Hepatic artery angioplasty after liver transplantation: experience in 21 allografts

Transplant Hepatic Artery Complications

Hepatic artery complications can be divided into 2 different categories, nonocclusive and steno-occlusive disease. Steno-occlusive disease is a collective term that encompasses hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks, while nonocclusive arterial disease encompasses less than 5% of complications and is a collective term used to describe arteriovenous fistulae, pseudoaneurysms, arterial rupture and nonocclusive hepatic artery hypoperfusion syndrome. This article details the angiographic techniques and definitions needed to accurately diagnose arterial transplant complications and describes the technical aspects and results of endoluminal management of these arterial complications. In addition, this article discusses the presentation, etiology and indications for treatment, including surgical management of these various complications.

Endovascular therapies for hepatic artery stenosis post liver transplantation

PURPOSE

To evaluate primary patency at 12 months after endovascular therapies in hepatic artery stenosis.

METHODS

A retrospective review of all endovascular interventions for hepatic artery stenosis (HAS) after liver transplantation that occurred between June 2013 and November 2020 was performed at a single institution in France. Follow up occurred from 1 month to 4 years (median 15 months). The treatment consisted of dilation with a balloon or stent. We analyzed short-term (technical success and complications) and long-term outcomes (liver function, arterial patency, graft survival at 12 months (GS), and reintervention). We also compared percutaneous balloon angioplasty (PBA) with stent placement. PBA alone was used if < 30% residual stenosis of the hepatic artery was achieved. Stenting was performed if there was greater than 30% residual stenosis and in the case of complications (dissection or rupture).

RESULTS

A total of 18 stenoses were suspected on the basis of routine surveillance duplex ultrasound imaging (peak systolic velocity > 200 cm/s, systolic accelerating time > 10 ms and resistive index < 0.5), all of which were confirmed by angio CT, but only 17 were confirmed by angiography. Seventeen patients were included (14 males, mean age 57 years; and three females, mean age 58 years). Interventions were performed in 17 cases (95%) with PBA only (5/17), stent only (5/17) or both (4/17). Immediate technical success was 100%. Major complications occurred in 1 of 17 cases (5.8%), consisting of target vessel dissection. The analysis of the three (groups PBA only, stent only or both) showed the same procedural success (100%), GS (100%) and normal liver function after the procedures but different rates of complications (20% vs. 0% vs. 0%), arterial patency at 12 months (60% vs. 80% vs. 85%) (p = 0.4), early stenosis (40% vs. 80% vs. 0%) or late stenosis (60% vs. 20% vs. 100%) and requirement for reintervention (40% vs. 20% vs. 14%) (p = 0.56).

CONCLUSION

This study suggests that PBA, stent, or both procedures show the same primary patency at 12 months. It is probably not a definitive answer, but these treatments are safe and effective for extending graft survival in the context of graft shortages.

Telemedicine for Follow-up Management of Patients After Liver Transplantation: Cohort Study

Background

Technical capabilities for performing liver transplantation have developed rapidly; however, the lack of available livers has prompted the utilization of edge donor grafts, including those donated after circulatory death, older donors, and hepatic steatosis, thereby rendering it difficult to define optimal clinical outcomes.

Objective

We aimed to investigate the efficacy of telemedicine for follow-up management after liver transplantation.

Methods

To determine the efficacy of telemedicine for follow-up after liver transplantation, we performed a clinical observation cohort study to evaluate the rate of recovery, readmission rate within 30 days after discharge, mortality, and morbidity. Patients (n=110) who underwent liver transplantation (with livers from organ donation after citizen's death) were randomly assigned to receive either telemedicine-based follow-up management for 2 weeks in addition to the usual care or usual care follow-up only. Patients in the telemedicine group were given a robot free-of-charge for 2 weeks of follow-up. Using the robot, patients interacted daily, for approximately 20 minutes, with transplant specialists who assessed respiratory rate, electrocardiogram, blood pressure, oxygen saturation, and blood glucose level; asked patients about immunosuppressant medication use, diet, sleep, gastrointestinal function, exercise, and T-tube drainage; and recommended rehabilitation exercises.

