Hepatic Artery Thrombosis Research Articles

Transplant Hepatic Artery Complications

Hepatic artery complications can be divided into two different categories, non-occlusive and steno-occlusive disease. Steno-occlusive disease is a collective term that encompasses hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks, while non-occlusive arterial disease encompasses less than 5% of complications and is a collective term used to describe arteriovenous fistulae, pseudoaneurysms, arterial rupture and nonocclusive hepatic artery hypoperfusion syndrome. This article details the angiographic techniques and definitions needed to accurately diagnose arterial transplant complications and describes the technical aspects and results of endoluminal management of these arterial complications. In addition, this article discusses the presentation, etiology and indications for treatment, including surgical management of these various complications.

A case of successful treatment of arterial and biliary complications in a patient after liver transplantation

In April, 2018, a 57-year old patient with cirrhosis of the liver (Child-Turcotte-Pugh B class) during the outcome of viral hepatitis B and C was performed Transjugular Intrahepatic Portosystemic Shunt (TIPS); and in June, 2018 – liver transplantation (LТ) from a deceased donor by Piggyback technique. In the postoperative period, abscesses in the left and right lobes of the liver and thrombosis of the hepatic artery thrombosis (HAT) were noticed. Balloon dilatations of biliary stricture with changes of biliary drainage were made during the period of 2 years. In May, 2022, according to the results of angiography, hepatic artery and its branches were seen up to segmental level that meant natural revascularization. Considering the low efficiency of the balloon plastic procedures carried out, there was formed trihepaticojejunostomy on the loop of the small intestine disconnected according to Roux-en-Y. The follow-up period is one and a half years; there are no signs of cholangitis and biliary hypertension.There is no unified scheme of treatment for vascular and biliary complications in the clinics engaged in LТ, because every technique has both advantages and disadvantages. The idea of choice between intervention revascularization, transplantation and surgical reconstruction in the treatment of arterial thrombosis still remains incompletely understood.

Impact and Consequences of Recipient Gastroduodenal Artery Ligation Before Hepatic Artery Anastomosis During Orthotopic Liver Transplantation.

The recipient's gastroduodenal artery is often ligated before the hepatic artery anastomosis during orthotopic liver transplant, to gain either mobility or length of recipient's hepatic artery, potentially protecting the anastomosis by preventing "steal syndrome." In this study, our aim was to evaluate the consequences of gastroduodenal artery ligation and its effect on prevention of hepatic artery thrombosis. We retrospectively analyzed deceased-donor orthotopic liver transplant procedures (n = 210) performed at a single center between January 2016 and July 2021 to compare outcomes between recipients with (group 1) and recipients without (group 2) gastroduodenal artery ligation. Group 1 included 78 patients (37%), in which the recipient's common hepatic artery was used for arterial anastomosis; group 2 included 132 patients (63%), in which the right hepatic artery orthe proper hepatic artery was used for arterial anastomosis. Occurrences of hepatic artery thrombosis, postoperative hyperamylasemia, nausea and vomiting, and delayed feeding were compared between the groups. There was no incidence of hepatic artery thrombosis reported in either group. In group 1, 31 patients (39.7%) were reported to have postoperative hyperamylasemia, ranging from 200 to 4700 U/L accompanied by delayed feeding, whereas, in group 2, only 16 of 132 patients (12%) had postoperative hyperamylasemia, ranging from 200 to 1400 U/L (P < .01). Ligation of recipient's gastroduodenal artery is not associated with decreased risk of hepatic artery thrombosis compared with nonligation. However, the procedure does have consequences in the form of possible postoperative hyperamylasemia, leading to delayed feeding probably due to decreased oral tolerance.

Mini-incision Right Hepatectomy for Living Donor Hepatectomy.

