Hepatic Artery Injury Research Articles

Abnormal right hepatic artery injury resulting in right hepatic atrophy: diagnosed by laparoscopic cholecystectomy.

An intact hepatic artery is the gateway to successful hepato-biliary surgery. Introduction of laproscopic cholecystectomy (LC) has stimulated a renewed interest in the anatomy of hepatic artery. In this case report we have highlighted importance of variations of right hepatic artery in terms of origin and course We present a rare asymptomatic case of liver atrophy due to an intraoperative lesion of right hepatic artery. We also performed a literature review about surgical vascular lesions and tried to confirm the right concept behind “non trivial procedure” of the LC.

English

Injuries to hepatic artery is uncommon, often associated with other abdominal visceral and vascular injuries. They can have a delayed presentation. The diagnosis, management of this condition requires high index of suspicion and surgical expertise. Most of injuries are due to penetrating trauma with blunt abdominal trauma being less common. Isolated hepatic artery injury without any abdominal visceral and vascular injuries is extremely rare. We present a case of isolated injury to the hepatic artery for which we did simple ligation of hepatic artery after achieving haemostasis by pringles maneuver. Post-operative period for the patient is uneventful. We want to emphasize that hepatic artery ligation will not cause major vascular compromise. We want to present this case because for its rarity of an isolated hepatic artery injury.

Hepatic Artery Injury Following Cholecystectomy – A Cause for Continued Concern

Hepatic Artery Injury Following Cholecystectomy – A Cause for Continued Concern

Angiographic evaluation of hepatic arterial injury after cisplatin and Gelfoam-based transcatheter arterial chemoembolization for hepatocellular carcinoma in a 205 patient cohort during a 6-year follow-up.

To evaluate the overall and cumulative incidence, degree, interval change and predictors of hepatic arterial injury (HAI) after cisplatin and Gelfoam® (Upjohn, Kalamazoo, MI)-based transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). A total of 205 patients with HCC who underwent three or more sessions of TACE without additional surgical or local treatment were included. HAI was evaluated at each segment of the hepatic artery using a three-grade scale: 1 (slight wall irregularity), 2 (overt stenosis) and 3 (occlusion). HAI interval change was categorized into three groups: progression, stable state and improvement. Cumulative incidence of HAI was analysed using Kaplan- Meier method, and predictors of HAI (patient age, sex, portal vein thrombosis and Child-Pugh classification) were analysed by univariate logistic regression. HAI occurred in 50 of the 205 study patients (24.4%). The cumulative incidence of HAI was 16.0% [95% confidence interval (CI), 10.21-21.77] during 5 sessions of TACE, 52.1% (95% CI, 37.83-66.29) during 10 sessions and 68.0% (95% CI, 67.62-88.46) during 15 sessions. Initial HAI was interpreted as grades 1, 2 and 3 in 11 (22.0%), 17 (34.0%) and 22 (44.0%) patients, respectively. When the interval change was assessed in 48 patients with available follow-up TACE, 40 (83.3%) were included in the progression, 2 (4.2%) in the stable state and 6 (12.5%) in the improvement groups. The univariate analysis used to determine the predictors of HAI revealed no significant predictors. In three or more sessions of TACE, the incidence of HAI was 24%. Increasing TACE causes increased incidence of HAI. The initial presentation was most commonly grade 3, and 12.5% of the patients with HAI showed improvement of the HAI grade during follow-up TACE. In patients who underwent three or more sessions of cisplatin and Gelfoam-based TACE, the overall incidence of HAI was 24.4%, and increasing TACE causes increased incidence of HAI.

Single-site robotic cholecystectomy.

Background:Laparoscopic single-incision surgery is fraught with significant technical drawbacks but has witnessed increased growth mainly for its presumed aesthetic advantages. Recently, a single-site robotic platform has been introduced to alleviate some of the technical challenges with laparoscopic single-site surgery, although literature on this topic is scant. The aim of this study is to analyze the experience of a single surgeon with single-site robotic cholecystectomies since the U.S. Food and Drug Administration gave its approval in December 2011, and to evaluate the robotic platform's safety and short-term surgical outcomes.Methods:From February 1st 2012 to February 28th 2013, patients who underwent single-site cholecystectomy at an academic institution in the United States were retrospectively reviewed from a prospectively maintained database. The following variables were analyzed: age, sex, body mass index, previous surgeries, total operative time, port insertion time, docking time, console time, estimated blood loss, closure time, conversion to open or multiport approach, postoperative outcomes for wound infection, bile leak, biliary ductal injury, right hepatic artery injury, reoperations, readmission, and mortality. Indication for cholecystectomy was symptomatic gallbladder disease. No exclusion criteria were used and no cost analysis was performed.Results:During the study period, 31 patients were enrolled. The mean patient age, body mass index, weight, and operative time was 33.6 years, 32.2 kg/m2, 86.3 kg, and 81.4 minutes, respectively. There were no conversions to the open or traditional multiport approach, and no major complications of biliary ductal or hepatic artery injury, bile leak, reoperations, or mortality occurred. There was 1 case of superficial wound infection.Conclusions:Single-site robotic cholecystectomy is feasible and safe and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy.