Results

No differences were detected between patients in the telemedicine group (n=52) and those in the usual care group (n=50) regarding age (P=.17), the model for end-stage liver disease score (MELD, P=.14), operation time (P=.51), blood loss (P=.07), and transfusion volume (P=.13). The length and expenses of the initial hospitalization (P=.03 and P=.049) were lower in the telemedicine group than they were in the usual care follow-up group. The number of patients with MELD score ≥30 before liver transplantation was greater in the usual care follow-up group than that in the telemedicine group. Furthermore, the readmission rate within 30 days after discharge was markedly lower in the telemedicine group than in the usual care follow-up group (P=.02). The postoperative survival rates at 12 months in the telemedicine group and the usual care follow-up group were 94.2% and 90.0% (P=.65), respectively. Warning signs of complications were detected early and treated in time in the telemedicine group. Furthermore, no significant difference was detected in the long-term visit cumulative survival rate between the two groups (P=.50).

Conclusions

Rapid recovery and markedly lower readmission rates within 30 days after discharge were evident for telemedicine follow-up management of patients post–liver transplantation, which might be due to high-efficiency in perioperative and follow-up management. Moreover, telemedicine follow-up management promotes the self-management and medication adherence, which improves patients’ health-related quality of life and facilitates achieving optimal clinical outcomes in post–liver transplantation.

Endovascular Treatment of Aortohepatic Conduit Stenosis Following Liver Transplant

BACKGROUND

Aortohepatic conduits (AHCs) are valuable alternatives when conventional hepatic artery anastomoses are not possible. However, AHCs have earlier and higher occlusion rates and reduced graft and patient survival. While endovascular therapy is safe and effective for conventional anastomotic stenoses, data on AHC stenoses are limited. This study reviewed outcomes for endovascular management of AHC stenosis at a single liver transplant center.

METHODS

A retrospective review of a prospectively maintained database was performed on the endovascular management of AHC stenosis between January 1, 2000, and December 31, 2016. Medical records, laboratory data, and imaging were analyzed for technical and hemodynamic success, primary and assisted primary patency, and patient and graft survival.

RESULTS

Seven patients underwent angioplasty a median of 142 days after transplant, and 2 required reintervention. The primary patency rate was 67% at 6 months and 22% at 1 year. The assisted primary patency rate was 83% at 6 months and 42% at 1, 3, and 5 years. Patient and graft survival were 86% at 6 months and 71%, 57%, and 38% at 1, 3, and 5 years, respectively. Four conduits were patent at last follow-up. There were no major adverse events after angioplasty. One reintervention was complicated by acute AHC thrombosis after stenting, causing biliary necrosis, sepsis, and death. There was no 30-day mortality, retransplant, or surgical revascularization because of endovascular intervention.

CONCLUSIONS

Endovascular treatment of AHC stenosis appears to be safe with a high technical success rate but lower long-term patency than standard hepatic arterial anastomoses.

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.

Doppler Characteristics of Recurrent Hepatic Artery Stenosis

OBJECTIVES

We sought to assess midterm sonographic findings in patients after stenting for hepatic artery stenosis.

METHODS

Thirty-nine hepatic artery stent procedures were performed for hepatic artery stenosis after liver transplantation between September 2009 and December 2013. Thirty cases were technically successful and met the minimum follow-up time (76 days, defined by earliest diagnosed stenosis). Routine ultrasound surveillance was obtained on all patients, and statistical analysis of the findings in the patency and restenosis groups was performed.