The application of a minimally invasive technique to graft procurement in living donor liver transplantation has minimized skin incisions and led to early recovery in donor hepatectomy while ensuring donor safety. This study aimed to evaluate the safety and feasibility of mini-incision living donor right hepatectomy compared with conventional open surgery. The study population consisted of 448 consecutive living donors who underwent living donor right hepatectomy performed by a single surgeon between January 2015 and December 2019. According to the incision type, the donors were divided into 2 groups: a right subcostal mini-incision group (M group: n = 187) and a conventional J-shaped incision group (C group: n = 261). A propensity score matching analysis was conducted to overcome bias. The estimated graft volume and measured graft weight were significantly lower in the M group ( P = 0.000). The total of 17 (3.8%) postoperative complications were identified. The readmission rate and overall postoperative complication rate of donors was not significantly different between the groups. The biliary complication rates in the recipients were 12.6% and 8.6% in the C group and M group, respectively ( P = 0.219). Hepatic artery thrombosis requiring revision developed in 2 patients (0.8%) in the C group and 7 patients (3.7%) in the M group ( P = 0.038). After propensity score matching, these complications were not significantly different between the groups. Mini-incision living donor right hepatectomy shows comparable biliary complications to open surgery and is considered a safe and feasible operative technique.

Isolated hepatic perfusion for metastases of uveal melanoma: hospital outcomes

Objective: To evaluate hospital outcomes of isolated hepatic perfusion for metastases of uveal melanoma.Methods: In 2020-2022, 38 isolated hepatic perfusion procedures for unresectable metastases of uveal melanoma were performed in the Kostroma Regional Cancer Center. Our study included the following complications: death, bleeding, tumor lysis syndrome, abscess in the left lobe of the liver, peritonitis, asystole, lower extremity deep vein thrombosis, hydrothorax, acute liver failure, anasarca, polyserositis, ischemic cholangiopathy, common hepatic artery thrombosis, detachment of the common hepatic artery intima. We calculated a composite end point (the sum of all the complications).Results: In 2 cases, there was an accidental decannulation of the cannula placed in the proper hepatic artery in the 30th minute of perfusion. Due to hemodynamic instability, the procedure was terminated. Death from worsening liver failure was reported in 3 cases. Postoperative bleeding was diagnosed in 7 patients, and relaparotomy was performed to stop the bleeding. Subsequently, no concerns were reported. The combined end point was 42.11%.Conclusion: Isolated hepatic perfusion is an unsafe treatment option for patients with liver metastases of uveal melanoma. Received 12 May 2023. Revised 16 June 2023. Accepted 21 June 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.D. Kaprin, Yu.V. BelovData collection and analysis: A.N. Kazantsev, V.M. UnguryanStatistical analysis: A.N. Kazantsev, V.M. Unguryan, A.V. KorotkikhDrafting the article: A.N. Kazantsev, V.M. UnguryanCritical revision of the article: A.D. Kaprin, Yu.V. Belov, S.A. IvanovFinal approval of the version to be published: V.M. Unguryan, A.N. Kazantsev, A.V. Korotkikh, S.A. Ivanov, Yu.V. Belov, A.D. Kaprin

Liver transplant in patients with primary sclerosing cholangitis: A retrospective cohort from Northeastern Brazil.