The problem with an Hepatic Artery Injury Postlaparoscopic Cholecystectomy in China

The incidence of vascular injury remains a problematic complication of laparoscopic cholecystectomy, due to the anatomic variations of the cystic artery. Therefore, the focus of this study was to investigate the origin, course, and termination of the cystic artery using dual source computed tomography. Currently, laparoscopic cholecystectomy (LC) has emerged as a golden standard in the treatment of cholelithiasis. A hepatic artery remains a problematic complication of laparoscopic cholecystectomy. The diversity of the anatomical variations of the cystic artery increases the risk of injury during LC, particularly in the presence of acute inflammation. It has been reported that a hepatic artery during laparoscopic cholecystectomy mainly occur during inadvertent procedure. Its incidence after cholecystectomy has been estimated to be 8% in an autopsy series of cadavers who had undergone laparoscopic cholecystectomy in China. This incidence seems increased in patients with a bile duct injury, ranging between 14% and 29%. As angiographic studies are usually not routinely performed, the exact figure is however unknown. It has been proposed that the presence of a hepatic artery may result in several complications including liver necrosis or abscess, increase the risk of bleeding at the time of the biliary repair, and favor recurrent stenosis. The development of multi-detector row CT has made it possible to clearly depict the cystic artery. Takahashi S et al.1 found that four–detector row CT made the hepatic artery more visible, including cystic artery. Sugita R et al.2 addressed the course of the cystic artery regarding the relationship to the Calot triangle with 64–detector row CT. In their study, they also reported the relationship between the cystic arteries and the Calot triangle and information on the anatomy of the cystic duct. Stewart L et al.3 published a discussion of the mechanisms to the right hepatic artery injury according to Stewart-Way classification. It is likely that the reason why the RHA injury lied on that is because the right hepatic artery is often mistaken for cystic artery (Stewart-Way class IV) (64%). But why the right hepatic artery mistaken for cystic artery is still not clear. Future research in China should focus on the anatomical details of the cystic artery and adjacent structures using dual source computed tomography (CT).

Proper Hepatic Artery Reconstruction With Gastroduodenal Artery Transposition During Pancreaticoduodenectomy

Vascular injuries to hepatic arterial blood flow present a challenge in reconstruction. The location and extent of the injury dictate intraoperative decision making, with repair being performed expeditiously to preserve hepatic function. Formal arterial repair either primarily or with interposition or transposition grafts is indicated in the majority of patients. Special consideration should be made in patients with underlying liver disease and those undergoing biliary reconstructions. This latter group of patients is at high risk of complications following the injury secondary to bile duct ischemia. A case of proper hepatic artery (PHA) transection repaired with gastroduodenal artery (GDA) transposition is presented with a relevant review of limited literature available on the subject. During an elective pancreaticoduodenectomy the PHA was inadvertently transected just distal to the origin of the GDA. As the GDA had not been transected at this stage of the operation, it was available for transposition. This was performed, restoring arterial blood flow to the liver and the bile duct. The patient did well postoperatively with no evidence of biliary or pancreatic leak or hepatic dysfunction at both discharge and follow-up clinic visit. Injuries to hepatic artery injury are uncommon in experienced hands. This case report is only the second instance of such injury requiring reconstruction in 434 cases of single operator experience pancreaticoduodenectomies. We present arterial transposition of GDA as a feasible method to ensure adequate arterial supply to the hepatobiliary system.

