injury. Her clinical findings from MS were characterized by severe mitral valve prolapse and bone-joint abnormalities. She was not affected from any vascular manifestation of arterial degeneration; however, the liver was the only organ harvested. Histological hepatic artery analysis, performed over the procurement, appeared normal; therefore, the organ was considered suitable. Before procurement, the recipient received a thorough informed-consent about MS. During posttransplant follow-up, the graft hepatic artery was checked by serial ultrasound-Doppler scans, weekly for the first month and subsequently once per month; angio-computed tomography scan was performed on the sixth month. The vascular changes from MS mostly involve the main vessels (incidence ranged between 30% and 50%) because of the greater content of compromised CT within the vessel walls and to the higher pressure and blood flow the arteries are exposed to. The incidence of visceral artery changes is approximately 0.4−2% and is usually manifested with cystic medionecrosis (1–3). In the literature, only two hepatic artery complications are described in patients with MS. Santiago-Delpin et al. (4) described a case of incomplete MS with multiple aneurysms of the aorta and its branches, in which a hepatic artery aneurysm perforated into the common bile duct. Ruschen et al. (5) in 1984 published a case in which a spontaneous hepatic artery rupture occurred in a patient with MS. The FBN1-gene mutation persists in the transplanted graft and, theoretically, may increase the risk of vascular complications such as dilation, aneurysmal changes, dissection, and intimal tears (6). Our rationale to accept a donor with MS was based on the low incidence of hepatic artery complications and total absence of hepatic dysfunction in patients with MS. The normal hepatic artery biopsy also gave a crucial piece of information in the acceptance process. Farese et al. (6) suggested another potential complication occurring in this setting: the possibility of antibodies developed against mutated fibrillin-1 donor liver cells. To date, we have not detected any posttransplant liver dysfunction and the recipient has not presented graft rejection. In conclusion, LT from MS donors may represent an opportunity to expand the potential donor pool. Moreover, the mean age at death of patients affected from MS is 45 (±16) years old; therefore, the liver status of such a young donor should be better than common marginal donors (7, 8). The biopsy at the time of procurement should be the first step in accepting an organ from a patient with MS. Furthermore, we advocate a closer follow-up of the graft vessels by means of Doppler-ultrasound in patients receiving such a graft. After a follow-up of 10 months our recipient did not show signs of graft complications or hepatic artery changes. Fabrizio Di Benedetto Stefano Di Sandro Nicola De Ruvo Michele Masetti Liver and Multivisceral Transplant Center University of Modena and Reggio Emilia Modena, Italy Cristiano Quintini Department of General Surgery Cleveland Clinic Foundation Cleveland, OH Roberto Montalti Roberto Ballarin Giorgio E. Gerunda Liver and Multivisceral Transplant Center University of Modena and Reggio Emilia Modena, Italy

Safety and efficacy of living donor liver preservation with HTK solution

Background In living donor liver transplantation (LDLTx) organ procurement is usually well controlled, and allows to assess liver preservation and graft function under standardized conditions. Because publications on histidine-tryptophan-ketoglutarate (HTK) solution are limited, we prospectively studied its safety and efficacy in a consecutive series of LDLTx. Methods Twenty-four patients received 22 right, 1 left, and 1 left lateral lobe graft. Liver preservation was done by gravity perfusion with HTK through portal vein, and hepatic artery, and flushing of bile ducts. Total ischemia time was 191 ± 68 minutes. Results There was no primary nonfunction, and all partial liver grafts showed good recovery: peak aspartate aminotransferase 577 U/L, total bilirubin 15.15 mg/dL, and partial thromboplastin time 49.37 seconds. One graft was lost from parenchymal fracture secondary to portal hyperperfusion after 6 days, and the patient was salvaged with retransplantation. Thirty-day mortality, including sudden cardiac death, pancreatitis, and hepatic artery rupture, was not related to graft dysfunction. Eight of 24 recipients developed early biliary leakage. There was no late ischemic type biliary lesion. Conclusion These results confirm that HTK solution is safe and effective when used in LDLTx. Potential advantages of HTK in comparison to other preservation solutions are low potassium concentration, low viscosity, no particles, in situ perfusion, no need to flush before reperfusion, improved biliary protection, better recovery of microcirculatory changes, ready to use, and lower costs. Because the risk–benefit ratio is of particular importance in LDLTx the use of HTK solution should be encouraged.