Primary sclerosing cholangitis (PSC) manifests within a broad ethnic and racial spectrum, reflecting different levels of access to health care. To evaluate the clinical profile, complications and survival rates of patients with PSC undergoing liver transplantation (LTx) at a Brazilian reference center. All patients diagnosed with PSC before or after LTx were included. The medical records were reviewed for demographic and clinical variables, including outcomes and survival. The level of statistical significance was set at P < 0.05. Our cohort represented 1.6% (n = 34) of the 2113 patients receiving liver grafts at our service over the past two decades. Most were male (n = 19; 56%). The average age (40 ± 14 years) was similar for men and women (P = 0.347). The mean follow-up time from diagnosis to LTx was 68 mo. Most patients had the classic form of PSC. Three women had PSC/autoimmune hepatitis overlap syndrome, and one patient had small-duct PSC. Alkaline phosphatase levels at diagnosis and pre-LTx model for end-stage liver disease. scores were significantly higher in males. Inflammatory bowel research (IBD) was investigated by colonoscopy in 26/34 (76%) and was present in most cases (18/26; 69%). IBD was less common in women than in men (44.4% vs. 55.6%) (P = 0.692). Cholangiocarcinoma (CCA) was diagnosed in 2/34 (5.9%) patients by histopathology of the explant (survival: 3 years 6 mo, and 4 years 11 mo). Two patients had complications requiring a second LTx (one after 7 d due to hepatic artery thrombosis and one after 17 d due to primary graft dysfunction). Five patients (14.7%) developed biliary stricture. The overall median post-LTx survival was 66 mo. Most deaths occurred in the first year (infection n = 2, primary liver graft dysfunction n = 3, unknown cause n = 1). The 1-year and 5-year survival rates of this cohort were 82.3% and 70.6%, respectively, matching the mean overall survival rates of LTx patients at our center (87.1% and 69.43%, respectively) (P = 0.83). Survival after 1 and 5 years was similar to that of other LTx indications. The observed CCA survival rate suggests CCA may be an indication for LTx in selected cases.

Hypothermic oxygenated perfusion in liver transplantation: a meta-analysis of randomized controlled trials and matched studies.

Hypothermic oxygenated machine perfusion (HOPE) is a novel organ-preservation technology designed to optimize organ quality. However, the effects of HOPE on morbidity and mortality after liver transplantation remain unclear. This meta-analysis evaluated the potential benefits of HOPE in liver transplantation. The Embase, Web of Science, PubMed, Cochrane Library, and Scopus databases were searched for articles published up to 15 June 2023 (updated on 12 August 2023). Mean differences (MDs), risk ratios (RRs), and 95% confidence intervals were calculated. Eleven studies encompassing five randomized controlled trials and six matched studies were included, with a total of 1000 patients. HOPE did not reduce the incidence of major postoperative complications (RR 0.80), primary non-function (PNF) (RR 0.54), reperfusion syndrome (RR 0.92), hepatic artery thrombosis (RR 0.92), renal replacement therapy (RR 0.98), length of hospital stay (MD, -1.38 days), 1-year recipient death (RR 0.67), or intensive care unit stay (MD, 0.19 days) after liver transplantation. HOPE reduced the incidence of biliary complications (RR 0.74), non-anastomotic biliary strictures (NAS) (RR 0.34), early allograft dysfunction (EAD) (RR 0.54), and acute rejection (RR 0.54). In addition, HOPE improved the retransplantation (RR 0.42) and 1-year graft loss rates (RR 0.38). Compared with static cold storage (SCS), HOPE can reduce the incidence of biliary complications, NAS, EAD, and acute rejection and retransplantation rate after liver transplantation and improve the 1-year graft loss rate. These findings suggest that HOPE, when compared to SCS, can contribute to minimizing complications and enhancing graft survival in liver transplantation. Further research is needed to investigate long-term outcomes and confirm the promising advantages of HOPE in liver transplantation settings.

Invasive aspergillosis in liver transplant recipients, an infectious complication with low incidence but significant mortality.

