Late Hepatic Artery Thrombosis 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.

S3212 Very Late Hepatic Artery Thrombosis After Orthotopic Liver Transplantation

Introduction: Hepatic artery thrombosis (HAT) is a serious complication after orthotopic liver transplantation (OLT) and is the most common vascular complication. It is often categorized into early HAT which is defined as occurring < 30 days after liver transplantation & late HAT defined as occurring > 30 days post transplantation. The etiology of HAT is often related to surgical factors, such as vessel kinking, anastomotic stenosis, and intimal dissection, but can factors such as hypercoagulability, elderly donors, and rejection episodes can contribute. Symptoms can often be vague with common complaints being abdominal pain, fever, nausea, & emesis. Case Description/Methods: A 68-year-old male with OLT (20 years prior to presentation) for primary sclerosing cholangitis (PSC), ulcerative colitis presented with 1 month history of nausea, emesis, and weakness. He was afebrile & hemodynamically stable. On physical exam, abdomen was soft, nontender, nondistended, and patient was jaundice. Laboratory data was notable for a two-month elevation of alkaline phosphatase, ALT, AST, direct bilirubin. An ultrasound of the liver with doppler evaluation was obtained that demonstrated an absence of flow in the left and right hepatic arteries within the liver. A computed tomography angiography (CTA) of the abdomen was obtained that confirmed these findings (Figure 1). Due to the history of PSC, a magnetic resonance cholangiopancreatography was obtained that showed no biliary dilation or evidence of recurrent PSC. A liver biopsy demonstrated paucicellular ductopenia with cholestasis consistent with chronic arterial insufficiency and no significant fibrosis. Transplant surgery and interventional radiology were consulted for potential recanalization. However, due to prolonged elevations in liver enzymes >4 weeks, both teams determined that recanalization would likely provide no benefit yet held greater risk. Discussion: This case highlights an uncommon, very late presentation of HAT. In the literature, late HAT has been described in the order of months, not years as it was in this case. It is usually associated with a less fulminant presentation and a milder course, in comparison to cases of HAT that present earlier in the post-transplant course. This case highlights the importance of considering HAT as a diagnosis in a patient with history of OLT who presents with abdominal pain, nausea, and emesis.Figure 1.: Focal filling defect in the hepatic artery seen in this venous phase CTA.

A Long Graft Artery is a Safe and Reproducible Procedure for Arterial Reconstruction In Liver Transplantation

Although a short and nonredundant anastomosis is most often performed in liver transplantation, there is no strong evidence in the literature about the ideal arterial reconstruction. We describe here the "long-artery" technique that enables a wide side-to-end anastomosis and preserves arterial length. We present the results between 2011 and 2019 of the "long-artery" technique performed in our center. Patients with a split liver transplantation or aortohepatic conduits were not included. This technique uses the whole arterial axis of the graft. A side-to-end anastomosis is performed between the common and/or proper hepatic artery of the recipient, and the celiac trunk with an aortic patch of the graft, while the gastroduodenal artery of the recipient is preserved. An omental flap is positioned under the graft artery to prevent kinking. Eight hundred thirty-two transplant patients were included in the analysis. Early hepatic artery thrombosis was diagnosed in 22 (2.6%) patients and occurred within the first 10 days after the procedure. A thrombectomy was performed in 7 patients, which was successful in 4 patients, and 18 patients were retransplanted. Seven patients (0.8%) developed a late hepatic artery thrombosis, including 2 patients who were retransplanted. The "long-artery" technique is a safe and efficient technique for arterial reconstruction in liver transplantation and does not seem to increase the rate of early hepatic artery thrombosis.

