Recipient Hepatic Artery Research Articles

Donor Atheromatous Disease is a Risk Factor for Hepatic Artery Thrombosis After Liver Transplantation.

The increasing age of liver donors and transplant candidates, together with the growing prevalence of metabolic comorbidities, could impact the risk of vascular complications after liver transplantation. We enrolled a consecutive cohort of adult patients undergoing liver transplantation from 2012 to 2021 who had a blinded pathological assessment of atherosclerosis in the donor and recipient hepatic arteries (HA). Patients receiving partial or reduced grafts, retransplantation, or combined organ transplantation were excluded. The relationship between HA atherosclerosis and HA thrombosis after liver transplantation was evaluated using logistic regression in the whole study cohort and in a propensity score-matched subpopulation. Among 443 eligible patients, 272 had a full pathological evaluation of the donor and recipient HA and were included in the study. HA atheroma was present in 51.5% of donors and in 11.4% of recipients. HA thrombosis occurred in 16 patients (5.9%), being more likely in patients who received a donor with HA atherosclerosis than in those without (10.7%vs. 0.8%; p<0.001). Donor HA atherosclerosis was an independent risk factor of HA thrombosis (OR=17.79; p=0.008), and this finding was consistent in the propensity score-matched analysis according to age, sex, complex arterial anastomosis, and alcoholic liver disease (OR=19.29; p=0.007). Atheromatous disease in the recipient had no influence on the risk of HA thrombosis (OR=1.70; p=0.55). In conclusion, patients receiving donors with HA atherosclerosis are at increased risk for HA thrombosis after liver transplantation. The evaluation of the donor graft vasculature could guide antiplatelet therapy in the postoperative period.

Effects of Hepatic Artery Type And Number on Bile Complications in Right Lobe Living Donor Liver Transplant Recipients: Single Center Experience Without Hepatic Artery Thrombosis

Purpose: Hepatic artery provides blood supply to the biliary tract of the graft, one of the causes of the biliary complications that may occur in the post-transplant period may be the problems of the recipient's hepatic artery. We examined the effect of post-transplant biliary complications according to the type and number of recipient hepatic artery. Materials and Methods: One hundred eighty five patients older than 18 years of age who underwent right lobe LDLT for end-stage liver cirrhosis were included in the study. The recipient's right hepatic artery (RHA), left hepatic artery (LHA), propria hepatic artery (PHA) and common hepatic artery (CHA), which were anastomosed to the graft artery and double hepatic artery anastomoses formed of the right and left hepatic arteries, were examined. Biliary complications were analyzed statistically in terms of single or double artery anastomosis and anastomoses with the right or the other hepatic arteries. Results: There was no statistically significant difference between single and dual artery anastomoses in terms of bile duct stricture or leakage (p=0.767). No statistically significant difference was observed between RHA, LHA, PHA, CHA, and between single and dual arteries in the evaluation of artery selection between those with and without biliary tract complications (p=0.445) Conclusion: Hepatic artery type selection and number of the recipient does not change the biliary tract complication.

Life-Threatening Ruptured Hepatic Artery Pseudoaneurysm Post-Liver Transplant: A Case Report

IntroductionHepatic artery pseudoaneurysm after liver transplantation is a rare condition, which can lead to spontaneous bleeding depending on its extent and location. Treatment involves endovascular and surgical approaches, and in cases of graft failure, liver retransplantation. Case ReportA 42-year-old female underwent deceased donor liver transplantation due to cryptogenic cirrhosis and schistosomiasis with an uneventful postoperative course. However, 18 days after the operation, she presented to the emergency department with abdominal pain, hypotension, and lipothymia. Computed tomography scan revealed a hepatic artery anastomotic pseudoaneurysm, and, due to hemodynamic instability, emergency laparotomy was indicated. During operation, the pseudoaneurysm was found to be ruptured and the recipient hepatic artery was ligated due to life-threatening bleeding. She later developed ischemic cholangiopathy and biliary complications, eventually undergoing retransplantation seven months after the emergency operation. The patient remains well 11 months after the retransplantation. ConclusionWe report a rare case of life-threatening rupture of hepatic artery anastomotic pseudoaneurysm, which required emergency ligation of the recipient hepatic artery and subsequent liver retransplantation due to biliary complications.

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.

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

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

Comparison of alternative arterial anastomosis site during liver transplantation when the recipient's hepatic artery is unusable.

