Vascular complications, treatment, and outcome following orthotopic liver transplantation

Intrahepatic Arterioportal Fistula: A Rare Cause of Portal Hypertension After Deceased Donor Liver Transplant

A 43-year-old male patient, who received a deceased donor liver transplant for background ethanol-related decompensated cirrhosis, presented 7 months after transplant with mild abdominal distension and pain. On evaluation, the patient had thrombocytopenia, high serum-ascites albumin gradient ascites, and deranged liver functions. The Doppler study of the splenoportal axis showed hepatofugal flow in the recipient's portal vein, normal hepatic veins, a normal liver, splenomegaly, mild ascites, and multiple periportal collaterals. A transjugular liver biopsy and a hepatic venous pressure gradient measurement were done, which suggested mild portal tract inflammation with portal tract fibrosis with prominent portal venous thickening and normal hepatic venous pressure gradient (4 mm). However, the patient had a progressive increase in ascites and a dramatic increase in serum bilirubin level. A triple-phase computed tomography was done that showed rapid contrast flow in both the portal and hepatic arterial phase, suggesting arterialization of the portal flow with possible suspicion of a communicating arterioportal fistula. The patient underwent digital subtraction angiography, which was followed by an embolization of the arterioportal fistula. After embolization, serum bilirubin gradually decreased and ascites resolved. A repeat Doppler of the portal venous system showed established hepatopetal flow with progressively rising portal flow velocities.

Imaging post liver transplantation part I: vascular complications

Liver transplantation continues to rise in frequency, with over 1,000 procedures performed in the UK in 2018. Complications are increasingly uncommon but when they occur, early recognition and intervention is vital to save grafts. Imaging after the perioperative period is often performed at patients' local hospitals meaning that all radiologists and sonographers need to have an understanding of how to assess a transplant liver. Part I of this series will focus on vascular complications, including the normal postoperative vascular anatomy following liver transplantation, normal post-transplantation vascular imaging findings and abnormal findings that may prompt further investigation. Vascular complications following liver transplantation will be illustrated using a collection of cases.

Maximizing Deceased-Donor Allograft Utilization: Management of a Celiac Artery Aneurysm in a Deceased-Donor Liver

As the scarcity of transplantable organs continues to rise, compounded with an aging donor population, transplant surgeons are increasingly confronted with organ offers from less than ideal donors. The presence of a celiomesenteric aneurysm involving the vascular supply of a donor allograft may predispose to vascular complications in the transplanted liver. We present a 61-year-old brain-dead donor who was discovered to have a celiac artery aneurysm during organ recovery. After gross atherosclerotic or mycotic involvement was ruled out and after careful consideration of the vascular reconstructive options, the donor common hepatic artery was divided distal to the aneurysmal dilatation and anastomosed to the recipient bifurcation of the left and right hepatic artery in an end-to-end beveled anastomosis. The postoperative course was unre-markable, with normal blood flow through the anastomosis and no significant com-plications. The recipient is doing well 6 months after transplant. The presence of a celiomesenteric aneurysm should not discourage the use of an otherwise adequate liver graft. Careful vascular reconstruction is encouraged to increase the rate of marginal graft utilization and minimize vascular complications. Liberal postoperative imaging can enable early detection of vascular com-plication and prompt intervention. Through this case, we demons-trate the remarkable potential of less-than-ideal grafts with acceptable posttransplant outcomes.

Catheter Thrombolysis of Thrombosed Hepatic Arteries in Liver Transplant Recipients: Predictors of Success and Role of Thrombolysis

Hepatic artery thrombosis is an uncommon complication of liver transplantation. However, it is a major indication for re-transplantation. The use of transcatheter thrombolysis and subsequent surgical revascularization as a graft salvage procedure is discussed. Four of 5 cases (80%) were successful in re-establishing flow and uncovering underlying arterial anatomic defects. None were treated definitively by endoluminal measures due to an inability to resolve the underlying anatomic defects. However, 2 of 5 cases (40%) went on to a successful surgical revascularization and represent successful long-term outcome of transcatheter thrombolysis followed by definitive surgical revascularization. We conclude that, definitive endoluminal success cannot be achieved without resolving associated, and possibly instigating, underlying arterial anatomical defects. However, reestablishing flow to the graft can unmask underlying lesions as well as asses surrounding vasculature thus providing anatomical information for a more elective, better planned and definitive surgical revision.

Endoluminal Management of Arterioportal Fistulae in Liver Transplant Recipients: A Single-Center Experience

Transcatheter embolization of arterioportal fistulae in liver transplant recipients is restricted to symptomatic arterioportal fistulae. Angiograms of liver transplant recipients from a single university medical center were retrospectively reviewed. Hemodynamically significant arterioportal fistulae were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Six arterioportal fistulae were found. Doppler ultrasound imaging detected 50% of all arterioportal fistulae and all 3 hemodynamically significant arterioportal fistulae. Three successful embolizations were performed. Follow-up (37 to 67 months) demonstrated patent hepatic arteries and no parenchymal ischemic changes with graft preservation. High-throughput arterioportal fistulae may require larger intrahepatic artery branch embolization. There is a window of opportunity for embolizing significant arterioportal fistulae before their progression to large symptomatic, high through-put arterioportal fistulae with their added risk of ischemic changes before and after embolization.

Diagnosis and Management of Hepatic Artery Complications After Liver Transplantation

BACKGROUND

We assessed the usefulness of color Doppler imaging in diagnosis and monitoring hepatic artery complications after liver transplantation.

METHODS

Subjects were 421 liver transplant recipients who underwent serial ultrasound (US) color Doppler evaluations of the hepatic arteries after surgery.

RESULTS

We 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.

CONCLUSIONS

The 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.

Impact of abdominal drainage systems on postoperative complication rates following liver transplantation

BACKGROUND

Depending on the extent of surgery, coagulation status and the number of anastomoses, drains are routinely used during liver transplantation. The aim of this study was to compare different drain types with regard to abdominal complication rates.

METHODS

All consecutive full-size orthotopic liver transplantations (LTX) performed over a 7-year period were included in this retrospective analysis. Abdominal drain groups were divided into open-circuit drains and closed-circuit drains. Data are reported as total number (%) or median (range); for all comparisons a p value <0.05 was considered statistically significant.