Infections, including invasive fungal infections (IFIs), are among the leading causes of mortality in liver transplant recipients during the first year post-transplantation. To investigate the epidemiology, clinical manifestations, risk factors, treatment outcomes, and mortality rate of post-liver transplantation invasive aspergillosis (IA). In this case-control study, 22 patients with IA were identified by reviewing the archived and electronic medical records of 850 patients who received liver transplants at the Imam Khomeini Hospital complex in Tehran, Iran, between 2014 and 2019. The control group comprised 38 patients without IA infection matched for age and sex. The information obtained included the baseline characteristics of liver transplant patients, operative reports, post-transplantation characteristics of both groups and information about the fungal infection of the patient group. The prevalence rate of IA among liver transplant recipients at Imam Khomeini Hospital was 2.7%. The risk factors of IA among studied patients included high serum creatinine levels before and post-transplant, renal replacement therapy, antithymocyte globulin induction therapy, post-transplant bile leakage, post-transplant hepatic artery thrombosis, repeated surgery within 30 d after the transplant, bacterial pneumonia before the aspergillosis diagnosis, receiving systemic antibiotics before the aspergillus infection, cytomegalovirus infection, and duration of post-transplant hospitalization in the intensive care unit. The most prevalent form of infection was invasive pulmonary aspergillosis, and the most common chest computed tomography scan findings were nodules, pleural effusion, and the halo sign. In the case group, prophylactic antifungal therapy was administered more frequently than in the control group. The antifungal therapy response rate at 12 wk was 63.7%. The 3- and 12- mo mortality rates of the patients with IA were 36.4% and 45.4%, respectively (compared with the mortality rate of the control group in 12 mo, which was zero). In this study, the prevalence of IA among liver transplant recipients was relatively low. However, it was one of the leading causes of mortality following liver transplantation. Targeted antifungal therapy may be a factor in the low incidence of infections at our facility. Identifying the risk factors of IFIs, maintaining an elevated level of clinical suspicion, and initiating early antifungal treatment may significantly improve the prognosis and reduce the mortality rate of liver transplant recipients.

Impact of patent foramen ovale on short-term outcomes in children with biliary atresia undergoing living donor liver transplantation: a retrospective cohort study

ObjectiveTo investigate the impact of patent foramen ovale (PFO) on the short-term outcomes of living donor liver transplantation (LDLT) in children with biliary atresia.MethodsWith the approval of the hospital ethics committee, 304 children with biliary atresia who underwent LDLT in our center from January 2020 to December 2021 were enrolled. According to the results of echocardiography before the operation, the subjects were divided into the PFO group (n = 73) and the NoPFO group (n = 231). The baseline characteristics; intraoperative recipient-related data and donor-related data; incidence of postreperfusion syndrome (PRS); postoperative mechanical ventilation time; ICU stay duration; postoperative hospital stay duration; liver function index; incidences of postoperative complications including acute renal injury (AKI), graft dysfunction, hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT); and one-year survival rate were compared between the two groups.ResultsThe median age in the PFO group was 6 months and that in the NoPFO group was 9 months (P < 0.001), and the median height (65 cm) and weight (6.5 kg) in the PFO group were significantly lower than those in the NoPFO group (68 cm, 8.0 kg) (P < 0.001). The preoperative total bilirubin level (247 vs. 202 umol/L, P = 0.007) and pediatric end-stage liver disease (PELD) score (21 vs. 16, P = 0.001) in the PFO group were higher than those in the NoPFO group. There were no significant differences in the intraoperative PRS incidence (46.6% vs. 42.4%, P = 0.533 ), postoperative mechanical ventilation time (184 vs. 220 min, P = 0.533), ICU stay duration (3.0 vs. 2.5 d, P = 0.267), postoperative hospital stay duration (22 vs. 21 d, P = 0.138), AKI incidence (19.2% vs. 24.7%, P = 0.333), graft dysfunction incidence (11.0% vs. 12.6%, P = 0.716), HAT incidence (5.5% vs. 4.8%, P = 0.762), PVT incidence (2.7% vs. 2.2%, P = 0.675) or one-year survival rate (94.5% vs. 95.7%, P = 0.929) between the two groups.ConclusionThe presence of PFO has no negative impact on short-term outcomes in children with biliary atresia after LDLT.

Treatment strategies for hepatic artery complications after pediatric liver transplantation: A systematic review.

