Treatment for accidental occlusion of the hepatic artery after hepatic resection: report of two cases

A modified kidney-sparing portal vein arterialization model of heterotopic auxiliary liver transplantation increases liver IL-6, TNF-α, and HGF levels and enhances liver regeneration: an animal model

BACKGROUND AND AIM

The success of partial donor liver transplantation is affected by the implantation site of the donor liver and the vascular reconstruction approach. We investigated the effects of different donor liver implantation sites and vascular reconstruction approaches on liver regeneration using a rat kidney-sparing heterotopic auxiliary liver transplantation model, with portal vein arterialization (PVA).

METHODS

Sixty male Sprague-Dawley rats underwent end-to-end anastomosis of the donor liver portal vein and the right renal artery stent (control group), or end-to-side anastomosis of the donor liver portal vein and the left common iliac artery (experimental group).

RESULTS

The experimental group had significantly lower plasma levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and cholinesterase than the control group (all, P < 0.05). The levels of tumor necrosis factor-α (TNF-α), interleukin 6 (IL-6), and hepatocyte growth factor (HGF) in the liver were significantly higher in the experimental group than that in the control group (all, P < 0.05). Hematoxylin and eosin (HE) staining of the liver tissue specimens indicated that the experimental group had greater hepatocyte regeneration compared to the control group.

CONCLUSIONS

The modified kidney-sparing PVA model of heterotopic auxiliary liver transplantation is more conducive to liver regeneration with quicker return of liver function.

Dissecting aneurysm of the proper hepatic artery after laparoscopic hepatectomy possibly related to the Pringle maneuver: A case report

In hepatectomy, the Pringle maneuver is commonly used, but its association with iatrogenic injury is not yet well understood. This report presents a case of dissecting aneurysm of the proper hepatic artery (PHA) possibly associated with the Pringle maneuver during laparoscopic hepatectomy, that was successfully treated by transcatheter arterial embolization (TAE). The patient was a woman in her 70s, and repeat hepatectomy for liver metastasis of rectal neuroendocrine neoplasm was planned. She underwent hand-assisted laparoscopic hepatectomy with the Pringle maneuver. On postoperative day (POD) 7, enhanced computed tomography showed a dissecting aneurysm of the PHA. TAE of the PHA to prevent hemorrhage was performed on POD 9 with no complications. Even after TAE, intrahepatic arterial flow was provided by the peribiliary arteries. This case suggests the possibility that the Pringle maneuver can cause a dissecting aneurysm of the hepatic artery.

Portal vein arterialization as a salvage procedure in hepatopancreatobiliary surgery: a systematic review

Background

Portal vein arterialization (PVA) is a possible option when hepatic artery reconstruction is impossible during liver resection. The aim of this study was to review the literature on the clinical application of PVA in hepatopancreatobiliary (HPB) surgery.

Methods

We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched the PubMed, Embase and Web of Science databases until December 2019. Experimental (animal) studies, review articles and letters were excluded.

Results

Twenty studies involving 57 patients were included. Cholangiocarcinoma was the most common indication for surgery (40 patients [74%]). An end-to-side anastomosis between a celiac trunk branch and the portal vein was the main PVA technique (35 patients [59%]). Portal hypertension was the most common long-term complication (12 patients [21%] after a mean of 4.1 mo). The median follow-up period was 12 (range 1–87) months. The 1-, 3- and 5-year survival rates were 64%, 27% and 20%, respectively.

Conclusion

Portal vein arterialization can be considered as a rescue option to improve the outcome in patients with acute liver de-arterialization when arterial reconstruction is not possible. To prevent portal hypertension and liver injuries due to thrombosis or overarterialization, vessel calibre adjustment and timely closure of the anastomosis should be considered. Further prospective experimental and clinical studies are needed to investigate the potential of this procedure in patients whose liver is suddenly de-arterialized during HPB procedures.

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

Background

Hepatic 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 presentation

A 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.

Conclusion

Partial 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.