RESULTS

A total of 256 LTX [age 56.89 (0.30-75.21) years; MELD 14.5 (7-40)] was included; 56 (21.8 %) patients received an open-circuit Easy Flow Drain (Group 1) and 200 (78.2 %) a closed-circuit Robinson Drainage System (Group 2). For Groups 1 and 2, overall infection rates were 78.6 and 56 % (p = 0.001), abdominal infection rates 50.82 and 21.92 % (p = 0.001), yeast infection rates 37 and 23 % (p = 0.02), abdominal bleeding rates 26.78 and 17 % (p = 0.07), biliary complication rates 14.28 and 13.5 % (p = 0.51), respectively.

CONCLUSIONS

In this retrospective series, open-circuit drains were associated with more abdominal complications, mainly due to intraabdominal infections, than were closed-circuit drains.

Pediatric transplantation: preventing thrombosis

Due to progressive advances in surgical techniques, immunosuppressive therapies, and supportive care, outcomes from both solid organ transplantation and hematopoietic stem cell transplantation continue to improve. Thrombosis remains a challenging management issue in this context, with implications for both graft survival and long-term quality of life. Unfortunately, there remains a general paucity of pediatric-specific data regarding thrombosis incidence, risk stratification, and the safety or efficacy of preventative strategies with which to guide treatment algorithms. This review summarizes the available evidence and rationale underlying the spectrum of current practices aimed at preventing thrombosis in the transplant recipient, with a particular focus on risk factors, pathophysiology, and described antithrombotic regimens.

Current state of the art in management of vascular complications after pediatric liver transplantation

Vascular complications by compromising the blood flow to the allograft can have significant and sometimes life-threatening consequences after pediatric liver transplantation. High level of suspicion and aggressive utilization of diagnostic modalities can lead to early diagnosis and salvage of the allograft. This review will summarize the current trends in management of vascular complications after pediatric liver transplantation.

Percutaneous Endovascular Treatment for Hepatic Artery Stenosis after Liver Transplantation: The Role of Percutaneous Endovascular Treatment

BACKGROUND

To retrospectively analyze the outcomes of interventional radiology treatment of patients with hepatic artery stenosis (HAS) after liver transplantation at our Institution.

MATERIAL/METHODS

Hepatic artery stenosis was diagnosed and treated by endovascular technique in 8 (2.8%) patients, who underwent liver transplantation between July 2007 and July 2011. Patients entered the follow-up period, during which we analyzed hepatic artery patency with Doppler ultrasound at 1, 3, 6, and 12 months after percutaneous endovascular treatment (PTA), and every six months thereafter.

RESULTS

During the 12-month follow-up period, 6 out of 8 patients (75%) were asymptomatic with patent hepatic artery, which was confirmed by multislice computed tomography (MSCT) angiography, or color Doppler (CD) ultrasound. One patient had a fatal outcome of unknown cause, and one patient underwent orthotopic liver retransplantation (re-OLT) procedure due to graft failure.

CONCLUSIONS

Our results suggest that HAS angioplasty and stenting are minimally invasive and safe endovascular procedures that represent a good alternative to open surgery, with good 12-month follow-up patency results comparable to surgery.

Endovascular treatment with primary stenting of inferior cava vein torsion following orthotopic liver transplantation with modified piggyback technique

PURPOSE

This study was undertaken to evaluate primary stenting in patients with inferior vena cava torsion after orthotopic liver transplantation performed with modified piggyback technique.

MATERIALS AND METHODS

From November 2003 to October 2010, six patients developed clinical, laboratory and imaging findings suggestive of caval stenosis, after a mean period of 21 days from an orthotopic liver transplantation performed with modified piggyback technique. Vena cavography showed stenosis due to torsion of the inferior vena cava at the anastomoses and a significant caval venous pressure gradient. All patients were treated with primary stenting followed by in-stent angioplasty in three cases.

RESULTS

In all patients, the stents were successfully positioned at the caval anastomosis and the venous gradient pressure fell from a mean value of 10 to 2 mmHg. Signs and symptoms resolved in all six patients. One patient died 3 months after stent placement due to biliary complications. No evidence of recurrence or complications was noted during the follow-up (mean 49 months).

CONCLUSIONS

Primary stenting of inferior vena cava stenosis due to torsion of the anastomoses in patients receiving orthotopic liver transplantation with modified piggyback technique is a safe, effective and durable treatment.

Reversed saphenous bypass for hepatic artery pseudoaneurysm after liver transplantation

BACKGROUND

Hepatic artery pseudoaneurysm (HAP) is found in 1-2% of liver transplantation (LT) patients. The mortality associated with pseudoaneurysm formation after orthotopic LT is reported to be as high as 75%. Because of the rarity of complications, particularly when considered individually, much of the direction for the management of complications is anecdotal. This article discusses the presentation, etiology, types, treatment indications, and vascular procedures used to manage complications with LT.

METHODS

Between January 2004 and December 2011, 464 LTs were performed at our institution. Of these, 9 (1.9%) consecutive patients underwent surgical treatment of HAP (8 men and 1 woman; median age, 58.4 years [range, 46-67 years]). Four patients underwent transarterial chemoembolization before LT for hepatocellular carcinoma. In all cases, revascularization with a reversed autologous saphenous vein bypass was performed.

RESULTS

Four patients had ruptured pseudoaneurysms, and the others were diagnosed as having asymptomatic pseudoaneurysms during the follow-up period. The median delay between LT and the diagnosis of HAP was 39.6 days (range, 22-92 days). All were anatomically extrahepatic. The median diameter was 15.3 mm (range, 9-30 mm). Four patients had a T-tube. In 6 cases, biliary leakage was associated with the LT and, in the remaining 3, mycosis was recorded. After surgery, 1 patient underwent retransplantation because of ischemic cholangitis. Five years later, 5 patients had normal arterial anatomy, and the other 3 patients had stenosis that was successfully treated by stents. All of the patients had normal liver function at follow-up. One patient died 16 months later because of a heart attack.

CONCLUSIONS

HAP with massive intraperitoneal bleeding is a rare but serious life-threatening complication when it occurs after LT. The majority of HAP cases are associated with bile leakage and mycosis; therefore, surgery must be the treatment of choice. Our conclusions support surgical revascularization with reversed saphenous grafts as a feasible and efficient treatment in cases of HAP.

