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Patrono D, Franchi E, Guarasci F, Bartoli G, Nada E, Rigo F, Ottobrelli A, Fonio P, Salizzoni M, Romagnoli R. Vascular Remodeling of Visceral Arteries Following Interruption of the Splenic Artery During Liver Transplantation. Liver Transpl 2019; 25:934-945. [PMID: 30882994 DOI: 10.1002/lt.25447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/01/2019] [Indexed: 02/07/2023]
Abstract
Splenic artery (SA) ligation can be performed during liver transplantation (LT) to avoid portal hyperperfusion, which is involved in the pathogenesis of both small-for-size and SA syndrome. The SA can also be used as an inflow for arterial reconstruction. Exceptionally, SA interruption or agenesis has been associated with positive remodeling of collateral arteries supplying the spleen via the left gastric artery (LGA), short gastric vessels, and the gastroepiploic arcade (GEA), with subsequent severe upper gastrointestinal (GI) bleeding. To determine incidence, magnitude, predictors, and clinical implications of vascular remodeling after SA interruption during LT, we identified 465 patients transplanted in the period 2007-2017 who had the SA ligated or interrupted at LT. Among them, 88 had a computed tomography angiography suitable for evaluation of vascular remodeling after LT. The presence of prominent gastric arterial collaterals and the increase in LGA and GEA diameter were evaluated on 2-dimensional axial images and multiplanar reconstructions. Of the 88 patients, 28 (31.8%), 32 (36.4%), and 22 (25.0%) developed gastric collateralization graded as mild, moderate, or severe. Of the patients for whom comparison with pre-LT imaging was possible (n = 54), 51 (94.4%) presented a median 37% and 55% increase in LGA and GEA diameter, respectively. Severe gastric collateralization was associated with lower body mass index (odds ratio, 0.84; 95% confidence interval [CI], 0.71-0.98; P = 0.03), whereas a GEA caliper measurement increase was positively correlated with Model for End-Stage Liver Disease score (r2 = 0.12; 95% CI, 0.65-4.15; P = 0.008). Out of 465 patients, 2 (0.43%) had severe episodes of arterial upper GI bleeding, possibly exacerbated by vascular remodeling. In conclusion, vascular remodeling after SA interruption during LT is frequent and can aggravate GI bleeding during follow-up.
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Affiliation(s)
- Damiano Patrono
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Eloisa Franchi
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Fabio Guarasci
- Radiology Department, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Germana Bartoli
- Radiology Department, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Elisabetta Nada
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Federica Rigo
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Antonio Ottobrelli
- Gastrohepatology Unit, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Paolo Fonio
- Radiology Department, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Mauro Salizzoni
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Renato Romagnoli
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
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Verzaro R, Spada M, Cintorino D, di Francesco F, Riva S, Caruso S, Gridelli B. Arterial anastomosis in a pediatric patient receiving a right extended split liver transplant: a case report. Pediatr Transplant 2009; 13:503-6. [PMID: 18822102 DOI: 10.1111/j.1399-3046.2008.01004.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report a case of a pediatric patient who received a right-extended liver transplant. The size of the recipient hepatic artery did not match with the donor right hepatic arterial stump. Moreover, recipient arterial anatomy made the direct anastomosis difficult or at increased risk for complications. The recipient's splenic artery was then mobilized, divided and anastomosed to the donor's right hepatic artery. The spleen was preserved and revascularization through collaterals is demonstrated by Angio CT Scan. Doppler US of the transplanted liver demonstrated good flow through the liver and the patient was discharged with perfect liver function. Splenic artery is perfectly suited for hepatic artery anastomosis. The use of splenic artery is favored in particular situations as in the case of a pediatric recipient receiving a right-extended liver graft with small caliber artery.
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Affiliation(s)
- Roberto Verzaro
- Division of Transplantation, Department of Surgery, Mediterranean Institute for Transplantation (IsMeTT), Palermo, Italy.
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Müller SA, Schmied BM, Mehrabi A, Welsch T, Schemmer P, Hinz U, Weitz J, Werner J, Büchler MW, Schmidt J. Feasibility and effectiveness of a new algorithm in preventing hepatic artery thrombosis after liver transplantation. J Gastrointest Surg 2009; 13:702-12. [PMID: 19034586 DOI: 10.1007/s11605-008-0753-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 10/28/2008] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Sascha A Müller
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
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D’Albuquerque L, Gonzalez A, Letrinda R, Copstein J, Larrea F, Mansero J, Peron G, Ribeiro M, Oliveira e Silva A. Use of the Splenic Artery for Arterial Reconstruction in Living Donor Liver Transplantation. Transplant Proc 2007; 39:3202-3. [DOI: 10.1016/j.transproceed.2007.03.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Accepted: 03/05/2007] [Indexed: 10/22/2022]
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Muller SA, Schmied BM, Welsch T, Martin DJ, Schemmer P, Mehrabi A, Weitz J, Buchler MW, Schmidt J. How to increase inflow in liver transplantation. Clin Transplant 2007; 20 Suppl 17:85-92. [PMID: 17100707 DOI: 10.1111/j.1399-0012.2006.00606.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Liver transplantation (LTx) has become the treatment of choice for selected cases of benign and malignant liver disease. Despite becoming increasingly safer in recent years this procedure still incurs several serious postoperative complications. The most significant surgical complications are related to surgical technique, particularly the reconstruction and/or anastomosis of the hepatic artery. Arterial hypoperfusion may lead to graft failure, sepsis, or ischemic biliary lesions. In this review we focus on the Achilles' heel of LTx: the hepatic artery. We provide transplant surgeons with an overview of the technical options that are available to increase arterial inflow and subsequently improve patient outcome. We exemplify some of the discussed techniques using a liver transplant case with an eventful postoperative course because of arterial complications.
