肝移植中肝动脉变异的重建

目的进一步探讨和总结供肝肝动脉的解剖变异及整形重建经验.方法回顾性分析1998年4月～2005年12月本组430例原位肝移植中供肝肝动脉的解剖类型和变异肝动脉的重建方式.应用显微外科技术对变异肝动脉进行整形然后再吻合.总结肝动脉变异情况及肝动脉的重建方法.结果430例供肝中,肝动脉解剖正常的为338例(78.6%,338/430),肝动脉解剖变异者92例(21.4%,92/430),其中48例(52.2%,48/92)需血管重建.此48例中异常的肝右或肝左动脉与胃十二指肠动脉吻合32例(67%,32/48),异常肝右动脉与脾动脉吻合16例(33%,16/48).变异肝动脉合理整形后再行肝移植,其动脉血管并发症的发生率并未升高.结论供肝肝动脉变异较为常见,因其是唯一的吻合血管,故修肝时对变异肝动脉进行显微重建是非常重要的.     

肝移植术中复杂的肝动脉重建

目的探讨供肝肝动脉解剖变异的整形重建方式及对移植后肝动脉血栓形成(HAT)、胆道并发症及移植疗效的影响。方法回顾性分析1999年5月至2005年9月完成的330例原位肝移植临床资料。应用显微外科技术对变异肝动脉进行整形。供肝肝动脉整形、重建及供受者间动脉的吻合在2.5倍放大镜下以7-0、8-0 Prolene或Vascufil缝线完成。术后每日用多普勒超声检查肝动脉血流1周,其后定期监测。结果67例供肝肝动脉存在解剖变异,占20.5%(67/327),实施血管重建性吻合79例次。存在动脉变异供肝附加血管整形重建组围手术期HAT发生率与无肝动脉变异供肝肝移植组围手术期HAT发生率比较(1.5%vs1.15%);随访期内胆道并发症发生率与无肝动脉变异供肝肝移植组发生率比较(9.0%vs7.7%),均无显著差异(P>0.05)。两组受者比较,1、3年生存率无显著差异(91.3%vs90.7%,86.7%vs88.2%)(P>0.05)。结论应用存在肝动脉变异并血管整形的供肝,实施肝移植不增加HAT及胆道并发症发生率,并可取得与无变异肝动脉供肝相同的远期疗效。     

活体肝移植中肝动脉的处理

目的 探讨活体肝移植中动脉重建技术及肝动脉变异的处理,减少肝动脉并发症.方法 行活体肝移植11例,其中右半肝5例、左半肝2例、左外叶1例、供体(右半肝+左半肝)3例,供受体术前均行肝动脉造影明确肝动脉的解剖及变异,肝动脉均采用显微外科技术重建.结果 肝动脉变异2例,1例右半肝供体副肝右动脉来源于肠系膜上动脉,1例左半肝供体副肝左动脉来源于胃左动脉.4例行双动脉重建,肝动脉吻合时间25～76 min,无肝动脉血栓形成、狭窄等并发症.受体并发症3例.结论 术前明确肝动脉的解剖及变异,选择合适的吻合部位,应用精细的显微外科技术重建肝动脉,能有效降低活体肝移植中动脉并发症的发生.     

79例成人活体肝移植的肝动脉显微重建技术与其并发症

目的:回顾性总结79例成人活体肝移植肝动脉显微外科重建技术及术后肝动脉血栓形成的诊治经验.方法:79例活体肝移植(76例右半肝,3例左半肝)采用显微外科技术,单支端端吻合重建肝动脉.结果:动脉平均吻合时间(55±16)min;吻合口内径<2 mm者12例(15.2%),均一次吻合成功;术后经肝动脉造影证实3例(3.8%)有肝动脉血栓形成,2例溶栓后痊愈.结论:显微外科技术重建肝动脉可以降低成人活体肝移植肝动脉血栓形成的发生率,术后肝动脉造影及溶栓可以有效地诊断和治疗肝动脉血栓形成.     