Arterioportal fistulas in liver transplant recipients

Arterioportal fistulas (APFs) are classified into intrahepatic (>75% of all reported) and extrahepatic (<25% of all reported ). Anecdotally, investigators are more likely to report more sensational cases (typically extrahepatic APFs), so the actual prevalence of intrahepatic APFs is probably much higher (likely >90% of APFs). All reported APFs in liver transplant recipients have been intrahepatic. Hemodynamically significant APFs in liver transplant recipients are rare, occurring in 0.2%; however, APFs (hemodynamically significant or not) are not uncommonly seen in hepatic angiograms of liver transplant recipients (up to 5.4% of hepatic arteriograms in transplants). Interestingly, hemodynamically significant APFs warranting endovascular treatment are reported more commonly in the literature in native compared with transplanted livers (n >280-300 versus n = 13, respectively). This article discusses APFs that are specific to liver transplant recipients; their incidence, etiology, pathogenesis, natural history, clinical presentation, and endovascular management are discussed in detail.

Stent placement versus angioplasty for hepatic artery stenosis after liver transplant: a meta-analysis of case series

BACKGROUND

Hepatic artery stenosis (HAS) is a serious complication of liver transplantation but data on the most effective endovascular management are lacking. We aimed to compare percutaneous balloon angioplasty (PBA) with stent placement.

METHODS

We searched MEDLINE, Cochrane, Web of Science, EMBASE, SCOPUS, and Biosis Previews between 1970 and December 2011 and performed meta-analysis of short-term (procedural success, complications) and long-term outcomes (liver function, arterial patency, survival, re-intervention, re-transplantation). Random effects models were used for the analysis and meta-regression performed for the year of study.

RESULTS

A total of 263 liver transplants in 257 patients [age 43 (±8) years] underwent 147 PBAs and 116 stents. Transplanted livers were from deceased donors in 240 (91 %). Follow-up was 1 month to 4.5 years (median 17 months). PBA and stent had similar procedural success (89 % vs. 98 %), complications (16 % vs. 19 %), normal liver function tests (80 % vs. 68 %), arterial patency (76 % vs. 68 %), survival (80 % vs. 82 %), and requirement for re-intervention (22 % vs. 25 %) or re-transplantation (20 % vs. 24 %) (P non-significant). In the most recent studies re-transplantation was reported less compared to older series (P = 0.04).

CONCLUSION

Both PBA and stent offer comparable results for HAS. These techniques have contributed to a recent decline in re-transplantation.

KEY POINTS

• Interventional radiological procedures are often used to treat post-transplant hepatic artery stenosis. • Meta-analysis shows that percutaneous balloon angioplasty and stent placement are both efficacious. • Percutaneous balloon angioplasty and stent placement appear to have similar complication rates. • Re-transplantation rates have declined, partly due to interventional management for arterial stenosis.

Prevalence, presentation, and endovascular management of hemodynamically or clinically significant arterio-portal fistulae in living and cadaveric donor liver transplant recipients

PURPOSE

To compare the prevalence (cadaveric vs. living donor transplants), clinical features, and the effectiveness of endovascular management of significant arterio-portal fistulae (APF) in liver transplant recipients.

METHODS

A retrospective audit of liver transplant recipients in two institutions was performed (1996-2009). Significant APF were included and were defined as symptomatic and/or hemodynamically significant (causing graft dysfunction and/or having abnormal Doppler findings in the portal vein). Patients with significant APF were evaluated for presenting symptoms, imaging features, size/branch order portal vein involvement, and effectiveness of the endovascular management (coil embolization).

RESULTS

Four significant APF were found in 1992 (0.2%) liver transplants. Two were symptomatic and two were asymptomatic but were hemodynamically significant with liver function test abnormalities. All four APF were found in cadaveric donor graft recipients (0.23%, N = 4/1753) and none in 239 living donor graft recipients. However, there was no statistical difference between cadaveric and living donor graft recipients (p = 1.0, odds ratio = 1.23). Coil embolization was technically and clinically successful in all 4 without complications and causing normalization of the abnormal Doppler findings.

CONCLUSION

Significant APF are a rare diagnosis (0.2% of transplants). Coil embolization is a safe and effective treatment option for APF in transplants.

Endovascular therapy for hepatic artery stenosis and thrombosis following liver transplantation

PURPOSE

To evaluate the effectiveness of endovascular management of steno-oclusive disease in liver transplants.

METHODS

Retrospective review of liver transplant recipients with hepatic artery stenosis (HAS) or thrombosis (HAT) was performed. The HAS group was treated with balloon angioplasty with selective stent placement. The HAT group was treated with catheter-directed thrombolysis. Primary, unassisted, and assisted patency and graft survival rates were calculated.

RESULTS

In all, 31 patients were identified (21 males; mean age, 51 years). A total of 25 of 31 (81%) patients had HAS and 6 of 31 (19%) had HAT. Collectively, a total of 35 endovascular procedures were performed to treat HAS in 25 patients. Overall technical success rate was 91%, with 11% major complication rate. Primary-assisted patency rate and graft survival at 6 and 12 months were 87% and 81%, and 76% and 72%, respectively. Only 1 successful thrombolysis of HAT was achieved.

CONCLUSION

Endovascular management is effective for HAS but not for HAT.

Early arterial revascularization after hepatic artery thrombosis may avoid graft loss and improve outcomes in adult liver transplantation

BACKGROUND

Hepatic artery thrombosis (HAT) represents a devastating complication after liver transplantation (LT), occurring in 1.6%-9.2% of adult recipients. Treatments of HAT include thrombectomy and thrombolysis (with or without redo of the arterial anastomosis), percutaneous thrombolysis through an angiogram, liver retransplantation, and clinical observation.

METHODS

We retrospectively analyzed data from 739 adult LTs between January 1992 and September 2009. HAT was classified as early (E-HAT), when occurring within the first 30 days after LT, or late HAT (L-HAT), when diagnosed from the 2nd month onward. HAT suspected clinically was confirmed by Doppler ultrasound and angiography in all cases. Attempted revascularization was defined as early (ER) if performed within the first 2 weeks after LT and late (LR) if performed between 15 and 30 days.