Therapeutic strategies of iatrogenic portal vein injury after cholecystectomy

BackgroundThe incidence of vascular injury after a cholecystectomy is often underestimated. Although injuries to the portal vein are rare, they are devastating. The aim of the present study was to analyze suitable therapeutic strategies regarding portal vein injury in the absence of biliary injury. Materials and methodsEleven patients with portal vein injuries after laparoscopic or open cholecystectomy were referred to our hospital between 2004 and 2010. The clinical presentation, diagnosis, and management of patients with severe portal vein injuries were reviewed. All the patients were discharged without outstanding clinical conditions. During retrospective analysis, these patients were divided into early, middle, and late stages. ResultsAll the 11 patients had a portal vein and/or right hepatic artery injury, but no biliary injuries were observed. Among these patients, different management strategies were managed according to the stage of the injury. Eight patients received a direct suture at the time of injury by an experienced hepatobiliary surgeon. Two patients received thrombolytic and anticoagulation therapy after cholecystectomy, without additional surgery. One patient received a liver transplant 3 mo after the injury. After long-term follow-up, these patients had no clinical conditions. ConclusionsDirect repair or suture is important during the early stage of portal vein injury. Conservative thrombolytic and anticoagulation therapy may serve an important role in the treatment of acute massive thrombus in portal vein injury during the middle stage. Liver transplantation is a salvage therapy that should be used during the late stage.

Endovascular management of RFAinduced hepatic arterial injury

Endovascular management of RFAinduced hepatic arterial injury

Educational Exhibit Abstract No. 314 - Percutaneous alleviation of abdominal compartment syndrome due to hemoperitoneum with simultaneous endovascular bleeding control: a case series

Learning Objectives Surgical decompressive laparotomy is the standard treatment for abdominal compartment syndrome (ACS). We demonstrate the feasibility of simultaneous bleeding control and alleviation of ACS, a method that can obviate the need for major surgical interventions plagued by preventable mortality and morbidity. Background ACS is defined by intrabdominal pressure greater than 20mm Hg with evidence of organ failure or dysfunction. Sequelae of ACS include decreased cardiac output due to IVC compression, decreased pulmonary compliance, renal dysfunction and intestinal and hepatic ischemia. Expeditious decompression of the abdomen is essential to allow reperfusion to vital organs. Decompressive laparotomies have been the mainstay of treatment but carry a mortality of 49%. We present a series of 3 cases of ACS due to massive hemoperitoneum caused by left inferior epigastric artery hemorrhage secondary to paracentesis, hepatic artery bleed after transjugular liver biopsy and hepatic artery injury during cardiac valve repair. All patients presented with clinical evidence of ACS, documented with bladder and direct abdominal pressure measurements. Clinical Findings/Procedure Details In each case, the bleeding artery was identified by selective angiography and embolized with particles - complete arterial occlusion was achieved. Ultrasound was then used to find the largest pocket of blood. After establishing access to the peritoneal space, direct intraperitoneal pressure was measured using an end hole catheter. The same access was then used to place a large bore drainage catheter in each case. Compartment syndrome resolved in each case as evidenced by intrabdominal pressures and patient's clinical status. There were no acute or latent complications as a result of embolization or catheter drainage. Surgery was avoided in all three patients. Conclusion and/or Teaching Points Simultaneous embolization and percutaneous drainage is a feasible and significantly less morbid alternative to surgery in the management of ACS caused by hemoperitoneum.

Outcomes of side-to-side conversion hepaticojejunostomy for biliary anastomotic stricture after right-liver living donor liver transplantation

Conversion hepaticojejunostomy is considered the salvage intervention for biliary anastomotic stricture, a common complication of right-liver living donor liver transplantation with duct-to-duct anastomosis, after failed endoscopic treatment. The aim of this study is to compare the outcomes of side-to-side hepaticojejunostomy with those of end-to-side hepaticojejunostomy. Prospectively collected data of 402 adult patients who had undergone right-liver living donor liver transplantation with duct-to-duct anastomosis were reviewed. Diagnosis of biliary anastomotic stricture was made based on clinical, biochemical, histological and radiological results. Endoscopic treatment was the first-line treatment of biliary anastomotic stricture. Interventional radiological or endoscopic treatment failed to correct the biliary anastomotic stricture in 13 patients, so they underwent conversion hepaticojejunostomy. Ten of them received end-to-side hepaticojejunostomy and three received side-to-side hepaticojejunostomy. In the end-to-side group, two patients sustained hepatic artery injury requiring repeated microvascular anastomosis, two developed re-stenosis requiring further percutaneous transhepatic biliary drainage and balloon dilatation, and two required revision hepaticojejunostomy. In the side-to-side group, one patient developed re-stenosis requiring further endoscopic retrograde cholangiography and balloon dilatation. No re-operation was needed in this group. Otherwise, outcomes in the two groups were similar in terms of liver function and graft survival. Despite the similar outcomes, side-to-side hepaticojejunostomy may be a better option for bile duct reconstruction after failed interventional radiological or endoscopic treatment because it can decrease the chance of hepatic artery injury and allows future endoscopic treatment if re-stricture develops. However, more large-scale studies are warranted to validate the results.