Lethal infection by candida (Torulopsis) incospicua complicating orthotopic liver transplantation

We report here an uncommon case of deep infection by Torulopsis incospicua, associated with multibacterial sepsis and complicated by several mycotic aneurysms of hepatic artery, liver graft necrosis, and hepatic acute failure in a liver orthotopic transplant recipient. Two successive emergency liver transplants were needed, but fast relapses of infection and mycotic aneurysms were experienced. The patient died soon after the third liver transplant; disseminated mycosis was demonstrated by post mortem examination. In conclusion, fungal infection should be considered in cases of spontaneous hepatic artery rupture.

SAFETY AND EFFICACY OF LIVING DONOR LIVER PRESERVATION WITH HTK SOLUTION

P44 Aims: Organ procurement in living donor liver transplantation (LDLTx) is usually well controlled, and allows to assess the quality of liver preservation as well as early graft function under standardized conditions. Since publications on histidine-tryptophan-ketoglutarate solution (HTK) are limited, we prospectively studied its safety and efficacy in LDLTx. Methods: This consecutive series included 23 patients (20 adults, 3 children; age 9 mo-61 yr), suffering from end-stage cirrhosis (16), malignant liver tumors (6), and acute hepatic failure (1), respectively. All donors (age 22-69 yr) had normal liver function tests, including six with steatosis of 5-20 %. The donor operation was performed by the same surgeon, and resulted in 21 right lobes, one left lobe, and one left lateral graft (graft weight 836±213 g). Liver preservation was done in a standard fashion by gravity perfusion with HTK, starting in situ through the portal vein (4.6±1.0 L), and continued on the backtable with infusion via the hepatic artery (1.0±0.5 L), for 10 min each to allow for adequate electrolyte equilibration. Aditionally, the bile ducts were flushed with HTK. Results: First and second warm ischemia times were <1 min, and 39±15 min, respectively; total ischemia time was 195±66 min. There was no primary non-function in this series, and all liver grafts showed good recovery with peak aspartate aminotransferase 589±498 U/L, total bilirubin 15.94±8.29 mg/dL, and partial thromboplastin time 49.90±9.58 sec. One graft was lost from parenchymal rupture secondary to portal hyperperfusion, and the patient was successfully retransplanted after six days. 30-day mortality was 13 %, and included pancreatitis, hepatic artery rupture, and sudden cardiac death. 7/23 recipients developed early biliary leakage after 8-45 d from the resectional surface, and following multiple duct reconstructions. There was no late ischemic type biliary complication. Conclusions: These results confirm earlier observations that HTK solution is safe and effective, also when used in LDLTx. Potential advantages of HTK in comparison to other preservation solutions are: low potassium concentration, low viscosity, high flow, fast cooling, ready to use, no particles, in situ perfusion, no flush before reperfusion, improved biliary protection, better recovery of microcirculatory changes, and lower costs. Since the risk-benefit ratio is of particular importance in LDLTx the use of HTK solution should be encouraged.