RESULTS

Of the 30 cases, restenosis occurred 9 times in 6 patients. Mean follow-up was 677 days. Mean time to restenosis was 267 days. Five cases (56%) were identified within the first 6 months after stent placement. Four cases (44%) were recognized in the second year after stent placement. Prior to the sonographic diagnosis of restenosis, the mean resistive indices of the main (.64 versus .57, P < .0001), left (.63 versus .54, P < .0001), right anterior (.60 versus .52, P < .0001), and right posterior (.60 versus .53, P = .001) hepatic artery branches differed among patency and restenosis groups, respectively. The mean peak systolic velocity also differed significantly between the 2 groups: 254 cm/sec in patients with eventual restenosis versus 220 cm/sec in patients without restenosis (P = .02).

CONCLUSIONS

The sonographic evaluation of hepatic artery stenosis remains critical during the first 2 years after stent placement. While the vast majority of patients do not restenose, resistive index and peak systolic velocity differed significantly between the 2 groups and may be prognostic surveillance markers for the development of restenosis.

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.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study)

OBJECTIVES

Hepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.

METHODS

We retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.

RESULTS

The overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.

CONCLUSION

HA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

Percutaneous Transluminal Angioplasty and Stenting for Hepatic Vessel Stenosis after Orthotopic Liver Transplantation

BACKGROUND

This study aimed to evaluate the efficacy of vascular intervention in percutaneous transluminal angioplasty (PTA) for the treatment of hepatic artery and hepatic vein stenosis after liver transplantation (LT), including thrombotic total occluded lesions.

METHODS

Percutaneous transluminal angioplasty after orthotopic liver transplantation was performed to re-open hepatic vessel lesions. We daily used routine Doppler ultrasound during admission for early detection of graft hepatic vessel lesions, including hepatic artery and vein lesions. In outpatients, Doppler ultrasound was performed every month. Urokinase was delivered with a dose of 150,000-300,000 IU by catheter before PTA for thrombotic total occlusion of the graft for hepatic artery patients. Laboratory data were collected to evaluate the effects of the PTA procedure.

RESULTS

The study involved a total of seven patients, six of whom were successfully treated by a first PTA procedure. Thrombolysis use of urokinase in totally occluded donor hepatic arteries post-LT following stenting was successful in three patients. One complication occurred, an arterial dissection and perforation, finalizing the success rate at ~86% and the complication rate at ~14%. Therefore, our study has a primary patency rate of 100% at 1 and 3 months. Also, the graft survival rate was 100 % and 86 % in the first and third months, respectively.

CONCLUSIONS

PTA with stenting is an effective treatment for hepatic vessel stenosis, including hepatic arteries and hepatic veins, after a liver transplantation without an increase in the complication rate. In addition, thrombolysis using urokinase intra-artery infusion in graft thrombotic total occluded patients is a good treatment strategy as well.

KEY WORDS

Angioplasty; Complication; Liver transplantation.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study)

Objectives

Hepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.

Methods

We retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.

Results

The overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.

Conclusion

HA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

•

Preoperative PVT was significant predictor of HA and/or PV complications.

•

HA and/or PV complications especially early ones lead to significant poor outcome.

•

Proper dealing with the risk factors like pre LT PVT improves outcome.

•

The effective management of these complications is mandatory for improving outcome.

Primary stent placement for hepatic artery stenosis after liver transplantation

OBJECTIVE

Significant hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT) can lead to thrombosis, with subsequent liver failure in 30% of patients. Although operative intervention or retransplantation has been the traditional solution, endovascular therapy has emerged as a less invasive treatment strategy. Prior smaller studies have been conflicting in the relative efficacy of percutaneous transluminal angioplasty (PTA) vs primary stent placement for HAS.

METHODS

This was a single-center retrospective review of all endovascular interventions for HAS after OLT during a 54-month period (August 2009-December 2013). Patients with ultrasound imaging with evidence of severe HAS (peak systolic velocity >400-450 cm/s, resistive index <0.5) underwent endovascular treatment with primary stent placement or PTA. Outcomes calculated were technical success, primary and primary assisted patency rates, reinterventions, and complications.