Percutaneous transhepatic biliary drainage complicated with hepatic hydrothorax

Percutaneous transhepatic biliary drainage complicated with hepatic hydrothorax

Hepatic Artery Transection Reconstructed With Splenic Artery Transposition Graft

Hepatic artery transection presents a technical challenge in vascular reconstruction. Formal arterial repair is indicated in patients with underlying liver disease and those undergoing bile duct reconstructions because of a higher risk of complication following hepatic artery injury. This report highlights a novel approach to hepatic artery transection with splenic artery transposition. A case of hepatic artery transection repaired with splenic artery transposition is presented with an accompanying literature review. During elective pancreaticoduodenectomy, the common hepatic artery was injured at its origin. The splenic artery was divided and transposed to the hepatic artery, thus restoring arterial flow to the liver and bile duct. Various strategies to manage a hepatic artery injury have been described, ranging from ligation to complex vascular reconstruction. In hemodynamically stable patients, arterial transposition using the splenic artery is a feasible method to ensure adequate arterial supply to the liver and biliary tract.

Radiological catheter placement for transcatheter arterial steroid injection therapy to treat severe acute hepatic failure: technical feasibility and efficacy

Severe acute hepatic failure (SAHF), which progresses to fulminant form in some cases, is a life-threatening disease. To assess the technical feasibility and the efficacy of transcatheter arterial steroid injection therapy (TASIT) for SAHF. Twenty-seven patients with SAHF, 10 of whom had variant anatomy of the hepatic artery, underwent radiologic placement of an indwelling catheter in the hepatic artery, and TASIT was subsequently performed for three days. The tips of the catheters were inserted as follows: common hepatic artery (n = 18), proper hepatic artery (n = 4), and replaced right hepatic artery (n = 5). The clinical success rate of TASIT and the prognosis after TASIT were evaluated. In one patient, intimal injury of the left hepatic artery was encountered; however, TASIT could be resumed and completed via intrahepatic arterial collaterals. In two patients, the catheter tip placement was corrected on the following day because of dislocation. Finally, TASIT could be carried out in all patients. Twenty-two patients (81.5%) responded to TASIT but five patients (18.5%) did not. Among the five non-responders, two patients were transferred to liver transplantation and survived, and three patients died. There was no significant difference in the response rates to TASIT among locations of catheter tip (P > 0.05) and extent of drug distribution in the liver (P > 0.05). TASIT is a feasible and efficient treatment option for SAHF regardless of the anatomic variation of the hepatic artery. Careful manipulation during the procedure to prevent injury of the hepatic artery may be the most essential factor not only for successful TASIT but also for liver transplantation, which may be performed on TASIT non-responders.

Right Gastroepiploic Artery Is the First Alternative Inflow Source for Hepatic Arterial Reconstruction in Living Donor Liver Transplantation

BackgroundSufficient arterial flow after living donor liver transplantation (LDLT) is closely related to graft survival and prevention of postoperative complications. However, some unfavorable hepatic arterial conditions in recipients preclude reconstruction, requiring alternative stumps. We have used the right gastroepiploic artery (RGEA) as a first alternative for hepatic inflow. MethodsFrom January 2006 to December 2008, we performed 754 LDLTs including 28 cases of RGEA among hepatic arterial anastomoses. The arterial anastomosis was performed by an single surgeon under 859 a microscope using an end-to-end interrupted suture technique. RGEA was mobilized over 15 cm from the greater curvature of stomach and greater omentum. ResultsThe indications for RGEA use included severe hepatic arterial injury from previous transarterial chemoembolization (n = 14), need for additional arterial flow in dual-grafts LDLT (n = 13), poor blood flow from the recipient hepatic artery (n = 3), and arterial injury during hilar dissection (n = 3). The mean diameter of the isolated RGEA was 2.0 ± 0.2 mm (range: 1.0–2.5). Most hepatic arterial anastomoses were performed with a significant size discrepancy of more than twofold. All reconstructed hepatic arterial flowes showed good; no complication was identified during the mean follow-up period of 56 months to date. ConclusionsUsing RGEA as an alternative arterial inflow is a simple, reliable procedure for situations of inadequate recipient hepatic or multiple graft arteries.