This study aimed to evaluate the effectiveness of different treatments for hepatic artery thrombosis (HAT) and hepatic artery stenosis (HAS) after pediatric liver transplantation. We systematically reviewed studies published since 2000 that investigated the management of HAT and/or HAS after pediatric liver transplantation. Studies with a minimum of 5 patients in one of the treatment methods were included. The primary outcomes were technical success rate and graft and patient survival. The secondary outcomes were hepatic artery patency, complications, and incidence of HAT and HAS. Of 3570 studies, we included 19 studies with 328 patients. The incidence was 6.2% for HAT and 4.1% for HAS. Patients with an early HAT treated with surgical revascularization had a median graft survival of 45.7% (interquartile range, 30.7%-60%) and a patient survival of 61.3% (interquartile range, 58.7%-66.9%) compared with the other treatments (conservative, endovascular revascularization, or retransplantation). As for HAS, endovascular and surgical revascularization groups had a patient survival of 85.7% and 100% (interquartile range, 85%-100%), respectively. Despite various treatment methods, HAT after pediatric liver transplantation remains a significant issue that has profound effects on the patient and graft survival. Current evidence is insufficient to determine the most effective treatment for preventing graft failure.

Liver transplantation with interposition saphenous vein conduits for arterial reconstruction: Impact of morbidity and arterial ischemia time

BackgroundThe outcomes of liver transplantation with hepatic arterial reconstruction using interposition saphenous vein conduits are not widely reported. Here, we share our experience using great saphenous vein conduits for hepatic arterial reconstruction in living donor liver transplantation. MethodsThis was a single-center retrospective review of patients who underwent living donor liver transplantation (n = 950). The saphenous vein conduits were used in 39 patients. We compared hepatic artery thrombosis, graft dysfunction, and 30-day and 1-year survival in the early (2012–2017) and late (2017–2020) transplant periods. ResultsAmong 39 patients (of whom 30 [76.9%] were males, median Model for End-Stage Liver Disease was 24 [interquartile range, 17–27], median age was 50 [interquartile range, 43–54]), saphenous vein conduits were placed on supra celiac aorta in 7 (17.9%), infrarenal aorta in 25 (64.1%), and other arteries in 7 (17.9%) patients. The number of biliary and hepatic vein anastomoses, total arterial ischemia time, portal vein–hepatic artery reperfusion time, and duration of surgery was different in the 2 groups (P < .05). The 30-day mortality was 5/21 (23.8%) and 0 in the early and late periods (P = .05). The 30-day survival was >90% in patients with portal vein–hepatic artery reperfusion time <240 minutes, ≤2 grade 3 complications, no graft dysfunction, and later period of transplantation (P < .05). The 1-year survival with standard transplantation, transplantation with saphenous vein conduits in the early and late period was 87%, 62%, and 89% (P = .022). ConclusionLiver transplantation with saphenous vein conduits is associated with acceptable outcomes. Major complications and arterial ischemia times are major determinants of outcomes.

Preexisting portal vein thrombosis and adult LDLT: A retrospective cohort analysis

BackgroundPortal Vein Thrombosis (PVT) is a common concern in cirrhotic patients awaiting liver transplantation (LT), with high morbidity and mortality rates. While preexisting PVT was traditionally considered a contraindication for the LT procedure, recent advances in surgical techniques have provided new possibilities for operating on these patients. This retrospective cohort study compared the surgical outcomes of adult living donor liver transplantation (LDLT) patients with and without preexisting PVT. MethodsThe study analyzed data from 416 liver transplant recipients and included 270 patients without PVT and 69 patients with PVT who underwent LDLT between March 2019 and March 2023. Preoperative imaging methods and intraoperative assessments were used to diagnose PVT and classify the extent of the thrombus using the Yerdel classification. Various surgical techniques were employed to remove the thrombus and establish a portal flow to the graft. Postoperatively, patients were monitored for complications and followed up regularly. ResultsThere were no significant differences between the non-PVT and PVT groups regarding recipient age, gender, body mass index, primary disease leading to transplantation, Child-Pugh class, or Model for End-Stage Liver Disease (MELD) score. The operative variables, including graft type, duration of surgery, and cold and warm ischemia times, were also similar between the groups. The surgical procedures varied based on the Yerdel classification grade of PVT, with most patients undergoing partial or complete thrombectomy. The mean hospital stays, intensive care unit (ICU) stay duration, and reexploration rates were comparable between the non-PVT and PVT groups. However, the incidence of portal vein thrombosis was significantly higher in the PVT group (p < 0.001). Other complications, such as portal vein stenosis and hepatic artery thrombosis, occurred in a small number of patients. ConclusionThis retrospective cohort analysis demonstrates the feasibility of performing LDLT in patients with preexisting PVT using various surgical techniques. While the overall surgical outcomes and postoperative complications were comparable between patients with and without PVT, the incidence of portal vein thrombosis was higher in the PVT group. Further studies are needed to explore optimal management strategies for PVT in LDLT patients and improve outcomes in this population.