RESULTS

Sixty-two interventions for HAS were performed in 42 patients with a mean follow-up of 19.1 ± 15.2 months. During the study period, 654 OLTs were performed. Of 61 patients diagnosed with HAS, 42 underwent an endovascular intervention. The rate of endovascularly treated HAS was 6.4% (42 of 654). Primary technical success was achieved in 95% (59 of 62) of the interventions. Initial treatment was with PTA alone in 17 or primary stent in 25. Primary patency rates after initial stent placement were 87%, 76.5%, 78%, and 78% at 1, 6, 12, and 24 months, respectively, compared with initial PTA rates of 64.7%, 53.3%, 40%, and 0% (P = .19). There were 20 reinterventions in 14 patients (eight stents, six PTAs). The time to the initial reintervention was 51 days in patients with PTA alone vs 105.8 days for those with an initial stent (P = .16). Overall primary assisted patency was 93% at 24 months. Major complications were one arterial rupture and two hepatic artery dissections. The long-term risk of hepatic artery thrombosis in the entire patient cohort was 3.2%.

CONCLUSIONS

HAS after OLT can be treated endovascularly with high technical success and excellent primary assisted patency. This series represents the largest reported cohort of endovascular interventions for HAS to date. Initial use of a stent showed a strong trend toward decreasing the need for reintervention. Avoidance of hepatic artery thrombosis is possible in >95% of patients with endovascular treatment and close follow-up.

Hepatic artery stenosis after liver transplantation: is endovascular treatment always necessary?

Hepatic artery stenosis (HAS) is thought to predispose patients to biliary complications secondary to ischemic injury. Despite this, the clinical significance of HAS remains poorly defined. The aims of this study were to determine the prevalence and outcomes of HAS and to define which patients might benefit from endovascular treatment. From a prospective database of 662 adult patients undergoing liver transplantation between 2000 and 2011, we identified 54 patients who developed HAS. HAS was defined as any stenosis > 70% that was seen during multidetector computed tomographic angiography (MDCTA) or digital subtraction angiography. The benefit of endovascular therapy was evaluated with propensity score matching. New biliary complications occurred in 17 patients (31.4%), and 23 of the 54 study patients with HAS received endovascular treatment. Among the propensity score-matched patients, the biliary stricture-free survival time was significantly longer for those who received endovascular therapy (P = 0.03). An incidental diagnosis (P = 0.07) and a time from transplantation > 6 months (P = 0.021) were associated with a reduced risk of developing biliary stricture. Patients with symptomatic HAS who received treatment had better biliary stricture-free survival than patients who were treated conservatively, although no significant difference was recorded (P = 0.11). No patient with asymptomatic HAS and normal liver function tests developed biliary strictures. In conclusion, HAS intervention was associated with improved biliary stricture-free survival. In patients with late-onset HAS (≥6 months) and asymptomatic patients, endovascular treatment is not warranted.

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.

A comparison of open surgery and endovascular intervention for hepatic artery complications after pediatric liver transplantation

There are currently 2 major therapeutic options for the treatment of hepatic artery complications: endovascular intervention and open surgery. We herein report a retrospective analysis of 14 pediatric patients with hepatic artery complications after pediatric living donor liver transplantation (LDLT) at our institution. We divided them into an open surgery group and an endovascular intervention group based on their primary treatment, and compared the results and outcomes. We then evaluated which procedure is more effective and less invasive. In the open surgery group, recurrent stenosis or spasm of the hepatic artery occurred in 3 of the 8 patients (37.5%). In the endovascular intervention group, 5 of the 6 patients were technically successfully treated by only endovascular treatment. Of the 5 successfully treated patients, 3 developed recurrent stenosis (60%). There were significant differences in the mean length of the operation for the first treatment of hepatic artery complications (open surgery, 428 minutes vs endovascular intervention, 160 minutes; P = .01) and in the mean value of the posttreatment aspartate aminotransferase (AST)/alanine aminotransferase (ALT) (open surgery > endovascular intervention; P = .04/.05). Although endovascular intervention needs to be examined in further studies to reduce the rate of relapse, it is a less invasive method for the patient and graft than open surgery.