Liver transplantation as an ultimate step in the management of iatrogenic bile duct injury complicated by secondary biliary cirrhosis

This report summarizes a single center's experience with liver transplantation (LT) performed for secondary biliary cirrhosis resulting from iatrogenic bile duct injury (BDI) sustained during cholecystectomy. Secondary biliary cirrhosis was the indication for LT in 5 (1.7%) out of 300 LTs performed in our center between Feb 2002 and April 2011. We analyzed the medical history of the patients, perioperative course and outcome following LT. The BDI was classified as Strasberg A in 1 case, B in two cases, and E in 2 cases. There was no hepatic arterial or portal vein injury in any patient. All of the surgical repairs prior to the development of cirrhosis were performed in general surgical units. The median time between BDI and listing the patient for LT was 11 years. The cadaveric whole-organ LT was done in all patients using the Piggy-Back technique. All patients are alive with a median follow-up of 53 months. Liver transplantation in patients with secondary biliary cirrhosis appears to result from a series of inadequate multiple surgical repairs following BDI. The immediate referral of such patients to centers with bile duct surgery experience is crucial.

A case of necrotizing pancreatitis subsequent to transcatheter arterial chemoembolization in a patient with hepatocellular carcinoma

Necrotizing pancreatitis is one of the rare complications of transcatheter arterial chemoembolization (TACE). Necrotizing pancreatitis after TACE may result from the development of ischemia caused by regurgitation of embolic materials into the vessels supplying the pancreas. We report a case of post-TACE necrotizing pancreatitis with abscess formation in a patient with hepatocellular carcinoma. The patient had suffered hepatic artery injury due to repetitive TACE; during his 25th TACE procedure he had submitted to selective catheterization of the feeding vessel from the dorsal pancreatic artery with a cytotoxic agent and Gelfoam particles. The patient complained of abdominal pain after the TACE procedure, and a CT scan led to a diagnosis of necrotizing pancreatitis with abscess formation. The pancreatic abscess progressed despite general management of the pancreatitis, including antibiotics. Percutaneous catheter drainage was performed, and the symptoms of the patient improved.

Assessment of Hepatic Arterial Anatomy Prior to Organ Recovery

Iatrogenic hepatic arterial injury during organ recovery increases ischaemic times and risk of hepatic artery thrombosis. A review of CT imaging prior to organ recovery would alert retrieving surgeons to the presence of anatomical variants. This study aimed to identify the proportion of donors with coincidental CT scans for review and the ability of organ retrieval surgeons to interpret these images. Consecutive organ donors with coincidental abdominal contrast enhanced CT scans were assessed by review of an electronic radiology database. These images, with additional cases, were blindly reviewed by organ recovery surgeons to assess their ability to define anatomy. 13/156 donors had coincidental imaging for review. Using 23 CT sequences, the median positive and negative predictive value of surgeons to correctly describe right hepatic arterial anatomy was 0.83 and 0.94, of the left hepatic anatomy was 0.75 and 0.94 respectively. The availability of CT imaging for review prior to donation is low. However, when available, surgeons can correctly define hepatic arterial anatomy in the majority of cases. A practice of routinely reviewing available imaging prior to organ recovery would be expected to decrease iatrogenic arterial injury.

Clinical impact of right accessory hepatic artery injury in deceased donor livers

Right accessory hepatic artery (RAHA) injury at retrieval is a rare complication of deceased liver procurement. Arterial reconstruction is often required under these circumstances which could potentially increase the risk of hepatic artery thrombosis (HAT). The aim of this study is to investigate whether RAHA injury affects the incidence of HAT, early biliary complications, or 3-month graft and patient survival rates. All adult liver transplants performed between 1994 and February 2007 at Addenbrooke's Hospital, Cambridge, UK were considered for inclusion in the study. Grafts were divided into three groups depending on the presence of RAHA and injury (Group 1: normal anatomy and single hepatic artery anastomosis; Group 2: RAHA requiring reconstruction; Group 3: RAHA injury requiring reconstruction). Eight hundred and forty-four liver transplants were included in the study (Group 1: 654 grafts; Group 2: 63 grafts; Group 3: 14 grafts). The incidence of HAT (Group 1, 2.9%; Group 2, 6.4%; Group 3, 14.3%) was significantly different between the three groups (P=0.01); biliary complications at 3months (Group 1, 7.1%; Group 2, 11.1%; Group 3, 7.1%) were not significantly different. Graft and patient survival at 3months were significantly worse in Group 3 when compared with Group 2 (61.5 vs. 88.3%, P=0.01; 81.8 vs. 98.2%, P=0.02). This is the first study analysing the clinical impact of RAHA injury during liver procurement. We conclude that the use of liver grafts with RAHA injury does result in a higher HAT rate and is also associated with lower graft and patient survival rates at 3months.

Delayed Right Hepatic Artery Haemorrhage After Iatrogenic Gallbladder by Laparoscopic Cholecystectomy that Required a Liver Transplant Due to Acute Liver Failure: Clinical Case and Review of the Literature

IntroductionRight hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. Patients and methodWe provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. ResultsLT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. ConclusionsRHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion.