Early hepatic arterial thrombosis in liver transplantation: Systemic intravenous alteplase as a potential rescue treatment after failed surgical revascularization

Ten years of a pediatric living donor liver transplantation program in Brazil

BACKGROUND

Pediatric living-donor liver transplantation is considered a safe alternative for the treatment of children with end-stage liver disease. Experienced tertiary centers and specialized medical staff are necessary to ensure compatible long-term survival rates and quality-of-life for these children.

AIM

To report the results and the 10-year learning curve of a pediatric living-donor liver transplantation program.

METHODS

We conducted a retrospective cohort study of pediatric recipients from 2013 to 2023. Post-transplant outcomes and patient survival rates were compared between two 5-year periods of the program.

RESULTS

A total of 25 and 48 patients underwent transplantation in the first (2013-2017) and second period (2018-2023), respectively. Portal vein and hepatic artery thrombosis occurred in 11 (15.1%) and seven (9.6%) patients, respectively. Biliary complications were observed in 39 of 73 patients (53.4%). A lower warm ischemia time was observed in the second period compared to the first (32.6 ± 8.6 minutes vs 38.4 ± 9.8 minutes, P = 0.018, respectively). Patient survival rates at 1 and 5 years were 84% in the first period and 91.7% in the second period, with no significant difference (P = 0.32).

CONCLUSION

The reported indications and outcomes align with the current literature. Our findings provide crucial evidence regarding the feasibility of establishing a living donor program with consistent results over time.

Recommendations for Hepatic Artery Anastomosis in Liver Transplantation: A Group Experience

BACKGROUND

Hepatic artery thrombosis (HAT) is a severe complication following living-donor liver transplantation that can be fatal if revascularization is not achieved. This study aims to present the 8-year experience of the Organ Transplantation Clinic at Harran University Faculty of Medicine.

METHODS

From 2014 to 2021, a total of 56 patients, comprising 35 men (62.5%) and 21 women (37.5%), who underwent either living-donor or cadaveric liver transplantation were included in the study. In cadaveric recipients, a continuous suture technique with 7/0 polypropylene was used, and in living-donor graft recipients, an interrupted suture technique with 7/0 polypropylene was performed in anastomosis. All patients received an intraoperative dose of 2500 to 5000 units (60 U/kg) of heparin prior to anastomosis. Doppler ultrasound was performed on all patients following the anastomosis.

RESULTS

Three out of the 56 patients (5.35%) developed HAT on postoperative day 1. One of these patients underwent hepatic artery revision on postoperative day 1, with no subsequent rethrombosis. The second patient underwent retransplantation on postoperative day 1. However, this patient could not tolerate the reoperation and passed away on the second day after transplantation. The last patient underwent endovascular stenting on postoperative day 1. However, this patient experienced rethrombosis on the first day after the procedure and rapidly deteriorated hemodynamically, which proved fatal.

CONCLUSIONS

HAT directly affects postoperative patient morbidity and mortality. The outcomes are favorable when hepatic artery anastomosis is performed using 7/0 polypropylene, with a continuous suture technique for cadaveric cases and an interrupted suture technique for living-donor cases, and is carried out by experienced hands.

The Impact of Hepatic Artery Thrombosis on the Outcome of Pediatric Living Donor Liver Transplantations

The aim of our study was to assess risk factors for hepatic artery thrombosis (HAT) and to evaluate the impact of HAT management on long-term outcomes after pediatric living donor liver transplantation (LDLT). We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. We compared preoperative data, surgical factors, complications, and patient and graft survivals in patients with HAT (HAT Group) and without HAT (non-HAT Group). A total of 27 patients (6.75%) developed HAT. Acute liver failure, a hepatic artery (HA) anastomosis diameter below 2 mm, and intraoperative HA flow dysfunction were significantly more common in the HAT Group (p < 0.05, p = 0.02026, and p = 0.0019, respectively). In the HAT Group, 21 patients (77.8%) underwent urgent surgical revision. The incidence of biliary stenosis and retransplantation was significantly higher in the HAT Group (p = 0.00002 and p < 0.0001, respectively). Patient and graft survivals were significantly worse in the HAT Group (p < 0.05). The close monitoring of HA flow with Doppler ultrasound during the critical period of 2 to 3 weeks after LDLT and the immediate attempt of surgical revascularization may attenuate the elevated risk of biliary stenosis, graft loss, and the need for retransplantation due to HAT.

Early Hepatic Artery Thrombosis After Living Donor Liver Transplant: A 13-Year Single-Center Experience in Jordan

OBJECTIVES

Early hepatic artery thrombosis is a serious complication that may follow living donor liver transplant. Acute graft loss and patient morbidity and mortality are possible consequences. The therapeutic algorithm includes surgical or interventional revascularization, conservative approaches, or retransplantation.

MATERIALS AND METHODS

Among 155 patients who underwent living donor liver transplant at our transplant center from 2004 to 2020, there were 5 who developed hepatic artery thrombosis. From our 13- year experience, we herein present their demographic and clinical characteristics, radiological imaging findings, perioperative courses, and the postoperative follow-up.

RESULTS

All patients displayed advanced liver disease with a Child-Pugh score of C and a mean Model for End-Stage Liver Disease score of 32. Underlying causes for end-stage liver disease included hepatitis B and C infection and cryptogenic liver cirrhosis. The mean patient age was 49 years; 2 patients were female. Living donor liver transplant was performed with donor tissue from immediate kin, according to Jordanian allocation rules. The diagnosis of hepatic artery thrombosis was made by Doppler ultrasonography and confirmed via computed tomography. After surgical revision of the anastomosis, our first patient experienced thrombotic recurrence. All patients received interventional catheterization with local thrombolysis and subsequently developed rethrombosis. Despite prevalent thrombosis, 4 patients achieved long-term survival without further deterioration of liver function. Cumulative 1-year, 5-year, and 10-year survival rates were 80%, 80%, and 60%, respectively. Spontaneous recanalization of the hepatic artery was observed in 1 patient.

CONCLUSIONS

Favorable long-term outcomes are achievable in patients with persistent hepatic artery thrombosis. When retransplant is not feasible and interventional approaches fail, conservative treatment with careful observation of liver function should be implemented. Attentive observation of collateral circulation toward the liver, distal of the thrombosis, may be beneficial to both graft and patient survival.