Interventional treatment of lumen-reconstruction-related complications after pediatric living-donor liver transplantation

BACKGROUND

Interventional radiology has recently been reported as an effective means of treating complications after liver transplantation. In children, however, the number of such reports is relatively small. In addition, there is ongoing discussion regarding the best interventional devices and methods for specific complications.

OBJECTIVE

The aim of this study was to determine the value of interventional treatment for vessel and bile duct complications after pediatric living-donor liver transplantation.

MATERIALS AND METHODS

Six cases with lumen-reconstruction-related complications after liver transplantation received intervention. Three cases had hepatic artery thrombosis, one had portal vein stenosis, and two had bilioenteric anastomotic stenosis. Catheter-directed thrombolysis was used to treat cases with hepatic artery thrombosis; balloon dilation and stent placement were used for portal vein stenosis; balloon dilation and drainage were used for bilioenteric anastomotic stenosis.

RESULTS

All interventions were performed successfully, and treatment efficacy was 100 %. Except for one death from multiple organ failure, all other cases survived through follow-up, which lasted up to 18 months. No case had intervention-related complication.

CONCLUSION

Interventional treatment is safe and effective, and can be the first choice for the treatment of complications associated with pediatric living-donor liver transplantation.

Dissection of the hepatic artery and the celiac trunk after a liver transplant: description of a complication and endovascular management

Dissection of the common hepatic artery is a rare complication after orthotopic liver transplant. Subsequent thrombosis and occlusion of the transplant artery can result in graft failure requiring retransplant. We describe a case of hepatic artery dissection, occurring on the basis of primary vasculopathy, extending into the celiac trunk, with subtotal occlusion of the vessel through accompanying thrombosis. An attempt of endovascular rescue led to successful recanalization of the vessel and graft survival.

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.

Repeat endovascular treatment of recurring hepatic artery stenoses in orthotopic liver transplantation

Hepatic artery stenosis (HAS) is a complication that impacts the results of orthotopic liver transplantation (OLT). Interventional radiological techniques are important therapeutic options for HAS. The aim of this retrospective study was to evaluate the outcome of repeated radiological treatments in recurring HAS after OLT. Of the 941 patients who underwent OLT at our center from January 1998 to September 2010, 48 (5%) were diagnosed with HAS, 37 (77%) of whom underwent transluminal interventional therapy with the placement of an endovascular stent. Success rate, complications, hepatic artery patency and follow-up were reviewed. After stent placement, artery patency was achieved in all patients. Three patients developed complications, including arterial dissection and hematoma. HAS recurrence was observed in 9 patients (24%), and hepatic artery thrombosis (HAT) occurred in 4 (11%). Radiological interventions were repeated 10 times in 8 patients without complications. At a median follow-up of 66 months (range 10-158), hepatic artery patency was observed in 35 cases (94.6%). The 5-year rates for graft and patient survival were 82.3% and 87.7%, respectively. Restenosis may occur in one-third of patients after endovascular treatment for thrombosis and HAS, but the long-term outcomes of iterative radiological treatment for HAS indicate a high rate of success.

Interventional radiology for hepatic artery complications soon after living donor liver transplantation in a neonate

Early hepatic artery complications after liver transplantation in children, having undergone LDLT, can directly affect graft and recipient outcomes, making early diagnosis and treatment essential. In the past, laparotomy (thrombectomy or reanastomosis) was generally employed to treat early hepatic artery complications. Recently, favorable outcomes of IR have been reported. In children, however, the number of such reports is small. To the best of our knowledge, there is no published report on IR applied to neonates with early hepatic artery complications. We recently succeeded in safely using IR for a neonate with early hepatic artery complications after LDLT and obtained a favorable outcome. This case is presented herein.