RESULTS

After a median follow-up (FU) of 62 months (range, 1-227 months), HAT occurred in 31/739 grafts (4.3%). E-HAT was recorded in 25/31 cases (3.4%) and L-HAT in 11/31 cases (0.8%). ER was performed in 20/31 patients (65%) leading to 62% graft salvage; it was 81% when the revascularization was performed within the first week after LT (P = ns). LR was unsuccessful in all cases (P = .08). The overall incidence of BC among rescued grafts was 54% without graft loss during FU. Graft survival was 79% versus 71%; and 50% versus 50% at 1 and 3 years for E-HAT and L-HAT, respectively (P = ns).

CONCLUSIONS

Urgent revascularization in cases of early HAT may decrease graft loss, especially when performed within the first week after LT, with improved overall outcomes.

Splenic artery syndrome after orthotopic liver transplantation: treatment with the Amplatzer vascular plug

PURPOSE

To evaluate the safety and efficacy of the Amplatzer vascular plug (AVP) for embolization of the splenic artery in patients with hepatic hypoperfusion after orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Thirteen patients (9 men and 4 women) with a mean age of 56 years (range 22-70) who developed splenic artery syndrome after OLT with decreased liver perfusion and clinically relevant impairment of liver function (increased transaminase or serum bilirubin levels, thrombocytopenia, and/or therapy-refractory ascites) were treated by embolization of the proximal third of the splenic artery using the AVP. The plugs ranged in diameter from 6 to 16 mm, and they were introduced through femoral (n = 9), axillary (n = 3), or brachial (n = 1) access using a 5F or 8F guiding catheter.

RESULTS

The plugs were successfully placed, and complete occlusion of the splenic artery was achieved in all patients. Placement of two plugs was necessary for complete occlusion in 3 of the 13 patients. Occlusion took on average 10 min (range 4-35). There was no nontarget embolization or plug migration into more distal segments of the splenic artery. All patients showed improved arterial perfusion, including the liver periphery, on postinterventional angiogram. After embolization, liver function parameters (transaminase and bilirubin levels) improved with normalization of concomitant thrombocytopenia and a decrease in ascites volume.

CONCLUSION

Our initial experience in a small patient population with SAS suggests that the AVP enables precise embolization of the proximal splenic artery, thus providing safe and effective treatment for poor liver perfusion after OLT due to SAS.

Vascular complications after deceased and living donor liver transplantation: a single-center experience

INTRODUCTION

Vascular complications (VC) after liver transplantation (OLT) are one of the most feared problems that frequently result in graft and patient loss. Herein we have reported our experience with VC after either deceased donor liver transplantation (DDLT) or living donor liver transplantation (LDLT).

PATIENTS AND METHODS

Between April 2001 and September 2009, we performed 224 OLT: 155 DDLT and 69 LDLT. The overall male/female ratio was 136/88 and the adult/pediatric ratio was 208/16. We retrospectively identified and analyzed vascular complications in both groups.

RESULTS

In the DDLT group, 11/155 recipients (7%) suffered vascular complications; hepatic artery thrombosis (HAT; n=5; 3.2%), portal vein thrombosis occurred (n=4; 2.6%); hepatic vein stenosis (n=1; 0.6%), and severe postoperative bleeding due to a slipped splenic artery ligature (n=1, 0.6%). In the DDLT group, 4/11 (36.4%) patients died as a direct result of the vascular complications. In the LDLT group, 9/69 recipients (13%) suffered vascular complications: HAT (n=3; 4.3%), portal vein problems (n=5; 7.2%), and hepatic vein stenosis (n=1; 1.5%). Among LDLT, 3/9 (33.3%) patients died as a direct result of the vascular complications. In both groups vascular complications were associated with poorer patient and graft survival.

CONCLUSIONS

In our experience, the incidence of vascular complications was significantly higher among the LDLT group compared with the DDLT group. Vascular complications were associated with poorer graft and patient survival rates in both groups.

Continuous Intraarterial Thrombolysis for Early Hepatic Artery Thrombosis Following Liver Transplantation: Case Report

Hepatic Artery thrombosis remains one of the major causes of graft failure and mortality in liver transplant recipients. Urgent re-transplantation has been considered as mainstay therapy; however, even with re-transplantation mortality of more than 50% has been reported by many series. Early detection on Doppler ultrasonography and subsequent revascularization in asymptomatic patients can avoid graft loss. Endovascular therapy including intra-arterial thrombolysis, percutaneous transluminal angioplasty, and stent placement have shown encouraging results in recent years; nevertheless, their use remains controversial due to potential risk of bleeding. We present a case of early hepatic artery thrombosis following liver transplantation treated successfully with continuous transcatheter intra-arterial thrombolysis using tissue plasminogen activator (t-PA).

Endovascular treatment of hepatic artery thrombosis following liver transplantation

Hepatic artery thrombosis (HAT) is the most frequent vascular complication following orthotopic liver transplantation. Urgent retransplantation has been considered as the mainstay therapy. Surgical revascularization is an effective alternative in asymptomatic patients. Endovascular therapies including intra-arterial thrombolysis, percutaneous transluminal angioplasty (PTA), and stent placement have shown encouraging results in recent years; however, their use remains controversial because of potential risk of hemorrhage. Until June 2009, 69 cases were published in 16 reports describing therapeutic potential of endovascular modalities. Interventions were performed as early as within 4 h to as late as 120 days in patients ranging from 4 months to 64 years of age. Majority of published reports suggested the use of urokinase. Thrombolysis was successful in 47 out of 69 (68%) patients. Bleeding was the most common complication including fatal intra-abdominal hemorrhage in three patients. Twenty-nine out of 47 (62%) patients underwent further intervention in the form of PTA, stenting, or both. The follow-up patency ranged from 1 month to 26 months. In conclusion, whenever possible, efforts should be made to rescue the liver grafts through urgent revascularization (surgical and/or endovascular) depending on patient's condition and interventional expertise at the transplant center; reserving the option of retransplantation for failure, complications, and cases with severe clinical symptoms or allograft dysfunction.