Few studies have analyzed outcomes of liver transplantation (LT) when the recipient hepatic artery (HA) was not usable. We retrospectively evaluated the outcomes of LT performed using the different alternative sites to HA. Between 2002 and 2017, 1,677 LT were performed in our institution among which 141 (8.4%) with unusable recipient HA were analyzed. Four groups were defined according to the site of anastomosis: the splenic artery (SA group, n=26), coeliac trunk (CT group, n=12), aorta using or not the donor's vessel (Ao group, n=91) and aorta using a vascular prosthesis (Ao-P group, n=12) as conduit. The median number of intraoperative red blood cell transfusions was significantly increased in the Ao and Ao-P groups (5, 5, 8.5 and 16 for SA, CT, Ao and Ao-P group respectively, P=0.002), as well as fresh frozen plasma (4.5, 2.5, 10, 17 for the SA, CT, Ao and Ao-P groups respectively, P=0.001). Hospitalization duration was also significantly increased in the Ao and Ao-P groups (15, 16, 24, 26.5 days for the SA, CT, Ao and Ao-P groups respectively, P<0.001). The occurrence of early allograft dysfunction (EAD) (P=0.07) or arterial complications (P=0.26) was not statistically different. Level of factor V, INR, bilirubin and creatinine during the 7th postoperative days (POD) was significantly improved in the SA group. No difference was observed regarding graft (P=0.18) and patient (P=0.16) survival. In case of unusable HA, intraoperative and postoperative outcomes are improved when using the SA or CT compared to aorta.

Impact and Consequences of Recipient Gastroduodenal Artery (GDA) Ligation Prior to Hepatic Artery (HA) Anastomosis during Orthotopic Liver Transplantation (OLT)

Introduction: In Orthotopic Liver Transplantation, the recipient GDA is often ligated for the HA anastomosis. It is done either to gain mobility, length on recipient HA or in support of the hypothesis that it would prevent “Steal syndrome” protecting the anastomosis. The aim of study is to evaluate its impact on prevention of HA thrombosis (HAT) and consequences of such ligation.

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

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

Splenic Artery Transposition for Hepatic Artery Reconstruction During Liver Transplantation: Is It the Best Choice for Adequate Arterial Inflow in Extraordinary Conditions?

Obtaining partial allografts and performing arterial reconstruction in living donor liver transplantation (LDLT) is technically demanding. The risk of hepatic artery thrombosis (HAT) remains high in LDLT due to the small caliber of the arteries. The graft and the recipient hepatic artery (HA) cannot be directly anastomosed in certain cases due to narrow diameter or short graft HA.

Using the Recipient's Left Gastric Artery for Hepatic Artery Reconstruction in Living Donor Liver Transplantation.

Since the first living-donor liver transplantation (LDLT) was performed by Raia et al. in 1988, LDLT has become a new hope for patients in countries with insufficient cadaveric organ pool, such as Turkey. However, the use of a partial liver allograft in LDLT and the harvesting of hepatic arteries (HA) with a relatively small diameter creates pose technical difficulties in terms of HA reconstruction. A graft HA and a recipient HA cannot be directly anastomosed in some undesirable situations.

A Technique of Hepatic Artery Anastomosis in Living Donor Liver Transplantation: Back-wall First Technique

Microvascular technique of placing three stay sutures at 120° intervals around the circumference of the arteries to be anastomosed is limited in its usefulness in LDLT as hepatic artery (HA) is shorter, smaller, and thin-walled hindering the surgeon's ability to rotate it with the vascular clamps in situ whilst completing the anastomosis. Our technique of HA reconstruction overcomes this problem by placing two adjacent sutures at 6 O'clock in the posterior wall after preparing and positioning donor's and recipient's HAs (A).

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

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

Urgent Endovascular Treatment of Severe Celiac Artery Stenosis during Liver Transplantation

Arterial reconstruction during orthotopic liver transplant (OLT) can often be quite challenging in cases where the recipient hepatic artery is inadequate to provide inflow to the allograft. In these situations, an aorto-hepatic interposition graft is typically performed using the donor iliac artery [1, 2]. We present a case describing the use of urgent endovascular treatment of severe celiac artery stenosis intra-operatively during liver transplantation in a patient with significant aorto-iliac atherosclerotic disease precluding the use of an interposition graft.

Managing Recipient Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation.

Recipient hepatic artery intimal dissection (HAD) followed by hepatic artery thrombosis (HAT) is a serious complication of liver transplantation. Once this is recognized intraoperatively, the accepted approach is to use an alternative arterial inflow, which may not be possible in all patients. We describe a new classification and technique for the management of HAD during living donor liver transplantation. On the basis of the longitudinal extent of intimal dissection, HAD was classified into 4 types. Management was based on the type of dissection, availability of an adequate length of hepatic artery (HA), and an alternate source of inflow. The dissected HA itself was used for arterial anastomosis in patients with preserved pulsatile flow in the dissected artery and a lack of an alternative source of arterial inflow. The technique of using the dissected artery was based on close approximation of the tunica intima to the media with the first 2 sutures of the arterial anastomosis. Of 47 (2.4%) patients who developed HAD, 22 (46.8%) had a type 2 dissection for whom the other (right or the left) undissected HA was used for the anastomosis, and 20 (42.6%) had major (type 3 or 4) dissection. The dissected artery was used for the anastomosis in 9 (45%) of these patients. Postoperative HAT developed in only 1 of 9 patients. Pre-existing portal vein thrombosis and prior transarterial embolization were found to be major risk factors for the development of HAD. Using the technique described, the dissected artery can be successfully used for a satisfactory HA anastomosis with low thrombosis rates.

Usefulness of microsurgical back-table angioplasty for multiple hepatic arteries in living donor liver transplantation.

The graft hepatic artery orifice is tiny in living donor liver transplantation, and therefore, it is more difficult to reconstruct the hepatic artery than in deceased donor liver transplantation. In situ, multi‐vessel hepatic artery reconstruction in living donor liver transplantation is time‐consuming, and reconstructions are often complicated if the hepatic graft has several stumps. We describe two living donor liver transplants using back‐table microsurgical angioplasty to combine two hepatic artery stumps to create a single orifice, and sequential single‐vessel hepatic artery reconstruction in the recipient. Briefly, we used double‐needle interrupted sutures for the two hepatic artery stumps with a biangular stay‐suture method in back‐table microsurgical angioplasty. Each suture was placed from the inner side of the arterial wall to the outer side, which allowed for safe and reliable suturing. After placing the interrupted sutures in the anterior wall, we turned over the vessels in the cold storage on the back table and placed interrupted sutures in the posterior wall. In the recipient, the single stump of the graft was anastomosed to the recipient's hepatic artery using an interrupted pattern and a surgical microscope. The postoperative courses of the donors and recipients were uneventful. Back‐table hepatic artery angioplasty is a feasible option to overcome the complexities of multi‐vessel arterial reconstruction in living donor liver transplantation. We recommend performing secure multi‐vessel hepatic arterial reconstruction adapted to the clinical scenario. Using simple appropriate anastomosis, back‐table microsurgical angiography may provide good results in living donor liver transplantation.

Splenic Artery Transposition for Arterial Reconstruction in Living Donor Liver Transplantation

PurposeIn living donor liver transplantation, poor compatibility of the recipient hepatic artery remains a technical challenge. Here, we analyzed our 14 years of experience with extra-anatomic hepatic artery reconstruction. MethodsBetween July 2004 and December 2018, there were 1063 liver transplantations at our center. All patients with an extra-anatomic hepatic artery reconstruction were identified. The gastroduodenal artery and the transposed splenic artery were the primary options for extra-anatomic arterial reconstruction. Patient characteristics, operative data, and post-transplant outcome were reviewed retrospectively. ResultsThere were 22 patients with extra-anatomic hepatic artery reconstruction, 6 with gastroduodenal artery, and 16 with splenic artery. There were 2 major complications: 1 patient underwent early reoperation due to bleeding from the splenic artery trunk and another had an iatrogenic injury to the transposed splenic artery during conversion hepaticojejunostomy. Both were treated successfully with surgery. One patient died perioperatively due to sepsis. The 1- and 3-year graft survival rates of these 16 patients were 93.7% and 87.5%. ConclusionIf the hepatic arteries are not suitable for anastomosis, then we consider the gastroduodenal artery and the splenic artery to be the conduits of choice for extra-anatomic arterial reconstruction. The transposed splenic artery is very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.

Partial portal vein arterialization during living-donor liver transplantation: a case report

BackgroundHepatic artery thrombosis can lead to graft loss associated with severe hepatic infarction or bile duct ischemia. When anatomical hepatic artery reconstruction is impossible in liver transplantation or hepato-pancreatic biliary surgery, portal vein arterialization (PVA) is proposed as a salvage technique. Herein, we report our experience with a case that showed favorable clinical outcomes after partial PVA during living-donor liver transplantation (LDLT) because of difficulties in arterial reconstruction.Case presentationA 62-year-old woman with non-B, non-C liver cirrhosis complicated with hepatocellular carcinoma was being prepared for LDLT using an extended left lobe graft. The graft presented with two arteries (left hepatic artery, 2 mm; middle hepatic artery, 2 mm). The first anastomosis was performed using the recipient hepatic artery stumps, but no flow was detected on Doppler control because of thrombus formation. The next attempt was executed using the middle colic artery with a radial artery jump graft and the right gastroepiploic artery, but it led to the same result. Thus, the graft oxygen support by the standard arterial procurement was abandoned, and a shunt was created between the ileocecal artery and the vein to obtain PVA. Arteriography of the superior mesenteric artery showed that the shunt was relatively patent, and the portal vein was apparent. No biliary complication or liver abscess occurred postoperatively, and the patient presented with good liver function and no complications related to portal vein hypertension, nor liver fibrosis 18 months after the LDLT.ConclusionPartial PVA with a shunt created between the ileocecal artery and the vein is useful when arterial reconstruction is difficult during LDLT for preventing graft loss caused by severe hepatic infarction or bile duct ischemia.