Angioplastia subintimal após trombose tardia de stent implantado em artéria hepática de fígado transplantado

Os autores relatam um caso de estenose de artéria hepática transplantada tratada com angioplastia e stent, que evoluiu para trombose completa após 30 dias do procedimento. Realizada trombólise intra-arterial e angioplastia subintimal com sucesso. Controle angiotomográfico após 90 dias demonstra perviedade da artéria hepática.

Interventional radiology in the treatment of the complications of organ transplant in the pediatric population-part 2: the liver

Organ transplantation continues to grow in demand in the pediatric population. The liver is the second most common organ that is transplanted in the pediatric population, but it results in the greatest number of interventional procedures. Transplant continues to be the preferred treatment for end-stage liver failure in children and has been shown to prolong life. There are several significant differences in liver transplantation between adults and children. They include different indications and diseases leading to transplant, the smaller body size of children, and differences in the surgical techniques used to implant the liver. These differences have led to a set of complications that is unique to or is more frequently seen in the transplanted child. The complications require interventional solutions tailored to the special needs of children. This paper will examine the complications that are encountered and the technical challenges that the interventionalist must address to successfully treat this subgroup of children. The purpose of this paper is to present the techniques and "pearls" that we have found to be helpful in treating this group of patients that in many ways is the most challenging in all of pediatric intervention.

Vascular complications following liver transplantation

Vascular complications (stenosis or thrombosis of the hepatic artery, portal vein or hepatic vein) are a relatively common occurrence following liver transplantation. Routine screening with ultrasound is critical to early detection of these complications. Careful application of standard interventional techniques (diagnostic catheter angiography, balloon angioplasty with selective stenting) may be used to confirm the ultrasound findings, treat the underlying lesions, and contribute to long-term graft survival.

Association of hepatic artery stenosis and biliary strictures in liver transplant recipients

Biliary complications are important causes of morbidity and graft failure in patients after orthotopic liver transplantation. Nonanastomotic biliary strictures (NAS) are frequently the most challenging biliary complications. Hepatic artery stenosis (HAS) as a cause of biliary strictures has not been studied well systematically. We performed a retrospective cohort study of patients who underwent liver transplantation at our institution between 1995 and 2007 to determine the incidence of biliary strictures (nonanastomotic and anastomotic) with HAS. Forty patients were identified, and they were compared with 62 matched non-HAS controls. Overall, NAS and biliary anastomotic strictures were seen more frequently in patients with HAS (24/40 or 60%) versus control patients (6/62 or 9.67%, P < 0.000001). Cholangiographic evidence of NAS was seen in 10 of 40 study patients (25%) and in 1 of 62 control patients (2%, P < 0.0001), whereas evidence of biliary anastomotic strictures was seen in 14 of 40 study patients (35%) and in 5 of 62 control patients (8%, P = 0.0006). The cold ischemia time was also found to be associated with the presence of NAS in patients with HAS (P = 0.024). Patients with biliary strictures were generally managed successfully with endoscopic retrograde cholangiopancreatography balloon dilation/stenting, except for 4 NAS patients who had significant morbidity and mortality. In conclusion, the development of HAS, particularly with a prolonged cold ischemia time, may increase the NAS risk after liver transplantation. HAS is also associated with the development of biliary anastomotic strictures. Prospective studies of frequent arterial monitoring for the early detection of HAS and interventions to prevent biliary complications are needed.

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.

Biliary complications after orthotopic liver transplantation

Liver transplantation has made many advances since its inception in the early 1970s. Despite volumes of basic science and clinical research related to liver transplantation, biliary complications continue to present the interventional radiologist with challenging cases in all transplant centers. Biliary complications can range from minor complications such as contained bile leaks to severe complications such as biliary necrosis resulting from hepatic artery thrombosis. Minor complications may require minimal or no intervention, whereas the more severe complications can require urgent surgery. To treat biliary complications such as anastomotic strictures, nonanastomotic strictures, biliary leaks, sludge or biliary necrosis, an accurate diagnosis must first be obtained. One must also be aware of how these complications can impair both allograft and transplant patient survival. With this information one can then plan a treatment knowing the potential success rates of specific treatments. Using proper technique with this information at hand can greatly increase the success rate in treating the spectrum of biliary complications. Interventional radiology serves a critical role in diagnosis and treatment of these liver transplant biliary complications and is important to the success of all transplant programs.

Prevalence, treatment, and outcomes of the hepatic artery stenosis after liver transplantation

INTRODUCTION

Hepatic artery stenosis (HAS) after liver transplantation can lead to altered hepatic function and/or thrombosis, there by increasing morbidity and mortality. The prevalence of HAS in the literatures varies from 4% to 11%.

OBJECTIVE

We sought to describe the prevalence and treatment of hepatic artery stenosis.

METHODS

We performed a descriptive retrospective analysis of 253 liver transplantations from March 1998 to May 2007, including patients with suspected HAS owing to increased hepatic enzymes, altered Doppler ultrasound (us) and hepatic biopsy. The confirmation of HAS was achieved through areriography.

RESULTS

Nine patients were identified to have HAS, a 3.5% prevalence. Among the HAS patients, seven were male and two female. Their average age was 35.5 years (range, 65 to 53). The average time between the diagnosis and transplantation was 14.2 months (range, 9 to 68). The increase in hepatic enzymes among this group averaged: aspartate aminotransferase 131 U/L (range, 26 to 412) and alanine aminotransferase 192 U/L (range, 35 to 511). Doppler US showed alteration in the resistance level index. All patients underwent areriography; only one could not be treated owing to severe hepatic artery spasm, which also occurred during another attempt weeks after the first one. Among the eight patients, six were treated with stents and two with angioplastis. All treated patients displayed improvements in parameters. Four patients treated with stents required retreatment: two underwent angioplasty and two, a thrombolytic. One graft rethrombosed but evolved in compensated fashion with recanalization by collaterals. There has been no graft loss or mortality in this population. The average time of posttreatment follow-up was 31.28 (range, 9 to 68) months.

CONCLUSION

The prevalence of HAS in our unit was within that reported in the literature. Treatment with a stent or angioplasty proved to be efficient to control this complication, considering that hepatic function recovered and that there was neither graft nor patient loss.

Successful arterial thrombolysis and percutaneous transluminal angioplasty for early hepatic artery thrombosis after split liver transplantation in a four-month-old baby

Early HAT is the most frequent and severe vascular complication following liver transplantation. It is one of the major causes of graft failure and mortality. Endovascular thrombolytic treatment in patients with thrombotic complications after liver transplantation is an attractive alternative to open surgery as lower morbidity and mortality rates are reported for it. PTA following transcatheter thrombolysis has been successfully used to treat HAT in adults. To the best of our knowledge, there have not been any reports of a successful transcatheter thrombolysis using interventional radiological techniques in a patient only four months old. The present report describes the successful endovascular emergency treatment of a HAT three days after DD split liver transplantation.

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.

Percutaneous transluminal angioplasty using a pull-through technique for hepatic arterial occlusion at the time of port-catheter implantation

We report a successful percutaneous transluminal angioplasty using a pull-through technique for the treatment of a hepatic arterial occlusion caused by iatrogenic subintimal dissection during the percutaneous placement of a port-catheter system.

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.

Percutaneous transluminal angioplasty for hepatic arterial occlusion following hepatic arterial infusion chemotherapy

We report a case in which hepatic arterial occlusion developed during repeated hepatic arterial infusion chemotherapy through an implanted port-catheter system for advanced malignant hepatic neoplasia. After successful recanalization of the hepatic artery by using percutaneous transluminal angioplasty, another port-catheter system was placed percutaneously by interventional radiology techniques, allowing the continuation of hepatic arterial infusion chemotherapy.

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.