Celiac trunk stenosis by median arcuate ligament in orthotopic liver transplantation: a potential hidden foe to the biliary tree

BackgroundCeliac trunk compression by the median arcuate ligament (MAL) increases the risk of ischemic complications following gastrointestinal surgical procedures. Previous studies suggest increased risk of hepatic artery thrombosis (HAT) in orthotopic liver transplant (OLT) recipients. The aim of this study is to investigate the impact of untreated MAL compression (MAL-C) on biliary complications in OLT. MethodsContrast-enhanced imaging was used to classify celiac trunk stenosis by MAL-C. Medical records were reviewed to extract pre-transplant, transplant and post-transplant data. Patients were divided into two groups: no MAL compression (nMAL-C) and MAL-C. The primary endpoint was biliary complications. Secondary endpoints were HAT and graft survival. Results305 OLT were performed from 2010 to 2021, of which 219 were included for analysis: 185 (84.5%) patients without and 34 (15.5%) with MAL-C. The incidence of HAT was 5.9% in both groups. Biliary complications were more common in the MAL-C group (35.3% vs. 17.8%, p = 0.035). Graft survival was decreased in patients with MAL-C (p = 0.035). ConclusionsMAL-C of the celiac trunk was associated with increased risk of biliary complications and inferior graft survival in OLT patients. These findings highlight the importance of preoperative screening and treatment of MAL in this population.

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study).

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications. Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients. Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Impact of Recipient’s Inflow Artery Selection on Hepatic Artery Thrombosis Post Living Donor Liver Transplantation

Abstract Background Hepatic artery reconstruction is one of the most important steps in liver transplantation, and complications associated with this vascular reconstruction, such as hepatic artery thrombosis (HAT) may have a significant influence on the recipients’ prognosis. Aim of the Work The purpose of this retrospective study is to evaluate whether the selection of the recipient’s right versus left hepatic artery for hepatic artery reconstruction as an inflow artery will influence the chance of HAT after living donor liver transplantation (LDLT). Patients and Methods This is a retrospective study that analysed and evaluated the hospital records of all patients who underwent LDLT at Ain Shams University specialized Hospital (ASCOT) from January 2010 to January 2020. Records of all 390 patients were reviewed and drop out of 101 patients was performed according to the exclusion criteria. Results The study showed that the right hepatic artery was used in 79.5% of cases while the left hepatic artery was used in 20.1% of cases in the study population. The incidence of HAT was 7.3% in the whole study population. On further analysis of the arterial complications and distribution according to the usage of the right or left hepatic artery as the recipient inflow artery, there was an increase in the incidence of HAT when the right hepatic artery was used (7.9 %) compared to left hepatic artery which was (5.2 %) although it did not reach statistical significance. Conclusion Incidence of HAT was generally higher following LDLT using the right hepatic artery as the recipient’s inflow artery.

Favorable experience of transplant strategy including liver grafts from COVID-19 donors: One-year follow-up results.