Long Graft Artery and Arterial Anomalies Are Associated with Hepatic Artery Thrombosis after Orthotopic Liver Transplantation

Introduction: Hepatic artery thrombosis is one of the most feared surgical complications after orthotopic liver transplantation (OLT). The aim of this study was to analyse factors involved in global, early (less than a month) and late (more than a month) hepatic artery thrombosis (HAT) after OLT. Methods: Inclusion criteria: patients who underwent OLT between November 2001 and December 2018. Exclusion criteria: liver retransplantation. Several preoperative and intraoperative variables were analysed. Graft artery was classified as long or short when the section was located distal or proximal to the proper/common hepatic artery bifurcation. In the same way, recipient patch for arterial anastomosis was classified as distal or proximal to the proper/common hepatic artery bifurcation. Student's T for continuous variables and Chi-Square for discrete variables were used for univariate analysis. Logistic regression was used for multivariate analysis (MVA). Results: Finally, 588 patients were eligible for statistical analysis. Global, early and late HAT appeared in 53 (9.01%), 35 (5.95%) and 18 (3,06%) patients, respectively. For global HAT, two variables proved to be significant after MVA: hepatocellular carcinoma as indication for OLT (p=0.035) and long graft artery (p=0.007). For early HAT, two variables turned out to be significant after MVA: hepatocellular carcinoma as indication for OLT (p=0.012) and arterial anomalies (p=0.036). For late HAT, only long graft artery reached statistical significance after MVA (p=0.026). Conclusion: Technical factors involving arterial anastomosis, as the presence of arterial anomalies and the length of the graft artery, seem to be essential risk factors for HAT after OLT.

Ex Situ Arterial Reconstruction During Normothermic Perfusion of the Liver.

Background.Aberrant hepatic arterial anatomy may be seen in up to 30% of liver grafts, and reconstruction prolongs the cold ischemic time or the arterialization times. If normothermic machine preservation (NMP) is used to preserve liver grafts, the presence of aberrant arterial anatomy poses a challenge. Dual arterial cannulation is a temporary solution to enable effective perfusion, until optimal circumstances are met for arterial reconstruction, without compromising ischemia time. To date the technical and logistical feasibility of arterial reconstruction ex situ and during NMP has not been reported.Methods.Series of 5 cases from the Consortium for Organ Preservation in Europe randomized controlled trial in which grafts with arterial anatomic variations were reconstructed while organs were perfused on NMP.Results.One donor after cardiac death and 4 donor after brain death livers with arterial anatomical variations reconstructed while on NMP were included. All patients survived transplantation, spending 1–7 d in intensive care unit and discharged home after 5–15 d. None of the cases developed early allograft dysfunction or any early technical complications. At follow-up, there were no late hepatic artery thrombosis, stenosis, or any other vascular–related complication. Four of 5 patients underwent magnetic resonance cholangiopancreatography at 6 mo with no evidence of ischemic cholangiopathy.Conclusions.The case series described above suggests that ex vivo arterial reconstruction surgery on liver grafts while on board the NMP device is feasible, safe, and effective.

Ligation Of The Left Renal Vein In Liver Transplant Recipients Diagnosed With A Spontaneous Splenorenal Shunt – Case Report

IntroductionFor patients diagnosed with hepatic cirrhosis and portal hypertension, qualified for liver transplantation, the presence of portosystemic collateral circulation constitutes a typical phenomenon. One of its types is the spontaneous splenorenal shunt. Large or multiple ones may cause the steal syndrome and graft hypoperfusion. An attempt to remove such shunts directly is technically difficult and fraught with complications. An easier and safer method would involve ligating the left renal vein. The aim of this paper is to present a case where proper perfusion of a transplanted liver is ensured by the left renal vein ligation, performed in a recipient with a splenorenal shunt, and to review the scientific reports devoted to portosystemic shunts in liver transplant recipients. Case reportA 63-year-old female with alcoholic liver disease was qualified for liver transplantation. The CT-angiography showed numerous splenorenal shunts with diameter up to 13 mm. During the anhepatic phase of the liver transplantation a very weak effusion from the portal vein was observed, which improved significantly following clamping of the left renal vein. Thus renal vein orifice was ligated in order to achieve the correct graft reperfusion. Postoperative Doppler ultrasound showed a correct portal blood flow. The early liver and renal function was good. Finally, in the 7th month, the patient underwent a re-transplantation due to biliary necrosis caused by late hepatic artery thrombosis. ConclusionLigation of the left renal vein efficiently prevents the steal syndrome in the liver transplant recipients with splenorenal shunt and ensures good graft perfusion.

2448 Late Hepatic Artery Thrombosis Causing Bowel Ischemia

INTRODUCTION: Hepatic artery thrombosis (HAT) is a potentially life-threatening complication following orthotopic liver transplantation (OLT). HAT can be further classified as early-onset HAT (EHAT), occurring &lt;30 days after OLT or late-onset HAT (LHAT), occurring &gt;30 days after OLT. Symptoms include elevated transaminases, fever, abdominal pain, nausea and vomiting. We report a rare case of LHAT in a liver transplant recipient 8 years status post from OLT presenting with atypical symptoms. CASE DESCRIPTION/METHODS: A 58-year-old male with a history of hepatitis C virus (HCV) cirrhosis with OLT in 2011, with sustained virologic response (SVR) s/p HCV treatment, presented with severe left-sided abdominal pain and fever. Laboratory data was remarkable for leukocytosis and a mild elevation in transaminases. Due to concern of possible sepsis, he was initially treated on broad-spectrum antibiotics. Subsequent abdominal ultrasound was unable to visualize the hepatic artery, which was confirmed with CT angiogram showing cut off of the transplant hepatic artery 8 mm from its origin as well as a small right lobe infarct. He was started on anticoagulation but three days later he had worsening fever, increasing oxygen requirement, and markedly elevated transaminases. Interventional radiology attempted catheter directed thrombolysis, however this failed. Over the course of the following weeks, his transaminases started to decline, but he continued to have several days of low-grade fevers, secondary to hepatic necrosis. DISCUSSION: This case provides an atypical presentation of HAT in a distant status post OLT patient. The etiology of late HAT remains unclear despite multiple reviews of literature. The overall incidence of late HAT is as low as 2.1%, and the likelihood of occurring years later is even lower. In our patient, despite his distant OLT, he presented with a unique presentation of LHAT, masquerading as a sepsis-like picture. This case demonstrates the importance of considering HAT in patients with a distant OLT presenting with abdominal pain. Identifying this could help us stratify these patients for consideration of re-transplantation and appropriate treatment. A recent study demonstrated that conservative management of late HAT patients with only minor complications was deemed safe. In the case of our patient, due the improving nature of his condition, he was ultimately treated conservatively and monitored on an outpatient basis.

Evaluation of histologic changes in the livers of patients with early and late hepatic artery thrombosis

Hepatic artery thrombosis (HAT) following orthotopic liver transplantation (OLT) can cause hepatic parenchymal necrosis and ischemic cholangiopathy. This study investigates additional histologic features that may suggest HAT in post-OLT liver specimens. For 94 liver specimens (explanted allografts and biopsies) from patients with a clinical or pathologic diagnosis of HAT, we recorded length of time between OLT and procedure, categorizing cases into early HAT (;≤30 days since OLT) and late HAT (>30 days since OLT). Common histologic findings in HAT included lobular necrosis (60 cases, 64%), portal inflammation (68 cases, 72%), ductular reaction (73 cases, 78%), lobular cholestasis (70 cases, 74%), and bile-tinged macrophages (40 cases, 43%). Ductular cholestasis was seen in 30 cases (32%); 10 of those patients were clinically septic. Bile in veins was seen in 16 (17%) cases and arteritis in 6 (6%) cases. Findings more common in resection than biopsy specimens included lobular necrosis (P < .0001), hemorrhage (P = .0044), ductular cholestasis (P = .0003), and bile-tinged macrophages (P < .0001). Lobular necrosis was more common in early HAT (P = .0002), and ductular reaction (P = .006) and bile in veins (P = .03) were more common in late HAT. Histologic changes in HAT vary based on specimen type and whether HAT is early or late. In late HAT, biliary injury might occur after a prolonged period of ischemia, with subsequent bile duct necrosis, bile in veins, and remodeling (eg, ductular reaction). Bile in veins is an unusual finding that may occur in HAT, although it can be seen in bile infarcts from other causes.

Selective retransplantation after late hepatic artery thrombosis.