2368 A Rare Case of Segmental Arterial Mediolysis in a Patient With Alpha-1 Antitrypsin Deficiency and Alcoholic Cirrhosis

INTRODUCTION: Alpha-1 antitrypsin deficiency (AAT deficiency) is a systemic disease characterized by lack of the protease inhibitor, alpha-1 antitrypsin and typically manifests as severe emphysema and/or liver disease. There are several case reports describing vascular compromise in patients with AAT deficiency, however mostly in the context of systemic vasculitis and connective tissue disease. Segemental arterial medioloysis (SAM) is a rare non-vasculitis, non-atherosclerotic arteriopathy of middle and small arteries that can lead to aneurysmal dilation or arterial stenosis. We report the first case of a patient with cirrhosis secondary to AAT deficiency noted to have arteriopathy due to SAM. CASE DESCRIPTION/METHODS: A 30 year old patient with end stage renal disease (ESRD) on hemodialysis, alcoholic cirrhosis and underlying AAT deficiency presented to our tertiary care center for liver transplant evaluation with a presenting MELD score of 39. Evaluation for other causes of cirrhosis revealed AAT deficiency with a homozygous ZZ phenotype and undetectable serum levels. As part of his pre-transplantation workup at our institution, he underwent computed tomography angiography (CTA) of the abdomen and pelvis which revealed severe irregular narrowing of the celiac axis. Similar narrowing was noted of the renal arteries and splenic artery and focal aneurysmal dilation of the hepatic and gastroduodenal arteries was additionally seen (Image 1). Autoimmune serologies were negative. Patient proceeded to orthotropic liver transplantation during his hospitalization. Intraoperatively, hepatic artery appeared visually vasculitic but histopathologic report was consistent with diagnosis of SAM. Due to concern for potential graft compromise that could result from the recipient hepatic artery aneurysm, an aortic conduit was performed using the donor vessels with anastomosis to the recipient supraceliac aorta. DISCUSSION: To our knowledge, there is only one other published report describing SAM in a patient with co-existing AAT deficiency. SAM in this case resulted in hepatic aneurysm which complicated liver transplantation, necessitating alternative graft revascularization via an aortic conduit. Although doppler evaluation 3 days after transplantation showed hepatic artery anastomosis was still patent, the rate of complications related to aorto-hepatic bypass grafts is high, and close follow up remains prudent.

Hepatic artery reconstruction in living donor liver transplantation: strategy of the extension of graft or recipient artery

In living donor liver transplantation (LDLT) patients, the reconstruction of insufficiently long hepatic artery (HA) is difficult. However, no report has described the relationship between the length of HA and its reconstructive procedure. Herein, we aimed to identify the risk factors for the requirement of additional reconstructive procedures of direct anastomosis. Sixty-eight HA reconstructions in LDLT were conducted (37, men; 31, women). The causes of LDLT were hepatitis (n = 36), biliary atresia (n = 13), and primary biliary cirrhosis (n = 12). The graft HA comprised the right HA (n = 37) and left HA (n = 31). The recipient HA comprised the right HA (n = 39), left HA (n = 28), and right gastro-omental artery (n = 1). Two cases had graft HAs measuring 8 mm or more. The gap between the graft and recipient HA was 6 mm or more in nine cases. In 63 cases, direct anastomosis was performed. The extension of graft HA was performed using radial graft (n = 1) and two-step method (n = 1). The extension of recipient HA was performed using arterial graft (n = 2) extraanatomical recipient artery. Less than 8 mm length of graft HA (OR, 84) and 6 mm or greater gap between the recipient and graft HA (OR, 46.0) were identified as the risk factors for the need of additional procedures of direct anastomosis. We must always pay attention to the length of the graft and donor HA. To perform HA reconstruction safely, we should always consider using arterial grafts, extra-anatomical recipient artery, or the two-step method.

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.