活体肝移植中变异供肝动脉的修整及重建

目的 总结活体肝移植中变异供肝动脉的修整和重建经验。方法 回顾分析自2006年9月至2010年5月间73例成人活体肝移植的临床资料,术前对供肝进行了充分的影像学评估,其中涉及供肝动脉较复杂变异者13例(17.8％),包括9例异位或副肝右动脉起自肠系膜上动脉(SMA),2例副肝右动脉发自腹腔干及2例肝动脉存在交通支。术中对这13例变异供肝动脉采用显微外科技术进行了修整和重建。结果 9例异位或副肝右动脉起自SMA者中,3例采用副肝右动脉与胆囊动脉行端侧吻合的方式成形,然后与受者的肝固有动脉或肝右动脉行端端吻合,另6例异位肝右动脉与受者肝右动脉或肝固有动脉行端端吻合;2例副肝右动脉起自腹腔干者,将供肝右动脉和副肝右动脉分别与受者肝右动脉和肝左动脉吻合重建;2例供肝动脉存在交通支者及1例双供肝移植者均予以双支动脉重建。另外,供、受者肝动脉内径不匹配者,采用供肝副肝右动脉与受者肝固有动脉行端侧吻合。所有血管均一次吻合成功,围手术期经密切监测动脉血流及给予相应抗凝治疗,术后长期随访中,所有受者均未发生肝动脉血栓形成及动脉狭窄等并发症。结论 根据动脉变异的不同,采用显微外科技术进行不同方式的修整,效果良好,其对预防活体肝移植后动脉血栓形成等并发症以及扩大活体供者范围具有重要意义。     

肝移植中肝动脉变异的显微外科重建

目的进一步探讨和总结供肝肝动脉的解剖变异及整形重建经验。方法回顾性分析 14 1例原位肝移植中供肝肝动脉的解剖类型和变异肝动脉的重建方式。应用显微外科技术对变异肝动脉进行整形然后再吻合。术后每天用多普勒超声检查肝动脉血流 1周 ,其后定期监测 ,观察肝动脉的血流及血栓形成情况。结果 14 1例供肝中 ,肝动脉解剖正常的为 12 1例 (85 8% ,12 1/ 14 1) ,肝动脉解剖变异者 2 0例 (14 2 % ,2 0 / 14 1) ,其中 9例 (6 4 % ,9/ 14 1)需行显微外科重建后再与受体肝动脉吻合。此 9例中异常的肝右动脉与胃十二指肠动脉吻合 7例 (4 9% ,7/ 14 1) ,异常的肝左或肝右动脉与脾动脉吻合 2例 (1 4 % ,2 / 14 1)。变异肝动脉合理整形后再行肝移植 ,其动脉血管并发症的发生率并未升高。结论供肝肝动脉变异较为常见 ,应用显微外科技术对变异的肝动脉植肝前采用适当的整形 ,以获得单一的备吻合血管 ,可以提高供肝动脉重建的质量 ,降低肝动脉并发症的发生率。     

儿童肝移植肝动脉重建技术分析

目的探讨儿童肝移植术中肝动脉的重建技术,比较活体部分和心脏死亡器官捐献(DCD)全肝肝动脉重建区别,以降低肝动脉栓塞的发生率,提高患儿生存率。方法回顾性分析2014年9月至2019年9月间实施的138例儿童肝移植临床资料,其中活体肝动脉显微重建采用10倍显微镜下的显微外科重建技术,DCD全肝移植采用2.5倍放大镜重建,术后采用彩色多普勒超声监测肝动脉血流,分别观察其术后发生肝动脉栓塞并发症的情况结果 138例儿童肝移植中100例为活体部分肝移植,38例为DCD供肝移植。两组均无术后肝动脉栓塞的病例发生。结论熟练应用肝动脉重建技术能降低儿童肝移植术后肝动脉栓塞发生率,取得满意效果。     