An experimental pilot study on controlled portal vein arterialization with an extracorporeal device in the swine model of partial liver resection and ischemia

AIM

To determine whether the physiologically oxygenated arterial blood reversed in the portal system by means of portal vein arterialization (PVA) through an extracorporeal device which we have called L.E.O2.NARDO (Liver Extracorporeal Oxygen. NARDO) is effective in treating swine with subtotal hepatectomy leading to acute liver failure (ALF).

METHODS

Ten swine with ALF induced by 85-90% liver resection and five minutes of ischemia-reperfusion injury were randomly divided into two groups: five animals received PVA extracorporeal treatment and five swine were not-treated (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system. An extracorporeal device was interposed between the outflow and the inflow in order to monitoring the hemodynamic parameters. Each treatment lasted 6 hours. Serum and liver samples were collected in both groups. The survival was assessed at 1 week.

RESULTS

The PVA-extracorporeal treatment yielded beneficial effects for subtotal hepatectomy-induced ALF swine with decreased serum ammonia, transaminases and total bilirubin as compared with the untreated group. INR recovered rapidly in the PVA-extracorporeal group remaining significantly lower than in untreated animals. The 7-day survival of PVA-extracorporeal group swine was significantly higher than that of untreated animals, with a statistically significant difference (p<0.05). Four swine in the PVA-extracorporeal group survived at 1 week while none of the swine in the control group were alive at that time; an average time of 144h+/-13h and 24.4h+/-5h was observed in the PVA-extracorporeal and control groups, respectively.

CONCLUSIONS

Arterial blood supply in the portal system through the extracorporeal device is easily applicable, efficacious, safe and may represent a novel approach for ALF swine induced by subtotal liver resection.

Arterial ischemia in the deportalized liver following associating liver partition and portal vein ligation for staged hepatectomy

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel 2-stage technique intended to induce rapid growth of the future liver remnant (FLR). Initial reports of a 12% mortality rate have sparked debate regarding the safety of the procedure. A 64 years old male was planned for a right-sided hemi-hepatectomy due to colorectal cancer liver metastases. Intra-operatively it was decided to convert to an ALPPS due to unexpectedly small segments 2-4. Post-operative serum laboratory tests indicated an acute liver failure and radiological imaging showed no sign of arterial blood flow to the right hemi-liver. A computed tomography examination on post-operative day 3 revealed that the FLR had increased from 290 to 690 mL in 3 d (138% growth). In the following days serum values gradually improved and stage 2 was carried out on post-operative day 7. The rest of the hospital stay was uneventful and the patient made a full recovery. ALPPS is a fascinating advancement in liver surgery. Despite severe post-operative complications, in properly selected cases it provides successful outcomes that other modalities of treatment cannot offer.

Portal blood arterialization with an extracorporeal device to treat toxic acute hepatic failure in a swine model

PURPOSE

This study aimed to determine whether a controlled portal blood arterialization by a liver extracorporeal device (L.E.O2 NARDO) is effective in treating acute hepatic failure (AHF) induced through CCl4 administration in a swine model.

METHODS

20 swine with AHF induced by intraperitoneal injection of carbon tetrachloride (CCl4) in oil solution, were randomly divided into two groups: animals receiving L.E.O2 NARDO treatment 48 h after the intoxication (study group); animals sham operated 48 h after the intoxication (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system by an interposed extracorporeal device. Each treatment lasted 6 h. The survival was assessed at 5 days after L.E.O2 NARDO treatment or sham operation. In both groups blood samples were collected for biochemical analysis at different time points and liver biopsies were collected 48 h after intoxication and at sacrifice.

RESULTS

We observed decreased transaminases levels and a more rapid INR recovery in the study group, as compared to the control group. Eight animals of the study group vs. two animals of the control group survived at five days after surgery with a statistically significant difference (p<0.05). Liver biopsies performed at sacrifice showed a reduction of the damaged hepatic areas in the study group as compared to the control group.

CONCLUSIONS

Arterial blood supply in the portal system through the L.E.O2 NARDO device is easily applicable, efficacious, and safe in a swine model of AHF induced by CCl4 intoxication.

Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience

BACKGROUND

Portal vein arterialization (PVA) has been used as a salvage inflow technique when hepatic artery (HA) reconstruction is deemed impossible in liver transplantation (LT) or hepatopancreatobiliary (HPB) surgery. Outcomes and the management of possible complications have not been well described.

METHODS

The present study analysed outcomes in 16 patients who underwent PVA during the period from February 2005 to January 2011 for HA thrombosis post-LT (n = 7) or after liver resection (n = 1), during curative resection for locally advanced HPB cancers (requiring HA interruption) (n = 7) and for HA resection without reconstruction (n = 1). In addition, a literature review was conducted.

RESULTS

Nine patients were women. The median age of the patients was 58 years (range: 30-72 years). Recovery of intrahepatic arterial signals and PVA shunt patency were documented using Doppler ultrasound until the last follow-up (or until shunt thrombosis in some cases). Of five postoperative deaths, two occurred as a result of haemorrhagic shock, one as a result of liver ischaemia and one as a result of sepsis. The fifth patient died at home of unknown cause. Three patients (19%) had major bleeding related to portal hypertension (PHT). Of these, two underwent re-exploration and one underwent successful shunt embolization to control the bleeding. Four patients (25%) had early shunt thrombosis, two of whom underwent a second PVA. After a median follow-up of 13 months (range: 1-60 months), 10 patients (63%) remained alive with normal liver function and one submitted to retransplantation.

CONCLUSIONS

Portal vein arterialization results in acceptable rates of survival in relation to spontaneous outcomes in patients with completely de-arterialized livers. The management of complications (especially PHT) after the procedure is challenging. Portal vein arterialization may represent a salvage option or a bridge to liver retransplantation and thus may make curative resection in locally advanced HPB cancers with vascular involvement feasible.

Partial portal vein arterialization in acute liver failure

Experimental studies have shown that increasing the oxygen supply to the liver through partial portal vein arterialization (PPVA) enhances liver regeneration after extensive liver resection or drug intoxication. In the last two decades, several PPVA procedures were performed in humans with the aim to prevent or treat acute liver failure (ALF) following major hepatobiliary surgery or other etiology. The aim of this review was to analyze literature data on PPVA and report our experimental and clinical experience of this procedure. In this setting, we report our positive experience in the realization and clinical application of an extracorporeal device able to increase the oxygenated blood delivered to the liver through the umbilical vein and to support liver function in a man subjected to an extended liver resection. PPVA procedure has shown promising results in the treatment of ALF following major hepatobiliary surgery or from other etiology. Moreover, less invasive approaches to PPVA demonstrated to be safe and efficacy. It is clear that further investigations must be done to fully understand the potentiality of PPVA as a strategy to treat ALF.

Extracorporeal portal vein arterialization in man after extended hepatectomy to prevent acute liver failure: a case report

Experimental studies have shown that increasing the oxygen supply to the liver through portal vein arterialization (PVA) enhances liver regeneration after partial hepatectomy. Moreover, our previous study demonstrated a beneficial effect of an extracorporeal device to increase the oxygenated blood to the liver and to improve the survival rate of animals subjected to subtotal hepatectomy. Herein we have reported a case of PVA through an extracorporeal device to treat a man after extended hepatectomy leading to acute liver failure (ALF). An obese 69-year-old man (body mass index > 35) affected by multiple metastases from colorectal cancer underwent 80% liver resection; at laparotomy, a steatotic liver was evident due to adjuvant chemotherapy. Moreover, the liver experienced 20 minutes of hepatic ischemia during the resection. At the end of resection he underwent extracorporeal PVA treatment. Blood was withdrawn from the femoral artery and returned into the portal venous system through the umbilical vein. An extracorporeal device was interposed between the outflow and inflow to monitor hemodynamic parameters. Starting from operating room each of six treatments lasted 6 hours per day. Serum and liver samples were collected daily. The extracorporeal device was dismounted at the seventh postoperative day. The postoperative course was assessed at 1 month. The PVA-extracorporeal treatment yielded beneficial effects for subtotal hepatectomy by decreasing serum ammonia, transaminases, and total bilirubin concentration. The international normalized ratio recovered rapidly, remaining significantly lower during the entire postoperative period. The ten-day postoperative period was uneventful. The patient was discharged in good health. He is alive and well at the moment. The arterial blood supply in the portal system through the umbilical vein using an extracorporeal device was easily applicable, efficacious, safe, and cost-effective. It may represent a novel approach to treat patients with potential ALF after subtotal liver resection.