Role of interventional radiology in the management of vascular complications after liver transplantation

The purpose of this study is to review the role of the percutaneous interventional procedures in the treatment of vascular complications after orthotopic liver transplantations (OLT). Vascular complications, such as arterial stenosis and venous thrombosis, which occur in approximately 1% to 10% of liver transplant patients, are associated with a higher risk of graft dysfunction. Percutaneous interventional procedures, including angioplasty, local thrombolysis, and embolization, are useful to manage these complications. A reduced blood loss and a low incidence of procedural complications allow for rapid recovery. Hepatic arterial and portal vein anastomotic stenosis can be treated effectively by means of balloon dilation; stenting has also been proposed, particularly for venous complications. Infusional local thrombolysis may be useful in venous thrombosis. Arteriovenous fistulas, occurring at the level of the anastomosis or after liver biopsy, require intraarterial embolization using microcoils or gelfoam. Timing of the intervention for the treatment of ischemic complications is of outmost importance to guarantee liver functional recovery and avoid irreversible parenchymal injuries. Other interventional procedures may be extremely useful to manage portal hypertension after OLT; for example, by creation of transjugular portosystemic shunts, or, in the case of associated hypersplenism, transarterial embolization of the splenic artery. Finally, in patients with recurrent hepatitis, the transjugular approach has been shown to be safe and effective for liver biopsy, whereas transarterial chemoembolization may be extremely useful to treat recurrent hepatocarcinoma.

Diagnosis and treatment of hepatic artery stenosis after orthotopic liver transplantation

PURPOSE

The purpose of this study was to evaluate the accuracy of Multidetector Computed Tomographic Angiography (MDCTA) to detect hepatic artery (HA) stenosis after orthotopic liver transplantation (OLT) and the efficacy of treatment using percutaneous transluminal angioplasty (PTA).

MATERIALS AND METHODS

Twenty-two consecutive patients with OLT underwent MDCTA for evaluation of HA, followed by digital subtraction angiography (DSA) (gold standard). Source images (Ax) were processed, obtaining multiplanar reformations (MPRs), maximum intensity projections (MIPs), and volume renderings (VRs). Images were evaluated to identify the following: (1) arterial depiction (celiac axis, anastomosis, and left [LHA] and right [RHA] HA), (2) detection of stenoses, and (3) grading of stenoses. Indications for PTA were set at MDCTA and DSA, and PTA was performed when appropriate.

RESULTS

MDCTA depicted the celiac axis and anastomoses in all patients; LHA and RHA were visualized in 21 of 22 patients with Ax, MPRs, and MIPs, and in 17 of 22 with VRs. All reconstruction modalities enabled correct diagnosis of celiac (n = 3) and anastomotic stenoses (n = 14). Of 6 LHA and RHA stenoses, 4 (66.7%) were visualized with Ax, MPRs, and VRs, and 5 (83.3%) were visualized with MIPs. Stenosis was overestimated in 9 (39.1%) cases with VRs and in 3 (13%) with the other modalities. PTA was performed in 8 cases, with 1 case of arterial dissection requiring re-OLT. At a median follow-up of 28 months, the primary and secondary patency rates were 71.4% (5 of 7) and 85.7% (6 of 7), respectively.

CONCLUSIONS

MDCTA and accurate postprocessing enable confident depiction of the arterial anatomy and detection of stenosis after OLT. PTA is safe and allows allograft saving, at least until another suitable donor becomes available.

Interventional Radiologic Treatment for Hepatic Arterial Occlusion after Repeated Hepatic Arterial Infusion Chemotherapy via Implanted Port–Catheter System

The present study evaluated the feasibility of interventional radiologic treatments for hepatic arterial occlusion after hepatic arterial infusion chemotherapy (HAIC) via an implanted port-catheter system. Treatment for hepatic arterial occlusion was attempted in seven patients with unresectable liver cancer. In six, the obstructed hepatic artery was recanalized. In three patients, the recanalized hepatic artery again became obstructed. However, by performing additional interventional radiologic procedures, secondary patency of the hepatic artery was successfully obtained in two patients. In conclusion, when hepatic arterial occlusion occurs, HAIC can be resumed in the attempt to recanalize the hepatic artery.