Increased risk of graft loss from hepatic artery thrombosis after liver transplantation with older donors

Hepatic artery thrombosis (HAT) is the most common vascular complication after liver transplantation; it has been reported to occur in 2% to 5% of liver transplant recipients. Most reports of HAT in the literature describe single-center series with small numbers of patients and lack the power to definitively identify nontechnical risk factors. We used the United Network for Organ Sharing database of adult deceased donor liver transplants from 1987 to 2006 to identify 1246 patients with graft loss from HAT. Univariate and multivariate regression analyses were performed to identify donor and graft risk factors for HAT-induced graft loss. Although most donor predictors of HAT-induced graft loss were surrogates for vessel size, donor age > 50 years was also a significant predictor of graft loss from HAT (relative risk = 1.45, P < 0.001). Furthermore, the risk of graft loss from HAT increased progressively with each decade of donor age > 50 years, such that a 61% increased risk of HAT-related graft loss (relative risk = 1.61, P < 0.001) was associated with donor age > 70 years. A separate analysis of risk factors for early HAT graft loss (<or=90 days) and late HAT graft loss (> 90 days) found that older donor age was associated with increased late HAT graft loss. These findings are of interest in an era of ongoing organ shortages requiring maximum utilization of potential allografts and increasing allocation of older allografts.

Feasibility and effectiveness of a new algorithm in preventing hepatic artery thrombosis after liver transplantation

INTRODUCTION

The incidence of hepatic artery thrombosis (HAT) after liver transplantation (LTx) is up to 9% in adult recipients.

MATERIAL AND METHODS

To minimize HAT, we developed an algorithm that we have routinely applied since 2001. The algorithm is a cascade of potentially necessary procedures to improve hepatic artery blood flow before proceeding with LTx when arterial blood flow is impaired. Incidence, outcome, and possible therapeutic approaches of HAT were analyzed in prospectively non-controlled collected data during a 5-year period. There were 335 LTx in 299 adults (199 male, 100 female) with a median age of 49.7 years.

RESULTS

HAT was defined as early and late HAT (diagnosis within or after 30 days following LTx). After a mean follow-up of 17 months, nine HAT were documented (2.7%; five early and four late HAT). Treatment consisted of thrombolysis (n = 1), surgical thrombectomy (n = 4), and re-transplantation (n = 4). Five HAT patients died during follow-up.

DISCUSSION

Complex arterial reconstruction was associated with HAT compared to branch-patch anastomoses (P = 0.0193). Median arterial intraoperative blood flow was no risk factor for HAT. One-year patient survival after HAT was 31%. Once HAT occurs, complication rates are high and long-term results are devastating.

CONCLUSION

Therefore, we have implemented the presented algorithm, which showed an acceptable HAT rate.

Early hepatic artery thrombosis after liver transplantation: a systematic review of the incidence, outcome and risk factors

To clarify inconsistencies in the literature we performed a systematic review to identify the incidence, risk factors and outcome of early hepatic artery thrombosis (eHAT) after liver transplantation. We searched studies identified from databases (MEDLINE, EMBASE, Science Citation Index) and references of identified studies. Seventy-one studies out of 999 screened abstracts were eligible for this systematic review. The incidence of eHAT was 4.4% (843/21, 822); in children 8.3% and 2.9% in adults (p < 0.001). Doppler ultrasound screening (DUS) protocols varied from 'no routine' to 'three times a day.' The median time to detection was at day seven. The overall retransplantation rate was 53.1% and was higher in children (61.9%) than in adults (50%, p < 0.03). The overall mortality rate of patients with eHAT was 33.3% (range: 0-80%). Mortality in adults (34.3%) was higher than in children (25%, p < 0.03). The reported risk factors for eHAT were, cytomegalovirus mismatch (seropositive donor liver in seronegative recipient), retransplantation, arterial conduits, prolonged operation time, low recipient weight, variant arterial anatomy, and low volume transplantation centers. eHAT is associated with significant graft loss and mortality. Uniform definitions of eHAT and uniform treatment modalities are obligatory to confirm these results and to obtain a better understanding of this disastrous complication.

False positive tardus-parvus waveforms after liver transplantation: a case of wide discrepancy between donor and recipient hepatic arteries mimicking anastomotic stenosis

BACKGROUND

Parvus-tardus waveforms of the hepatic artery after liver transplantation usually indicate an arterial complication and severe impairment of hepatic arterial perfusion with a sensitivity of 91% and a specificity of 99.1%. Thus, it has been emphasized that detection of such waveforms should prompt emergency angiography.

MATERIALS AND METHODS

Arterial reconstruction during a liver transplantation was successfully accomplished by an end-to-end anastomosis, performing a "flute-spout" widening of the anastomosis with a 7/0 prolene running suture between a small recipient proper hepatic artery and the donor common hepatic artery.

RESULTS

On day 7 posttransplantation color Doppler ultrasonography revealed a parvus-tardus waveform pattern in the hepatic arterial flow. Computed tomographic (CT) angiography showed only a caliber discrepancy between the donor and recipient stumps, excluding an arterial stenosis or thrombosis. Since normal liver function persisted, the patient underwent routine follow-up. After 15 months the patient was alive and well; hepatic artery spectral waveforms were unchanged and liver functions were consistent with a mild hepatitis C virus (HCV) recurrence.

CONCLUSIONS

This is a report of false positive tardus-parvus waveforms, due to a discrepancy between the donor and recipient arteries despite a wide anastomosis. Knowledge of technical reconstruction details may be helpful for correct interpretation of color Doppler findings. CT angiography should be considered before more invasive examinations.

False aneurysm of a hepatic artery branch complicating intrahepatic islet transplantation

Islet transplantation, an innovative treatment strategy for type 1 diabetes mellitus, is a relatively safe procedure, with less morbidity than pancreas transplantation. Vascular injuries have not been reported to date. We report a percutaneous transhepatic intraportal islet transplant infusion that was followed by bleeding from a false aneurysm of an intrahepatic branch of the hepatic artery. The bleeding was controlled by selective embolization. Despite the complication and its treatment, the patient gained insulin independence, which was sustained for 285 days. She is currently on a small dose of insulin with good glycemic control.

Management of nonocclusive hepatic artery complications after liver transplantation

Nonocclusive arterial disease represents less than 5% of posttransplant arterial complications. Nonocclusive arterial complications are classified into (1) nonocclusive diminished flow in the hepatic artery, (2) arteriovenous fistulae, (3) pseudoaneurysms, and (4) arterial rupture. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. Transcatheter embolization is the main mode of minimal invasive management of these uncommon complications. Other minimal invasive methods have been described such as stent placement or direct percutaneous embolization/thrombosis. The article discusses the presentation, etiology, types, treatment indications, and various modes of minimal invasive therapy used to manage these complications.

Hepatic artery stenosis after liver transplant, managed with percutaneous angioplasty and stent placement

Hepatic artery stenosis is a recognized vascular complication of orthotopic liver transplant that carries significant morbidity and mortality. The authors present a case of hepatic artery stenosis in a 50-year-old female successfully treated with balloon angioplasty and stent. This case report highlights the importance of percutaneous intervention as a preferred treatment option in patients with hepatic artery stenosis post-orthotopic liver transplant.

Early Hepatic Artery Thrombosis After Liver Transplantation: Diagnosis and Treatment

BACKGROUND

Hepatic artery thrombosis (HAT) occurs in 3% to 9% of all liver transplantations with acute graft failure as a possible sequel.

METHODS

Eleven episodes of HAT were identified among 256 orthotropic liver transplantations (whole, LDCT, split) performed on 253 patients between April 1993 and July 2006. HAT was suspected clinically and confirmed by Doppler ultrasonography, magnetic resonance angiography, angiography, or reexploration. One patient was excluded due to poor follow-up. Treatment options included exploration with HA thrombectomy plus thrombolysis, retransplantation, or conservative treatment of hepatic and biliary complications.

RESULTS

Among 11 patients of mean age 29.98 +/- 17.14 years (range, 10 months to 56 years). 2 had split right lobe liver transplantations and 9 received whole organs. None of LDLTs were identified to have HAT. The causes of liver cirrhosis among HAT patients were autoimmune hepatitis (n=3), cryptogenic (n=3), Wilson (n=1), PBC (n=1), biliary atresia (n=1), and HBs (n=1). HAT was diagnosed at 5.9 +/- 4.43 (range, 2 to 16) days after operation. Most patients developed right upper quadrant (RUQ) pain at presentation. Two patients developed acidosis, fever, or SIRS and underwent retransplantation. Four underwent exploration of HA and 1 was treated conservatively. Three cases expired due to HAT complications.

CONCLUSION

We found RUQ pain to be the presenting sign of early HAT in majority of cases. RUQ pain has been reported to occur in late HAT. Whenever HAT is confirmed, liver transplanted patients should be revascularized or even retransplanted. Intra-arterial thrombolysis and thrombolytic therapy for HAT should be done cautiously due to the potential risk of hemorrhage.

Pseudoaneurysm of the Hepatic Artery Following Liver Transplantation

We report 12 cases of pseudoaneurysm hepatic artery (PA) among 825 liver transplantations (OLT) performed between January 1985 and December 2005. In the early period (1985 to 1995), the incidence was 2.6% and in the later period (1996 to 2005), 0.9%. Median time to onset was 39.5 days post-OLT (range 14 days to 5 years). Six patients presented with rupture into the peritoneum (n = 4) or gastrointestinal tract (n = 2), while five patients presented with gastrointestinal bleed due arteriobiliary fistulation with hemobilia. The twelfth PA was found incidentally during retransplantation. PAs were detected with radiological imaging (n = 4), exploratory laparotomy (n = 6), at autopsy (n = 1) or at retransplantation (n = 1). We performed immediate revascularization, after surgical excision was performed in three and endovascular embolization in one patient. In six patients hepatic artery ligation without revascularization was inevitable with subsequent successful retransplantation in four patients. No PA-specific treatment was attempted in two cases due to the poor prognosis or diagnostic ambiguity. In 10 cases microbial pathogens were cultured in the blood, subhepatic abscesses, or from the wall of the hepatic artery. A hepaticojejunostomy was performed for biliary reconstruction in six patients and two had a hepaticojejunostomy conversion due to biliary leak. Survival in the early period (1985 to 1995) was 14%, whereas during the later period (1996 to 2005), the survival increased to 100% with a 4.2-year median follow-up (range 7.4 months to 6.9 years). Infrequently PA complicates OLT, becoming evident primarily after rupture with hemoperitoneum or a gastrointestinal bleed. Early recognition with angiography is important but acute hemorrhage often requires immediate exploration with ligation of the PA, although surgical or endovascular exclusion of the PA followed by revascularization provides a feasible treatment option.

Clinical outcomes from hepatic artery stenting in liver transplantation

Hepatic artery stenosis after liver transplantation may affect liver function and result in hepatic artery thrombosis. Surgical reconstruction has been the first choice for treatment. Interventional radiologic technique can be used, but there is no report on long-term outcome. The aim of this paper is to assess current outcome and complications of hepatic artery stenting. Twenty-six adult patients were stented for hepatic artery stenosis between 1998 and 2003. Nine patients had previous surgical reconstruction for hepatic artery stenosis. Seventeen patients suffered newly developed hepatic artery stenosis. Three patients were retransplanted. After stenting, the patients were followed by Doppler ultrasound at day 1, 1 month, and 6 months. Angiography was scheduled in 6 months. Four patients died within 2 months. The other 22 patients were followed for mean 31 +/- 14 months (8-71 months). One of 22 patients died from renal failure 2 years later. Twelve patients' hepatic arteries looked normal after stenting. Restenosis was seen in 8 patients (36%). Other complications were artery thrombosis (n = 1) and long segment stricture (n = 1). In 2 patients (25%) restenosis resulted in thrombosis. Six of the 8 patients who developed recurrent stenosis were successfully treated interventionally: restent (n = 5) and balloon dilation (n = 3). However, 3 patients (38%) restenosed. Kaplan-Meier complication-free survival was 54% at 1 year after stenting. In conclusion, hepatic artery stenting is a viable treatment for hepatic artery stenosis with reasonable results. Stenting is useful as adjuvant treatment after surgical revision.

Interventional radiology in liver transplantation

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation.

Percutaneous transluminal angioplasty for hepatic artery stenosis after living donor liver transplantation

The purpose of this study was to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) for treatment of hepatic artery stenosis after living donor liver transplantation. Eighteen patients with hepatic artery stenosis after living donor liver transplantation were included in this study. The success rate and complications of PTA and recurrent stenosis of the hepatic artery were evaluated. Seventeen of 18 patients (94.4%) were successfully treated without complication by a first PTA procedure. Recurrence of hepatic artery stenosis occurred in 6 patients (33.3%). Repeated PTA was performed 12 times for the 6 patients. Two complications occurred as arterial dissection and perforation. As a consequence, the complication rate was 6.7%, involving 2 of 30 procedures in total. In conclusion, PTA is effective for treatment of hepatic artery stenosis after living donor liver transplantation without an increase in the complication rate.