Portal vein arterialization in liver transplantation: an option to restore arterial flow: a case report

We report a 66-year-old woman who underwent emergency orthotopic liver transplantation due to acute liver failure. The donor's liver graft displayed extensive arteriosclerosis, involving the celiac trunk and hepatic artery. Arterial revascularization of the graft could not be achieved, requiring an arterioportal shunt between the gastroduodenal artery and the portal vein of the recipient. During the early postoperative period, the patient's clinical condition and liver function tests improved rapidly; the patient was discharged on postoperative day 30. Two months later, she developed acute cholangitis. Ischemic-type stenosis of the intrahepatic biliary tree was present, so successful elective retransplantation was undertaken at the ninth postoperative month. In our experience, portal vein arterialization may be useful as a bridging therapy in extreme situations.

Portal vein arterialization for hepatic artery thrombosis in liver transplantation: a case report, Doppler-ultrasound aspects, and review of the literature

Portal vein arterialization (PVA) is a salvage procedure for insufficient hepatic arterial or portal vascularization. It plays a role in auxiliary and orthotopic liver transplantation (OLT). In OLT, current indications for PVA include hepatic artery thrombosis (HAT), pre-OLT or post-OLT extended splanchnic vein thrombosis, intraoperative low portal flow, and anatomic variations like the absence of portal and mesenteric veins. Out of the transplantation domain, PVA is used both in extensive surgery for malignancies of the liver, biliary tract, and pancreas and in the treatment of fulminant hepatic failure (FHF) due to intoxications. We describe a case of acute post-OLT HAT successfully treated with PVA as a short bridge to retransplantation. By Doppler ultrasound of clinical PVA we detected an increased intrahepatic portal flow velocity, with disappearance of the arterial spikes, a finding that needs further investigation. PVA represents a rare surgical procedure. In fact, it has been used most of all in urgent conditions or in case of abrupt vascular complications during surgery. According to the literature, PVA emerges as a salvage procedure for poor arterial or portal hepatic flow, both in OLT and in general abdominal surgery. The outcome of this procedure is unpredictable. The aim of the shunt is to gain time, awaiting the onset of collateral arterial vessels or the performance of definitive surgery. Its early thrombosis may be a catastrophic event, due to acute liver ischemia. In contrast, a late occlusion is often well tolerated. Strict surveillance is always useful because sometimes it is mandatory to embolize the arterioportal fistula to treat or to prevent the onset of portal hypertension.

Portal vein arterialization increases hepatocellular apoptosis and inhibits liver regeneration

BACKGROUND

Portal vein arterialization is performed in particular situations to guarantee sufficient blood flow in the portal vein. In addition, some authors have postulated a proliferation-promoting influence of portal vein arterialization on the liver tissue. However, portal vein arterialization is an unphysiological procedure: It increases portal blood flow and blood pressure as well as oxygenation of the liver tissue. On the other hand, it reduces the influx of hepatotrophic factors from the portal venous blood. The aim of these experiments was to investigate apoptosis and proliferation of hepatocytes during various conditions of the portal perfusion.

MATERIALS AND METHODS

After 70% liver resection in Lewis rats, the following four experimental groups were formed differing in portal perfusion: (I) hyperperfused, nonarterialized; (II) flow-regulated, nonarterialized; (III) hyperperfused, arterialized; (IV) flow-regulated, arterialized. A warm ischemia of 30 min was kept in all groups.