Since November 2020, Italy was the first country to carry out a protocol and use liver from COVID-19 donors. We aimed to evaluate the medium-term outcome of patients who underwent liver transplant (LT) with those grafts. We consecutively enrolled 283 patients who underwent first LT from November 2020 to December 2022 in our Center (follow-up 468 days). Twenty-five of 283 (8.8%, study population) received a graft from donors with previous (4%) or active (96%) SARS-CoV-2 infection, and 258/283 (91.2%, control group) received a graft from COVID-19-negative donors. SARS-CoV-2-RNA was tested on graft tissue of COVID-19 donors and their recipients underwent weekly evaluation of SARS-CoV-2-RNA in nasal swabs for the first month after LT. One-year and 2-year patient survival was 88.5% and 88.5% in study group versus 94.5% and 93.5% in control group, respectively (p = .531). In study population there was no evidence of donor-recipient virus transmission, but three (12%) patients (vs. 7 [2.7%] of control group, p = .048) developed hepatic artery thrombosis (HAT): they were SARS-CoV-2-RNA negative at LT and 1/3 grafts tested SARS-CoV-2-RNA positive on liver tissue. COVID-19 donor was independently associated with HAT (odds ratio (OR) = 4.85, 95% confidence interval (CI) 1.10-19.15; p = .037). By comparing study population with control group, acute rejection and biliary complication rates were not significantly different (16%vs. 8.1%, p = .26; 16%vs. 16.3% p = .99, respectively). Our 1-year results of transplant strategy including liver grafts from COVID-19 donors were favorable. HAT was the only complication with significantly higher rate in patients transplanted with COVID-19 donors compared with control group.

Successful endovascular embolization of the common hepatic artery for pseudoaneurysm associated with pancreatic fistula after liver transplantation: a case report

BackgroundAfter orthotopic liver transplantation (OLT), complications such as hepatic artery stenosis, thrombosis, and bleeding are possible. Hepatic artery pseudoaneurysms (HAP) are prone to rupture, rupture hemorrhage, and increased mortality risk. Endovascular treatment of HAP may result in recurrence, even after successful embolization with thrombin. Formation of a HAP in the common hepatic artery (CHA) is challenging because the CHA is the only artery in the liver graft after OLT. Therefore, CHA embolization in HAP is not an initial option. We report a case of HAP at the CHA after OLT that was treated with endovascular therapy, resulting in the occlusion of the CHA with coil embolization, achieving a radical cure.Case presentationA 59-year-old man with decompensated hepatitis C virus cirrhosis underwent deceased donor whole-liver transplantation after graft failure of a living donor liver transplantation. After the second transplantation, the patient developed infectious narrow-necked HAP at the CHA associated with postoperative pancreatic fistula. Repeated transcatheter arterial embolization with thrombin and n-butyl-2-cyanoacrylate was unsuccessful, as confirmed by postprocedure angiography, which revealed recanalization and regrowth of the HAP. Eight months after the first transcatheter arterial embolization, the patient presented with a chief complaint of abdominal pain due to an enlarged HAP. Angiography of the superior mesenteric artery (SMA) revealed a collateral bypass around the bile duct from the SMA to the liver graft. Coil embolization of the HAP in the CHA completely occluded the HAP without complications. More than 2 years after coil embolization, the liver graft function test results remained within normal limits without HAP recurrence.ConclusionsHAP at the CHA after liver transplantation can be fatal if ruptured. Because the liver is a highly angiogenic organ, even if initial treatment is not successful, radical treatment to occlude the CHA with HAP is possible if sufficient collateral vessels are developed.

Hepatic artery thrombosis and use of anticoagulants and antiplatelet agents in pediatric liver transplantation.