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Affiliation(s)
- S A Muller
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
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Tannuri U, Maksoud-Filho JG, Silva MM, Suzuki L, Santos MM, Gibelli NE, Ayoub AA, Velhote MCP, Pinho-Apezzato ML, Maksoud JG. An alternative method of arterial reconstruction in pediatric living donor liver transplantation with the recipient right gastroepiploic artery. Pediatr Transplant 2006; 10:101-4. [PMID: 16499596 DOI: 10.1111/j.1399-3046.2005.00392.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The classical method for arterial reconstruction in pediatric living donor liver transplantation using left lateral segment consists of end-to-end anastomosis between the donor left hepatic artery and the recipient right hepatic artery. In the present case, an intra-operative hepatic artery thrombosis occurred because of extensive intima wall dissection of the recipient hepatic artery. The patient was a 6-yr-old boy with fulminant hepatic failure, who underwent living donor partial liver transplantation with left lateral segment from his father. The graft was irrigated by a left hepatic artery and an accessory left hepatic artery from gastric artery, both arteries with diameter of <2 mm. These arteries were anastomosed to the recipient right and left hepatic arteries, respectively. Before performing the bile duct reconstruction it was noted that these anastomoses were occluded by clots of blood. An extensive subintimal dissection of the recipient hepatic artery was the cause of this problem. The creation of a new anastomosis by using a more proximal part of this artery without subintimal dissection was judged impossible. Then, the right gastroepiploic artery was mobilized and an anastomosis was performed with the donor left hepatic artery in an end-to-end fashion. Arterial blood flow to the graft was established successfully and the patient's postoperative recovery was excellent. Fifteen days after the transplantation, an angiotomography demonstrated a good hepatic arterial blood flow. The patient is now alive and well, 4 months after the transplantation. In conclusion, the method of hepatic graft arterialization described here is an important option for patients who undergo living donor or split liver transplantation.
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Affiliation(s)
- Uenis Tannuri
- Liver Transplantation Unit, Children Institute, Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil.
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Kishi Y, Sugawara Y, Akamatsu N, Kaneko J, Tamura S, Kokudo N, Makuuchi M. Splenectomy and preemptive interferon therapy for hepatitis C patients after living-donor liver transplantation. Clin Transplant 2006; 19:769-72. [PMID: 16313323 DOI: 10.1111/j.1399-0012.2005.00419.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recurrent hepatitis C after liver transplantation is a major cause of graft failure. We routinely perform preemptive interferon and ribavirin therapy in patients after living-donor liver transplantation indicated for hepatitis C-related cirrhosis. One of the obstacles for the therapy includes blood cytopenia. To overcome this problem, we recently performed splenectomy concurrently with liver transplantation. Thirty-five patients underwent liver transplantation and received preemptive therapy for hepatitis C. They were divided into two groups: those with splenectomy (group A, n = 21) and those without (group B, n = 14). There was no significant difference in the frequency of morbidity between the groups. Platelet counts were well maintained in group A patients during the therapy, and cytopenia led to the discontinuation of the therapy in one group B patient. The results of the preliminary study warrant a randomized control trial to examine the feasibility of splenectomy and preemptive viral therapy during liver transplantation for hepatitis C.