RESULTS

Portal vein arterialization of 70% reduced rat livers significantly reduced liver regeneration as shown by a significant reduction in liver weight, body weight, and liver function after 6 wk, in contrast to the group with 70% liver mass reduction and portal venous inflow of the portal vein. Furthermore, we found a significantly elevated number of apoptotic hepatocytes after portal vein arterialization. These results were independent from blood flow regulation of the arterialized portal vein, which caused no improvement of the results.

CONCLUSIONS

Portal vein arterialization should be performed only temporarily and is clinically not recommended as a permanent option, because of the increased hepatocellular apoptosis and the very distinctive, negative long-term effects on liver weight.

Portal vein arterialization in hepatobiliary surgery and liver transplantation

We reviewed the literature reports and our personal experience on partial portal vein arterialization (PPVA) to prevent and treat acute liver failure (ALF) following major hepatobiliary surgery or another etiology. Experimental studies in rats have assessed the efficacy of PPVA in treatment of ALF induced by extended resections in normal or fatty livers or in toxic carbon-tetrachloride damage. The treated groups showed greater survival and faster recovery of liver function. Among 11 clinical cases reported in the literature, PPVA was performed in four cases to prevent and in seven cases to treat ALF. Eight patients survived, showing rapid recovery of liver function and resolution of the clinical condition. This relatively simple procedure has shown itself able to promote liver regeneration. The PPVA procedure has shown itself to be safe and simple as well as to offer a promising approach to the failing liver.

Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection

Background

Portal vein and hepatic artery resection and reconstruction may be required in radical surgery for biliary cancer. Microvascular reconstruction requires special equipment and training, and may be difficult to accomplish when the arterial stump is small, when there are multiple vessels or when the stump lies deep within the wound. This study examined the feasibility and safety of arterioportal shunting as an alternative to arterial reconstruction.

Methods

Over 30 months, ten patients with biliary cancer (six bile duct and four gallbladder carcinomas) underwent radical surgery with en bloc resection of the hepatic artery and end-to-side arterioportal reconstruction between the common hepatic or gastroduodenal artery and the portal trunk.

Results

No patient died. Complications included bile leakage in two patients and liver abscess in one. Routine angiography performed 1 month after surgery revealed shunt occlusion in three patients. Once the existence of hepatopetal arterial collaterals had been confirmed in the remaining patients, the shunt was occluded by coil embolization.

Conclusion

Arterioportal shunting appears to be a safe alternative to microvascular reconstruction after hepatic artery resection. However, the safety of the procedure and its potential to increase the cure rate require further assessment in a larger series with a longer follow-up.

Efficacy of continuous infusion of prostaglandin E1 through the superior mesenteric artery against ischemic liver cell necrosis after hepatic artery occlusion

BACKGROUND

Hepatic artery occlusion (HAO) can cause severe ischemic liver injury, especially after an interruption of collateral circulation after extensive hepatobiliary surgery. To minimize a decrease in oxygen delivery after HAO, a continuous infusion of prostaglandin (PG)E1 through the superior mesenteric artery (SMA) was studied in comparison with other infusion routes.

METHODS

Twenty-four pigs were assigned to four groups: HAO without PGE1 (control group); HAO with PGE1 (0.02 microg/kg/min, continuously) through the jugular vein (intravenous group); HAO with PGE1 through the portal vein (PV group); and HAO with PGE1 through the SMA (SMA group). PV flow, hepatic oxygen delivery, and serum aspartate aminotransferase were measured after infusion. In addition, 72-hr survival rates were observed, and histologic examination of liver specimens was performed.

RESULTS

PGE1 infusion through the SMA seems to affect PV flow and elevate the oxygen content of portal blood, whereas other routes of administration do not. The reduction of hepatic oxygen delivery after HAO was 51% in the control group, 46% in the intravenous group, and 49% in the PV group, whereas it was limited to 13% in the SMA group. Serum aspartate aminotransferase values 24 hr after HAO were lowest in the SMA group, which was statistically significant, as confirmed by histology. The survival rate of animals was 100% in the SMA group and 33% in the other three groups.

CONCLUSION

These findings indicate that continuous PGE1 infusion through the SMA may prove useful in clinical settings to prevent liver damage after HAO.