Technical Feasibility and Clinical Outcomes of Interventional Endovascular Treatment for Hepatic Artery Thrombosis After Living-donor Liver Transplantation

Time is of the essence: A single-center experience of hepatic arterial supply impairment management in pediatric liver transplant recipients

BACKGROUND

Impairment of hepatic arterial flow including hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), and splenic artery steal syndrome (SASS) is potentially life-threatening complications. The proposed early diagnosis and urgent treatment strategy of graft arterial flow reduction aim to decrease morbidity and mortality.

METHODS

Pediatric patients with known hepatic arterial flow impairment were retrospectively reviewed. Patients were grouped by occlusive (HAT) and non-occlusive (HAS/SASS) arterial flow reduction. Patients with HAT were further divided in two groups based on the estimated maximal hepatic artery occlusion time ≤8 and >8 hours.

RESULTS

Impairment of hepatic arterial flow developed in 32 of 416 pediatric liver transplant recipients. HAT, HAS, and SASS incidences were 4.1% (n = 17), 2.2% (n = 9), and 1.4% (n = 6), respectively. Neither graft loss nor death occurred in the non-occlusive group. The probabilities of sepsis (OR, 1.7; 95% CI, 1.14-2.53; P=.008) and graft loss or death (OR, 1.42; 95% CI, 1.04-1.92; P=.046) were higher in the occlusive group. Patients with estimated maximal duration of hepatic artery occlusion ≤ 8 hours (n = 7; 41.2%) did not have ischemic-type biliary lesions and sepsis (P=.044 and 0.010, respectively) but had excellent 3-year graft survival compared with > 8 hours group (100% vs 40%; P=.037). Multivariate analysis revealed HAT manifestation by fever was associated with increased chances of graft loss or death.

CONCLUSION

Occlusive arterial complications impose higher risks of graft loss and death. Thorough arterial supply monitoring by Doppler ultrasonography and urgent endovascular arterial flow restoration may salvage both graft and the recipient.

The Application of Interventional Radiology in Living-Donor Liver Transplantation

Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.

Complications after endovascular treatment of hepatic artery stenosis after liver transplantation

BACKGROUND

Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis (HAT) and a subsequent 30% to 50% risk of graft loss. Although endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment, the potential risks of these interventions are poorly described.

METHODS

A retrospective review of all endovascular interventions for HAS after liver transplantation between August 2009 and March 2016 was performed at a single institution, which has the largest volume of liver transplants in the United States. Severe HAS was identified by routine surveillance duplex ultrasound imaging (peak systolic velocity >400 cm/s, resistive index <0.5, and presence of tardus parvus waveforms).

RESULTS

In 1129 liver transplant recipients during the study period, 106 angiograms were performed in 79 patients (6.9%) for severe de novo or recurrent HAS. Interventions were performed in 99 of 106 cases (93.4%) with percutaneous transluminal angioplasty alone (34 of 99) or with stent placement (65 of 99). Immediate technical success was 91%. Major complications occurred in eight of 106 cases (7.5%), consisting of target vessel dissection (5 of 8) and rupture (3 of 8). Successful endovascular treatment was possible in six of the eight patients (75%). Ruptures were treated with the use of a covered coronary balloon-expandable stent graft or balloon tamponade. Dissections were treated with placement of bare-metal or drug-eluting stents. No open surgical intervention was required to manage any of these complications. With a median of follow-up of 22 months, four of eight patients (50%) with a major complication progressed to HAT compared with one of 71 patients (1.4%) undergoing a hepatic intervention without a major complication (P < .001). One patient required retransplantation. Severe vessel tortuosity was present in 75% (6 of 8) of interventions with a major complication compared with 34.6% (34 of 98) in those without (P = .05). In the complication cohort, 37.5% (3 of 8) of the patients had received a second liver transplant before intervention compared with 12.6% (9 of 71) of the patients in the noncomplication cohort (P = .097).

CONCLUSIONS

Although endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery and prior retransplantation were associated with a twofold to threefold increased risk of a major complication. Acute vessel injury can be managed successfully using endovascular techniques, but these patients have a significant risk of subsequent HAT and need close surveillance.

Endovascular Mechanical Thromboaspiration of Right Hepatic Arterial Thrombosis After Liver Transplantation

A 56-year-old male Patient presented 27 days after a liver transplantation (LT) with fever and hyperbilirubinemia. He underwent CT examination resulting in a diagnosis of right hepatic artery (HA) occlusion with hepatic bilomas. Once placed a long right femoral 6F introducer at the origin of the HA, a 0.014" guidewire was advanced over the thrombus, in a segmental branch. A 4MAX (Penumbra, Alameda, USA) catheter was advanced and withdrawn under constant aspiration until complete clot removal was achieved. Follow-up CT and D-US assessments at 12 months demonstrated regular HA patency and bilomas reduction. Endovascular thromboaspiration is an effective strategy in cases of E-HAT after LT.