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Affiliation(s)
- Yoji Kishi
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Asakura T, Ohkohchi N, Orii T, Koyamada N, Satomi S. Arterial reconstruction using vein graft from the common iliac artery after hepatic artery thrombosis in living-related liver transplantation. Transplant Proc 2000; 32:2250-1. [PMID: 11120153 DOI: 10.1016/s0041-1345(00)01787-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- T Asakura
- Tohoku University School of Medicine, Sendai, Japan
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Chen TY, Chen CL, Chen YS, Lee TY, Huang TL, Hsu SW, Lui CC, Cheng YF. Asymptomatic vascular complications in liver transplantation. Transplant Proc 2000; 32:2252-3. [PMID: 11120154 DOI: 10.1016/s0041-1345(00)01788-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- T Y Chen
- Departments of Diagnostic Radiology and Liver Transplant Program, Chang Gung University, and Memorial Hospital, Kaohsiung Medical Center, Taiwan, Japan
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Ikegami T, Kawasaki S, Hashikura Y, Miwa S, Kubota T, Mita A, Iijima S, Terada M, Miyagawa S, Furuta S. An alternative method of arterial reconstruction after hepatic arterial thrombosis following living-related liver transplantation. Transplantation 2000; 69:1953-5. [PMID: 10830238 DOI: 10.1097/00007890-200005150-00036] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatic artery thrombosis (HAT) remains an important cause of graft loss after liver transplantation. Emergency rearterialization methods are limited in cases of living-related liver transplantation in which the graft hepatic artery is thin and short. CASE A 19-year-old woman who underwent living-related liver transplantation for biliary atresia developed HAT on the 4th postoperative day. During the emergency laparotomy the recipient hepatic artery was found to be too short to anastomose, so the recipient's right gastroepiploic artery was anastomosed to the graft hepatic artery. The patient is now alive and well 6 months after reoperation, and she has experienced no further episode of HAT. CONCLUSION The right gastroepiploic artery can be used easily and safely for hepatic graft revascularization without causing ischemia of the stomach. An additional skin incision is not required, and the artery is long enough to anastomose to the graft artery directly. The method of hepatic graft rearterialization described here is an important option for patients who undergo living-related or split liver transplantation.
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Affiliation(s)
- T Ikegami
- First Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Figueras J, Parés D, Aranda H, Rafecas A, Fabregat J, Torras J, Ramos E, Lama C, Lladó L, Jaurrieta E. Results of using the recipient's splenic artery for arterial reconstruction in liver transplantation in 23 patients. Transplantation 1997; 64:655-8. [PMID: 9293883 DOI: 10.1097/00007890-199708270-00020] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Arterial reconstruction is essential in liver transplantation. In some patients there may be an inadequate flow as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. METHODS This study analyzes our experience with 23 patients in whom arterial anastomosis was performed using the splenic artery due to the inadequacy of the hepatic artery. During the same period an aortoiliac conduit was used in 12 liver transplantations due to the same problem. RESULTS No splenic infarction, pancreatitis, or other related complications were found. Artery thrombosis developed in only two patients in the aortoiliac conduit group. One- and three-year patient actuarial survival were 78% vs. 80% and 72% vs. 80%, respectively, for the splenic artery group and the aortoiliac conduit group. CONCLUSIONS Anastomosis with the splenic artery is an alternative in liver transplantation and is particularly suitable when splenomegaly is present.
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Affiliation(s)
- J Figueras
- Liver Transplant Unit, Ciutat Sanitaria i Universitaria Bellvitge, University of Barcelona, Spain
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Matsui A, Shimada T, Sasaki N, Ishikawa T, Momoya T, Makino S. Splenic infarction in a child with portal hypertension secondary to biliary atresia. J Pediatr Surg 1997; 32:648-9. [PMID: 9126779 DOI: 10.1016/s0022-3468(97)90732-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The authors describe for the first time a case of splenic infarction in a 7-year-old boy with portal hypertension and biliary cirrhosis secondary to biliary atresia. This rare complication may cause serious acceleration of chronic liver failure.
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Affiliation(s)
- A Matsui
- Department of Pediatrics, Jichi Medical School, Tochigi, Japan
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Inomoto T, Nishizawa F, Sasaki H, Terajima H, Shirakata Y, Miyamoto S, Nagata I, Fujimoto M, Moriyasu F, Tanaka K, Yamaoka Y. Experiences of 120 microsurgical reconstructions of hepatic artery in living related liver transplantation. Surgery 1996; 119:20-6. [PMID: 8560381 DOI: 10.1016/s0039-6060(96)80208-x] [Citation(s) in RCA: 146] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We reviewed 120 microsurgical reconstructions of a hepatic artery in living related liver transplantation and discussed the problems encountered. METHODS From January 1991 to July 1994 we performed a series of 105 living related liver transplantations on children with end-stage liver disease. Arterial reconstruction was performed under the optical field of a continuous zoom magnification of approximately 10 times with an operating microscope. RESULTS Twenty-six percent of the graft arteries were less than 2 mm in diameter. The time required for an arterial reconstruction was 49.5 +/- 1.8 minutes. In 15 of the 31 cases in which there were two graft arteries, two arterial reconstructions were required. The caliber differences between the graft artery and the recipient artery in 30 instances was dealt with by cutting an undersized artery obliquely (17 instances), by fish-mouth method (10 instances), by end-to-side anastomosis (1 instance), or by funnelization method (2 instances). In one case we performed an intimal dissection of a recipient hepatic artery and substituted a splenic artery. Consequently, hepatic arterial thrombosis occurred in only two cases (1.7%). CONCLUSIONS Microsurgical technique has overcome the high risk of hepatic arterial thrombosis in cases of fine graft arteries, enabled the reconstruction of arteries with caliber difference, and decreased arterial complications with its delicate manipulation.
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Affiliation(s)
- T Inomoto
- Second Department of Surgery, Faculty of Medicine, Kyoto University, Japan
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