成人活体肝移植肝动脉重建50例

目的 总结成人活体肝移植的肝动脉重建经验.方法 我院2002年1月至2006年7月施行了50例成人右半肝活体肝移植,供、受者肝动脉的重建采用显微外科技术成形端端连续缝合方式完成.结果 术后肝动脉血栓形成2例(4%).随访时间2～52个月(中位随访时间9个月),术后和随访期未发现肝动脉狭窄、肝动脉假性动脉瘤等并发症.1年实际生存率为92%(46/50).结论 根据供、受者肝动脉解剖及变异情况,选择适宜的长度和匹配的口径,采用显微外科吻合技术重建肝动脉,是减少肝移植围手术期并发症发生的关键.     

成人间右半肝活体肝移植的肝动脉重建

目的 探讨成人间右半肝活体肝移植的肝动脉重建的相关问题.方法 我院移植中心2007年5月至2008年10月,共完成17例成人活体右半肝肝移植,结合此组病例的临床资料,就肝动脉重建的术前评估、手术技巧和并发症防治进行回顾性分析.结果 17例右半肝供体均为单一肝右动脉供血,动脉平均直径3.1 mm,S4段主要由左肝动脉供血有12例(12/17,70.1%),由肝右动脉供血4例(4/17,23.5%),肝右和肝左动脉均发出动脉分支供血的1例.利用胆囊动脉扩大供肝肝右动脉吻合口径2例.供肝肝右动脉与受体肝右动脉吻合10例(10/17,60%),与受体肝左动脉吻合4例,与受体肝固有动脉吻合2例.吻合方式均为间断吻合,先吻合动脉后壁再吻合前壁,缝合针数12～16针.均为一次吻合成功,平均吻合时间(51±26)min,术后未出现肝动脉相关并发症.结论 对供肝S4段肝动脉的详细评估和保护是活体肝移植肝动脉重建的重点,不翻转供受体动脉的吻合方法可以有效降低手术难度,减少动脉并发症的发生.     

儿童肝移植肝动脉显微重建技术探讨

目的探讨儿童肝移植术中肝动脉的显微重建技术,以降低肝动脉栓塞的发生率,提高患儿生存率。方法回顾性分析2015年4月至2016年7月间实施的22例儿童肝移植病例,肝动脉显微重建采用10倍显微镜下的显微外科重建技术,分别观察儿童活体供肝肝移植和DCD供肝肝移植术后发生肝动脉栓塞并发症的发生情况。结果 22例儿童肝移植中16例为活体部分肝移植(左外叶12例,扩大左外叶1例,不带肝中静脉右半肝3例),6例为DCD供肝移植。两组均无术后肝动脉栓塞的病例发生。结论应用显微外科技术行肝动脉重建能降低儿童肝移植术后肝动脉栓塞发生率,取得满意效果。     

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.     

Jejunal Artery Can Be a Useful Option for Arterial Reconstruction in Living Donor Liver Transplantation When the Suitable Arterial Inflow Is Absent

Successful arterial reconstruction is essential for liver transplantation. In the case of inadequate arterial inflow, an arterial conduit from the aorta using artery graft or re-establishment of arterial flow through other arteries such as the splenic artery, gastroepiploic, or sigmoid artery is considered. Herein we report our experience of 27 cases of hepatic artery reconstruction using alternative methods. The most common cause of hepatic artery reconstruction requiring alternative methods was intimal dissection for which we usually used the gastroepiploic artery. Many patients had a previous operation or transarterial chemoembolization history. Among these cases, hepatic artery reconstruction using the jejunal artery was performed for 2 cases of living donor liver transplantation due to the absence of suitable alternatives. These patients have been followed up with patent hepatic arterial flow until now. Thus, the jejunal artery can be a useful option for arterial reconstruction in living donor liver transplantation when suitable arterial inflow is absent.     