Hepatic artery stenosis in liver transplant recipients: primary treatment with percutaneous transluminal angioplasty

PURPOSE

To evaluate the efficacy of hepatic artery percutaneous transluminal angioplasty (PTA) in the treatment of hepatic artery stenosis (HAS).

MATERIALS AND METHODS

A retrospective analysis was performed of all cases of HAS documented by angiography from January 1995 to June 2003 at the authors' institution. Management was evaluated and long-term patency was documented by Doppler ultrasonography. The patency, restenosis, and hepatic artery thrombosis (HAT) rates were determined by the Kaplan-Meier method. The technical success of hepatic artery PTA was stratified according to the location of the stenoses relative to the anastomosis, as well as by the presence of associated hepatic arterial kinks.

RESULTS

Thrombosis was seen in 65% +/- 13% of untreated HAS cases within 6 months. Stenotic lesions without associated arterial kinks had an improved technical success rate and a reduced complication rate of 94% and 10%, respectively, compared with lesions with associated hepatic arterial kinks treated with hepatic artery PTA (14% and 29%, respectively). The 1-year primary and primary assisted patency rates of hepatic artery PTA for all lesions were 44% +/- 12% and 60% +/- 11%, respectively, and were 65% +/- 10% and 80% +/- 8%, respectively, for lesions not associated with hepatic arterial kinks. The 1-year HAT rate and restenosis rate after hepatic artery PTA were 19% +/- 10% and 32% +/- 11%, respectively. The 1-year primary assisted patency rate for hepatic artery PTA with repeat PTA performed for restenosed lesions and surgical revascularization performed for failed PTA was 74% +/- 10%.

CONCLUSIONS

Untreated HAS carries a high morbidity rate. Hepatic artery PTA can play a large role in the management of HAS by reducing the HAT rate more than threefold. With appropriate lesion selection, hepatic artery PTA will have better patency rates than those associated with hepatic artery stent placement.

Hepatic artery pseudoaneurysms in adult living-donor liver transplantation: efficacy of CT and Doppler sonography

OBJECTIVE

The purpose of this study was to evaluate the efficacy of contrast-enhanced CT and Doppler sonography in the diagnosis of hepatic artery pseudoaneurysm after adult living-donor liver transplantation (LDLT).

CONCLUSION

Because patients with hepatic artery pseudoaneurysm after LDLT can have diverse clinical presentations, routine imaging follow-up is important for early detection. Although Doppler sonography is limited in showing the pseudoaneurysm, contrast-enhanced CT, especially MDCT with CT arteriography, is effective in showing it in most patients.

Diagnosis and treatment of arterial steal syndromes in liver transplant recipients

Arterial steal syndromes (ASSs) after orthotopic liver transplantation (OLT) are characterized by arterial hypoperfusion of the graft caused by shifting of blood flow into the splenic or gastroduodenal artery. Despite their potentially devastating consequences, such as ischemic biliary tract destruction or graft failure, ASSs have received little attention to date. We report the incidence, diagnosis, and treatment of ASS among 1,250 consecutive OLTs. ASS was observed in 69 patients (5.9%). All these patients presented with elevated liver enzyme levels, impaired graft function, or cholestasis. Treatment consisted of splenectomy (n = 18), coil embolization of the splenic or gastroduodenal artery (n = 29), or reduction in splenic artery blood flow through administration of an artificial stenosis (banding; n = 9). Mild symptoms of ASS did not warrant treatment in 13 patients. However, 3 of these patients developed ischemic biliary destruction requiring re-OLT. Serious complications also were observed after splenectomy and coil embolization, requiring re-OLT in 18%. Conversely, no complications were observed after banding the splenic artery. Prophylactic banding of the splenic artery was performed in 97 patients and was associated with a complication rate of 4%. In summary, the incidence of ASS is similar to that of other vascular complications. Untreated ASSs may lead to serious complications in more than 30% of patients. Of a variety of treatment options, banding the splenic artery was associated with the lowest complication rate. Banding also may be performed prophylactically in selected patients to prevent the development of ASS after OLT.

Hepatic artery thrombosis after adult liver transplantation

The incidence, clinical presentation, therapeutic options, and outcome of hepatic artery thrombosis (HAT) were analyzed in a series of 1,192 consecutive adult orthotopic liver transplantations (OLTs). HAT after OLT was observed in 30 cases, resulting in an incidence of 2.5%. The incidence of HAT increased 5.76-fold when the donor hepatic artery was reconstructed with an interposition graft to the supraceliac aorta (P <.05). Early HAT (within the first 30 days after OLT) occurred in 14 of these patients (46.7%), whereas in 16 patients (53.3%), HAT occurred beyond 30 days post-OLT. Clinical presentation of HAT ranged from an increase in serum transaminase levels with or without cholestasis to liver abscess and biliary complications, including cholangitis, bile duct stenosis or necrosis, to liver dysfunction and failure. Impairment of graft function was observed in patients with early HAT, whereas biliary tract destruction was seen more often in patients with late HAT. In only 1 patient was HAT clinically asymptomatic. Therapy consisted of recombinant plasminogen lysis with hepaticojejunostomy, liver abscess drainage, endoscopy or surveillance, and surgical thrombectomy. In 14 of 30 patients (46.7%), the occurrence of HAT required re-OLT. Nine patients with HAT died during follow-up; however, only 4 of these deaths were related to HAT, resulting in a mortality rate of 13.3%. Our results indicate that HAT is a rare but serious complication after OLT, requiring re-OLT in almost 50% of patients. In particular, conservative treatment modalities may significantly prolong graft survival, thus postponing re-OLT.