Hepatic artery thrombosis (HAT) is a reported complication of 5%-10% of pediatric liver transplantations, rates 3-4 times that seen in adults. Early HAT (seen within 14 days after transplant) can lead to severe allograft damage and possible urgent re-transplantation. In this report, we present our analysis of HAT in pediatric liver transplant from a national clinical database and examine the association of HAT with anticoagulant or antiplatelet medication administered in the post-operative period. Data were obtained from the Pediatric Health Information System database maintained by the Children's Hospital Association. For each liver transplant recipient identified in a 10-year period, diagnosis, demographic, and medication data were collected and analyzed. Our findings showed an average rate of HAT of 6.3% across 31 centers. Anticoagulant and antiplatelet medication strategies varied distinctly among and even within centers, likely due to the fact there are no consensus guidelines. Notably, in centers with similar medication usage, HAT rates continue to vary. At the patient level, use of aspirin within the first 72 h of transplantation was associated with a decreased risk of HAT, consistent with other reports in the literature. We suggest that concerted efforts to standardize anticoagulation approaches in pediatric liver transplant may be of benefit in the prevention of HAT. A prospective multi-institutional study of regimen-possibly including aspirin-following transplantation could have significant value.

Profile of Liver Transplant Recipient in a Tertiary Hospital in Northern Spain.

Spain has the highest rates of liver transplantation (LT) per million inhabitants in the world, with the profiles of both donors and recipients in Asturias, a region in northern Spain, being different from the rest of the country. The main goal of this study was to carry out a preliminary analysis of the characteristics of LT recipients in Asturias, as well as of the basic characteristics of surgery and the postoperative period, and to discuss whether the results obtained in this study were comparable to what is described in the literature. This was a retrospective, descriptive, cross-sectional study, analyzing the LT carried out in a reference center of Asturias between 2002 and 2017. Relative and absolute frequency distributions for qualitative variables are provided, as are position and dispersion measures for quantitative variables. Using the multivariate Cox regression model, the prognostic factors associated with overall survival were determined. A total of 533 LTs were analyzed; 431 were men and 102 were women. The mean age was 55.1 years, concentrated between 40 and 69 years for both genders. LT was performed for chronic parenchymal liver disease (mostly of alcoholic etiology) and the recipients underwent surgery in an advanced stage of liver disease. Of these recipients, 8.1% (43 patients) were retransplantions, 65.1% in the first year due to primary graft dysfunction and complete hepatic artery thrombosis. Most patients had presented a grade II of Clavien-Dindo as the most frequent complication. Biliary complications were found in 12.3% of patients, with the main cause of death in the first 30 days being instability in the 24 h after LT. The median survival of the group was 13 years, with a 5-year survival probability of 79.3% and a 10-year survival probability of 61.9%. In view of the analyzed series, it can be concluded that the most frequent recipient profile was a male patient (mean age 55 years), with a significant alcohol habit, who was overweight, with chronic parenchymal liver disease of alcoholic or viral etiology, and who had reached the Child C stage before LT. This study could lay the foundations for future studies, to complete this analysis with the characteristics of LT surgery, its postoperative period, and the follow-up after discharge, to obtain a broader view of LT recipients in this region.

Novel Benchmark for Adult-to-Adult Living-Donor Liver Transplantation. Integrating Eastern and Western Experiences.

To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT). LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. While references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments. Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from three continents over 5 years (2016-2020), with a minimum follow-up of one year. Benchmark criteria included MELD ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no ICU admission. Benchmark cutoffs were derived from the 75th-percentile of all centers' medians. Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), non-anastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-LT (≤3.6%) at 1-year were below the DDLT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and CCI® (≤56) were above the DDLT benchmarks, while mortality (≤9.1%) was comparable. The right-hemiliver graft, compared to the left, was associated with a lower CCI® score (34 vs.21, P<0.001). Preservation of the MHV with the right-hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI® score (21 vs.47, P<0.001), graft loss (3.0%vs.6.5%, P=0.002), and redo-LT rates (1.0%vs.2.5%, P=0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%). Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness and centralization policy are however mandatory to achieve benchmark outcomes worldwide.