Hepatic artery thrombosis (HAT) is a serious and life-threatening complication that can occur any time after liver transplantation. HAT is generally subdivided into 2 categories. Early HAT frequently presents with profound graft dysfunction and sepsis, and requires urgent revascularization or retransplantation. This article is protected by copyright. All rights reserved.

Late hepaticartery thrombosis after liver transplantation: which strategy? A single-center retrospective study.

The management of late hepatic artery thrombosis (LHAT) after liver transplantation (LT) is not codified. The objective of this study was to retrospectively evaluate outcomes after LHAT. All patients with HAT diagnosed 3months or later after LT on computed tomography between 1993 and 2017 were included. Our policy was to apply a conservative management for asymptomatic or mild symptomatic patients and reserve retransplantation to symptomatic patients with diffuse cholangitis or liver abscess. A total of 56 patients were analyzed. LHAT diagnosis was made after a median interval of 48months from LT (ranging from 3 to 368.3). At diagnosis, 28 (50%) patients were asymptomatic, 10 (17.8%) had mild symptoms (transient acute cholangitis), and 18 (32.1%) had severe complications. Asymptomatic patients experienced a 5-year graft survival of 57% vs. 40% in those with mild symptoms and 11% in those with severe complications (P<0.001). However, there was no difference in overall patient survival between groups. Our results suggest that conservative management of LHAT for asymptomatic patients or patients with mild complications is safe. Retransplantation should be reserved to patients with severe biliary complications.

Recipient celiac trunk stenosis is a significant risk factor for early hepatic artery thrombosis after liver transplantation

Background: Hepatic artery thrombosis (HAT) is a rare but severe complication after liver transplantation (LT). The aim was to study risk factors of HAT, notably a recipient celiac trunk stenosis and a variant anatomy of the recipient hepatic artery, in our single center experience. Methods: Between 1997 and 2013, a total of 709 LT in 618 patients were performed at our center. Early (<30 days) HAT (EHAT) occurred in 18, late HAT (LHAT) in 12 patients. Patients with EHAT and LHAT were compared to a randomized control group of 100 patients without HAT. Recipient celiac trunk stenosis was assessed on pre-LT imaging by two independent radiologists. Univariate analysis by Fishers exact test and a multivariate logistic regression were used the EHAT group, a descriptive analysis in the LHAT group. Results: In univariate analysis, stenosis of the recipient celiac trunk, presence of accessory hepatic arteries, retransplantation, use of an aortic conduit and the amount of transfused FFP were significantly associated with the development of EHAT. Upon multivariate regression, only a stenosis of the celiac trunk (p=0.001) and retransplantation (p=0.002) were significantly associated with EHAT. LHAT seemed to be associated with the use of an aortic conduit and retransplantation. Conclusion: This is the first study to identify a stenosis of the recipient celiac trunk as a significant risk factor for the development of early hepatic artery thrombosis after LT. Patients should be systematically screened.

Clinical Course of Hepatic Artery Thrombosis After Living Donor Liver Transplantation Using the Right Lobe.

Hepatic artery thrombosis (HAT) can result in biliary tree necrosis and graft loss, necessitating retransplantation. The most effective treatment approach is still controversial. This study was performed to review the outcomes of HAT after living donor liver transplantation (LDLT) and to clarify the feasibility of different strategies. From May 1996 to August 2017, LDLT using the right lobe was performed in 827 adult patients in our center. Our technique of hepatic artery (HA) reconstruction is end-to-end anastomosis under a microscope (10×). Diagnosis of HAT was performed using Doppler sonography and computed tomography (CT) angiography. HAT was initially treated with surgical or endovascular procedure, and retransplantation was considered according to the graft condition. Among the 827 cases of LDLT using the right lobe, HAT occurred in 16 (1.9%) cases within 1 month after transplantation. Within the first week, 7 of these HAT cases (43.8%) occurred (early HAT), while the remaining 9 cases (56.2%) occurred between the first week and 1 month (late HAT). The incidence of graft failure was high in early HAT (42.9%), and the frequency of biliary complications was high in late HAT (77.8%). The success rate of HA recanalization was 62.5% (10/16): 100% (5/5) after reoperation and 45.5% (5/11) after the endovascular procedure. Of the patients in whom treatment failed in late HAT (n = 5), 4 underwent neovascularization during observation. A total of 5 patients underwent graft failure, and 3 of these patients underwent repeat liver transplantation (LT). Mortality occurred in 3 patients, including 1 in the surgical group and 2 in the endovascular group. In conclusion, early diagnosis and aggressive treatment of HAT are necessary to avoid graft failure, and the choice of treatment depends on various factors. Although further studies are required, early HAT requires preparation for graft failure, while late HAT requires treatment for biliary complications.