Hepatic-artery aneurysm in adult liver transplantation

Hepatic artery aneurysm (HAA) is a rare vascular complication, but has a high mortality rate in liver transplant recipients. This study reports the precipitating factors, clinical manifestation, pre-operative diagnosis, related micro-organism, management, and outcome, in a series of HAAs that developed after adult orthotopic liver transplantation (OLT). Data on the primary disease as well as on the above were obtained from a prospective database, and all case records were reviewed. There were eight (0.5%) HAAs in 1,575 adult cadaveric OLTs between 1982 and March 2001. All were pseudo-aneurysms around the native hepatic-artery (HA) anastomosis, and all occurred in whole-organ OLTs. There were three types of clinical presentations: sudden hypotension (n=4), gastrointestinal (GI) bleeding (n=2), and abnormal liver-function tests (LFTs) (n=2). The majority (n=7) presented within the first 2 months (median: 27.5 days, range: 12-760 days) following OLT. A pre-operative diagnosis of HAA was not determined in five cases. The sensitivity of abdominal ultrasound scan (USS), computed tomography (CT) scan and angiography for detection of HAAs was 3 of 5, 1 of 2 and 3 of 4, respectively. Micro-organisms could be identified in six patients (bacteria n=4 and fungi n=3). All patients underwent urgent operations (excision of HAA in six and ligation in two cases). Immediate reconstruction of the HA was carried out, two different methods being used: repair of native arteries (n=2) and arterial conduit (interposition n=3 and aortic conduit n=2). Two patients died peri-operatively, two died within 2 months, and the remaining four patients are alive at between 8.6 and 12.8 years after repair. HAA following OLT is unpredictable in its presentation, and the sensitivity of clinical and radiological detection is low. A high index of suspicion is required, and urgent surgery with immediate re-vascularisation and use of appropriate antibiotic/anti-fungal agents is recommended.

Hepatic artery thrombosis and intraoperative hepatic artery flow rates in adult orthotopic liver transplantation

INTRODUCTION

Thrombosis of the hepatic artery following orthotopic liver transplantation (OLT) can be a devastating com-plication impacting on recipient outcome. The utility of routine intraoperative flow measurements of the hepatic artery in predicting subsequent hepatic artery thrombosis (HAT) is presented in this study.

METHODS

Data on all adult OLT recipients between July 1995 and May 2000 were analysed. This included the routine intra-operative flow measurements of both the hepatic artery and portal vein using a Doppler flow meter.

RESULTS

Thirteen out of 198 (6.6%) instances of OLT were complicated by HAT. The mean and median flow rates of the hepatic artery in the OLT with HAT were 262 mL/min and 220 mL/min, respectively. These were significantly lower than the respective values of 436 mL/min and 400 mL/min in the OLT without HAT (P = 0.0036). This was independent of recipient age, sex, weight and intraoperative portal flow rates. However there was extensive overlap for the intraoperative hepatic artery flow rates obtained between the HAT and non-HAT groups. The risk of HAT was increased by a factor of 6 if the intraoperative hepatic artery flow rate was less than 200 mL/min. The average allograft survival was significantly lower in the HAT group at 373 days vs the non-HAT group at 763 days (P = 0.026).

CONCLUSION

The routine use of intraoperative flow measurements of the hepatic artery may be a useful adjunct in identifying the hepatic artery reconstruction, which is at risk of subsequent HAT.

Vascular complications associated with pancreaticoduodenectomy adversely affect clinical outcome

BACKGROUND

Early survival after pancreaticoduodenectomy has improved, but its morbidity remains high. The purpose of this study is to determine how the intra-operative (OR) occurrence of major vascular complications affects the outcome of pancreaticoduodenectomy.

METHODS

The medical records of 180 consecutive patients having pancreaticoduodenectomy from 1991 to 2001 were reviewed. Vascular complications were defined as "an unanticipated injury or thrombosis of a major vessel necessitating intervention." Age, sex, type of pancreaticoduodenectomy, tumor size, estimated blood loss, OR time, time in intensive care, post-OR hospitalization, and survival were compared.

RESULTS

Eighteen vascular complications were identified. Differences in age, sex, and type of resection between patients with or without vascular complications were not significant. OR time, estimated blood loss, blood transfusions, tumor size, time in intensive care, and post-OR hospitalization were all significantly greater in patients with vascular complications. Median survival for patients with vascular complications was significantly shorter than for patients without vascular complications. Thirty-day mortality was greater in patients with vascular complications.

CONCLUSION

Vascular complications significantly affect the outcome of pancreaticoduodenectomy increasing OR time, estimated blood loss, blood transfusion requirements, time in intensive care, post-OR hospitalization, and mortality.

Stent placement in four patients with hepatic artery stenosis or thrombosis after liver transplantation

Hepatic artery stenosis and thrombosis represent dangerous complications of liver transplantation because the associated mortality and morbidity rates are high. In the past, repeat transplantation was considered the first-choice therapy; however, new surgical and interventional revascularization techniques have been suggested recently. Although extensive experience has been acquired with percutaneous transluminal angioplasty (PTA) and fibrinolysis techniques, only sporadic cases of stent placement in the hepatic artery of a transplanted liver have been reported, and no long-term results of this technique are available. In this study, seven stents (five Wallstents and two Palmaz stents) were positioned in four patients (two with stenoses and two with thromboses). Stent placement was performed in three cases after PTA and fibrinolysis, whereas primary stent placement was performed in the fourth. In all cases, technical success was achieved. During 18-25 months of follow-up, all stents proved patent and no patient required another transplantation. Although experience is still limited, the authors' experience indicates that placement of a stent in the hepatic artery in cases of stenosis or thrombosis yields good medium-term success, improving the results obtained by fibrinolysis and PTA and consequently enabling the graft to survive and avoiding the need for repeat transplantation.

Use of preserved vascular homografts in liver transplantation: hepatic artery aneurysms and other complications

Hepatic artery aneurysms/pseudoaneurysms (HAAs) are rare but serious complications after orthotopic liver transplantation (OLT). Revascularization should accompany aneurysmectomy if possible and is more feasible if the aneurysm presents late after transplantation. The optimal conduits for revascularization in this situation are not known. Two patients with hepatic artery aneurysms/pseudoaneurysms who had aneurysmectomy and revascularization with third-party cadaveric iliac arterial grafts 1 and 4 years after OLT are presented in detail, with an emphasis on the preservation method used for the grafts. Both livers were successfully revascularized with arterial grafts preserved for 21 and 26 days after procurement. Hepatic patency was documented in both 5 and 6 months after repair; graft function has remained normal 13 and 32 months after repair. Third-party vessels preserved for shorter periods have been used successfully in four other situations, including living-donor liver transplantation, and are briefly discussed. In conclusion, properly preserved vascular homografts are useful in LT for purposes other than initial vascular reconstruction. They also provide an excellent vascular conduit in recipients of livers from other (possibly living) donors.