Sonographic Evaluation of Complications of Liver Transplantation

This article reviews several of the major complications that occur after liver transplantation and describes radiologic modalities used to diagnose and evaluate them. To illustrate the discussion, case presentations of five patients who under-went liver transplantation at the Nazih Zuhdi Transplantation Institute at Integris Baptist Medical Center in Oklahoma City are given. Many of the major complications of liver transplantation can be characterized as vascular or biliary in origin. Hepatic artery thrombosis is the most dreaded complication in the immediate postoperative period because it often necessitates retransplantation. Hepatic artery stenosis can alter graft function as well. Less common arterial complications include pseudoaneurysm formation, hepatic artery rupture and arteriovenous fistula formation. Venous complications include inferior vena cava and portal vein thrombosis and stenosis. Gray-scale and color Doppler ultrasound play a primary role in detection of vascular complications. Angiography or venography may be used for definitive diagnosis. Biliary complications, such as biliary leakage or stricture, occur with some frequency after transplantation and are best evaluated with sonography, cholangiography, and nuclear medicine studies. A late complication of liver transplantation is posttransplant lymphoproliferative disorder, which may be detected and evaluated by ultrasound, computed tomography, and magnetic resonance imaging. Graft rejection is better detected by nonradiologic means.

Rupture of the hepatic artery after left hemihepatectomy for hilar bile duct carcinoma

Hilar bile duct carcinoma has a poor prognosis, but this has been improved in recent years by an aggressive surgical approach. We treated a 73-year-old woman who had obstructive jaundice due to bile duct carcinoma at the hepatic hilum. The jaundice decreased after percutaneous transhepatic biliary drainage. The tumor was resected with the left and caudate lobe of the liver and a part of portal vein. The right hepatic artery was located behind the common hepatic duct, and was suspected to be invaded by the tumor. We dissected the tumor from the arterial wall without carrying out combined resection of the hepatic artery. On the 6th postoperative day, the hepatic artery ruptured and the patient suffered hypovolemic shock. Resection of the hepatic artery and reconstruction were done, but the patient died 2 days later. Histological examination of the resected artery showed that the tumor had been curatively removed by dissection and that no tumor remained at the arterial wall. The rupture of the right hepatic artery was thought to have been caused by damage to the wall during the dissection procedure.

Arterial and pseudoaneurysm ruptures complicating liver transplantation

Ruptures of the hepatic artery and hepatic pseudoaneurysms (PA) are rare but serious complications of hepatic transplantation. We conducted a retrospective study of 640 liver transplantations performed in our institution for a variety of pathologies. After surgery, seven major arterial bleeds occurred (0.9%). Of these seven cases, there were due to hepatic artery rupture (HAr) and four to PA rupture; all confirmed at either surgery (six cases) or autopsy (one case). Five of the seven patients died. In all cases the transplantation was difficult. All vascular injuries but one were caused by sepsis and occurred either after an undetermined cause septicemic syndrome (five cases) or graft dysfunction (one case). The last vascular injury was biliary drainage related. Six of the seven patients had imaging studies. Sonography (five cases) found a sub-hepatic hypoechoic collection in three cases but failed to do so in two. Duplex doppler (three cases) failed in all three cases to demonstrate a PA. Computed tomography (three cases) showed one PA, one perihilar sub-hepatic collection and failed in one. Conventional angiography (three cases) depicted a PA in all three cases. At the present time, our practice is to perform systematic angiography in patients with undetermined cause septicemic syndrome to research a PA. And if angiography is normal, to then puncture systematically any sub-hepatic collection to determine the bacteriological nature of this collection.

Vascular complications after orthotopic liver transplantation

Over a 57-month period, we performed 430 orthotopic liver transplants in 372 patients. A total of 38 vascular complications were identified including hepatic artery thrombosis (n = 24), portal vein thrombosis (n = 6), combined hepatic artery thrombosis/portal vein thrombosis (n = 3), and hepatic artery rupture (n = 5). A number of potential risk factors for the development of vascular thrombosis were evaluated with only children, weight less than 10 kg, and cold ischemia time found to be significant. The clinical presentation included fulminant hepatic failure, allograft dysfunction, biliary sepsis, and screening ultrasound. Duplex ultrasonography was diagnostic in nearly all cases. Therapeutic modalities included revascularization, revascularization followed by retransplantation, retransplantation alone, and observation. Five cases of hepatic artery rupture occurred in four patients. Infectious arteritis was present in four patients. The 6-month actuarial survival in patients with vascular complications was 70%. Early diagnosis is critical for graft salvage, with surgical intervention the mainstay of therapy.