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

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

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

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

Indigo Thrombectomy System for Hepatic Artery Thrombosis After Liver Transplantation: A Case Report

IntroductionHepatic artery thrombosis still represents a major complication after liver transplantation responsible for graft failure, possibly resulting in the need for retransplantation. Case ReportWe describe a case of a patient undergoing liver transplant complicated by hepatic artery thrombosis, successfully treated with an endovascular approach using the Indigo System. This new system allows mechanical fragmentation and aspiration of the thrombus, with no injection of any thrombolytic agents, thereby reducing the risk of bleeding. Hepatic artery flow was immediately restored, with no complications for the patient and the graft. DiscussionThe Indigo System appears to be a safe, affordable, and manageable technique for endovascular management of late hepatic artery thrombosis after liver transplant.

Progress in the diagnosis and treatment of hepatic artery thrombosis after liver transplantation

Hepatic artery thrombosis (HAT) is the most frequent vascular complication following with liver transplantation, whichis the foremost cause of primary graft nonfunction, graft loss and recipient’s death. Hepatic artery thrombosis after liver transplantation wasdivided into early hepatic artery thrombosis (E-HAT) and late hepatic artery thrombosis (L-HAT). And the etiologywascomplex, clinical presentations were diversity, treatment effects were controversial, therefore, the early detection, early diagnosis and early treatment of hepa-tic artery thrombosis after liver transplantation are very important. In this paper, the progress in the diagnosis and treatment of hepatic artery thrombosis after liver transplantation were reviewed. Key words: Liver transplantation; Hepatic artery thrombosis

Retransplantation in Late Hepatic Artery Thrombosis: Graft Access and Transplant Outcome.

BackgroundDefinitive treatment for late hepatic artery thrombosis (L-HAT) is retransplantation (re-LT); however, the L-HAT–associated disease burden is poorly represented in allocation models.MethodsGraft access and transplant outcome of the re-LT experience between 2005 and 2016 was reviewed with specific focus on the L-HAT cohort in this single-center retrospective study.ResultsNinety-nine (5.7%) of 1725 liver transplantations were re-LT with HAT as the main indication (n = 43; 43%) distributed into early (n = 25) and late (n = 18) episodes. Model for end-stage liver disease as well as United Kingdom model for end-stage liver disease did not accurately reflect high disease burden of graft failure associated infections such as hepatic abscesses and biliary sepsis in L-HAT. Hence, re-LT candidates with L-HAT received low prioritization and waited longest until the allocation of an acceptable graft (median, 103 days; interquartile range, 28-291 days), allowing for progression of biliary sepsis. Balance of risk score and 3-month mortality score prognosticated good transplant outcome in L-HAT but, contrary to the prediction, the factual 1-year patient survival after re-LT was significantly inferior in L-HAT compared to early HAT, early non-HAT and late non-HAT (65% vs 82%, 92% and 95%) which was mainly caused by sepsis and multiorgan failure driving 3-month mortality (28% vs 11%, 16% and 0%). Access to a second graft after a median waitlist time of 6 weeks achieved the best short- and long-term outcome in re-LT for L-HAT (3-month mortality, 13%; 1-year survival, 77%).ConclusionsInequity in graft access and peritransplant sepsis are fundamental obstacles for successful re-LT in L-HAT. Offering a graft for those in need at the best window of opportunity could facilitate earlier engrafting with improved outcomes.

The role of arterial conduits for revascularisation in adult orthotopic liver transplantation.

The successful outcome in orthotopic liver transplantation (OLT) is critically dependent on the uncompromised hepatic graft blood inflow. Arterial conduits represent a good solution in cases where conventional revascularisation is not possible. The purpose of this systematic review is to analyse the published evidence on the use of arterial conduits in adult OLT. After review of the Pubmed and EMBASE databases, 19 relevant studies were identified and analysed. Even though patient survival was comparable, most large studies reported worse 1-, 3- and 5-year graft survival rates compared to grafts with standard arterial revascularisation. Primary grafts were more commonly affected than re-grafts. Early and late hepatic artery thrombosis occurred more commonly, while the use of an arterial conduit was identified as an independent risk factor. The overall biliary complications were comparable, however, ischaemic cholangiopathy was encountered about 3 times more in patients with arterial conduits and strongly correlated with the occurrence of late HAT. In conclusion, the use of arterial conduit is a useful option in adult OLT in cases that the conventional revascularisation technique cannot be used or results in suboptimal arterial inflow. More studies directly addressing issues such as pre-operative evaluation regarding the need for arterial conduit, the types of vessels used, positioning of the conduit and post-operative management are required.

Diagnosis and Management of Hepatic Artery Complications After Liver Transplantation

BackgroundWe assessed the usefulness of color Doppler imaging in diagnosis and monitoring hepatic artery complications after liver transplantation. MethodsSubjects were 421 liver transplant recipients who underwent serial ultrasound (US) color Doppler evaluations of the hepatic arteries after surgery. ResultsWe saw 4 hepatic arterial complications after liver transplantation (13 thrombosis, 29 stenosis, 2 kinking, 2 pseudo-aneurysm, and 2 pseudo-aneurysm rupture). All subjects underwent US color Doppler examination periodically after surgery. In 6 cases of early thrombosis, hepatic arterial obstruction was diagnosed with absence of Doppler signals; in the other 7 cases (late hepatic artery thrombosis), thrombosis was suspected for the presence of intra-parenchymal “tardus-parvus” waveforms. In all of the cases, computed tomography angiography showed obstruction of the main arterial trunk and the development of compensatory collateral circles (late hepatic artery thrombosis). In 10 of the 29 cases of stenosis, Doppler ultrasonography examination revealed stenotic tract and intra-hepatic tardus-parvus waveforms; in 17 stenosis cases, the site of stenosis could not be identified, but intra-parenchymal tardus-parvus waveforms were recorded. In 2 patients, hepatic artery stenosis occurred with ischemic complications. ConclusionsThe use of US color Doppler examination allows the early diagnosis of hepatic arterial complications after liver transplantation. Tardus-parvus waveforms indicated severe impairment of hepatic arterial perfusion from either thrombosis or severe stenosis. The presence of these indirect signs enhanced the accuracy of color Doppler diagnosis, and detection should prompt therapy.

Outcome of Early Hepatic Artery Thrombosis After Living Donor Liver Transplantation

Hepatic artery thrombosis (HAT) is a serious complication after liver transplantation (LT) which often resulted in biliary complication, early graft loss and patient death. According to the time course, HAT within 30 days is defined as early HAT, while HAT occurs more than 30 days after LT is defined as late HAT. In a large review of 21,822 patients underwent LT, the overall incidence of early HAT is 4.4%, with higher incidence in children than in adult (8.3 vs 2.9%), and a median time of diagnosis on POD7. Early HAT resulted in an overall re-transplantation rate of 53.1% (children higher than adult, 62 vs. 50%) and an overall mortality rate of 33.3% (adult higher than children, 34.3 vs 25%). It is generally thought that early HAT without urgent re-vascularization or re-transplantation almost always leads to mortality, especially those occuring within a few days of post-transplant. Here we presented 3 cases of early HAT after living donor LT, in which the attempts of arterial re-vascularization failed through surgical or endovascular intervention. Unexpectedly, these 3 patients survive well with acceptable graft function and followed up for 32 months, 11 months, and 4 months, respectively. Possible explanations from anatomical aspect were reviewed and discussed. Our experience showed that early HAT occuring within one week postoperatively, without successful re-vascularization or urgent re-transplantation, may not always lead to mortality, and re-transplantation may be preserved for selective patients who had irreversible liver failure.