肝移植术中的肝动脉重建

目的探讨肝动脉重建在肝移植中的作用。方法回顾性研究1999年4月至2007年1月进行的140例尸体肝移植和2例活体肝移植的随访结果,分析肝动脉的重建技术及其对移植后胆道并发症的影响。所有供、受者肝动脉均采用显微技术端端吻合,术中根据供、受者动脉条件,选择管径相互匹配的动脉进行吻合,其中,管径≥3mm者采用连续缝合,〈3mm者采用间断缝合。术后常规以多普勒超声监测肝动脉血流。结果142例中未发现肝动脉血栓形成,术后出现高胆红素血症17例,其中,吻合效果满意5例（5／86）,一般12例（12／56）。结论影响肝动脉吻合效果的因素主要有供者和受者肝动脉条件、术者的显微缝合技术及术后抗凝治疗,良好的肝动脉吻合在预防移植术后胆道并发症及提高肝移植生存率方面有着重要的作用。     

Hepatic artery reconstruction in living donor liver transplantation from the microsurgeon's point of view

Microvascular surgery for the reconstruction of the hepatic artery in living donor liver transplantation is discussed from the microsurgeon's point of view. A refined operative procedure to improve the safety of the anastomosis is described. In living donor liver transplantation, the hepatic artery of the graft is short and small, the operative site is deep and mobile, and the anatomic arrangement of the graft left hepatic artery may differ from that of the recipient's dilated hepatic artery. To create a safe anastomosis under these conditions, recipient arteries that were slightly smaller than the graft artery were dissected. Without the size discrepancy, and end-to-end anastomosis could be created. Some refinements to create a good operative field made the anastomosis easy. The apparatus and techniques used in free- flap transfer facilitated a clean anastomosis. We anastomosed 44 arteries in 40 patients undergoing living donor liver transplantation using microsurgical techniques. Neither a decrease in the arterial blood flow nor hepatic artery thrombosis was noted. The refined operative procedure we describe in this report can be used to overcome the problems associated with the hepatic artery anastomosis in living donor liver transplantation. (Liver Transpl Surg 1997 Jul;3(4):388-93)     

Hepatic Artery Reconstruction in Living Donor Liver Transplantation With the Radial Artery Interpositional Graft

IntroductionReconstitution of hepatic artery inflow is essential for a successful liver transplantation. Living donor transplantation presents additional challenges in the form of a short and small donor vessel stump, exacerbating the poor surgical access for microsurgery. Few reports have described the use of the radial artery as an interposition graft in liver transplantation; we present a series of 6 cases and discuss the technical merits of this procedure.MethodsRetrospective review of consecutive patients undergoing living donor liver transplantation from December 2015 to December 2019 was performed. Demographics, operative details, and postoperative outcomes were reviewed.ResultsTwenty-two patients underwent living donor liver transplantation. Radial artery interposition grafting was used in 6 cases, including 1 salvage case for hepatic artery thrombosis. One patient developed hepatic artery stenosis (2 weeks postoperatively) that was conservatively managed. After radial artery grafting, all patients had normal resistive indices on duplex ultrasonography at up to 20 months postoperatively. The mean follow-up was 15.2 months.ConclusionWhen faced with a significantly short vessel stump or caliber mismatch, radial artery interpositional grafting is a safe and useful technique for reducing tension and overcoming vessel size mismatch in hepatic artery reconstruction.     

应用供者髂动脉行腹主动脉搭桥重建移植肝动脉的临床分析

目的探讨应用供者髂动脉行腹主动脉搭桥重建移植肝动脉对肝移植受者预后的影响。 方法回顾性分析中国医科大学附属第一医院2006年1月至2018年4月应用供者髂动脉行腹主动脉搭桥重建肝动脉的肝移植受者临床资料,观察其术后肝功能恢复情况及肝动脉血栓等并发症的发生情况,分析采用搭桥方式进行移植肝动脉重建的原因。 结果共纳入8例受者,其中1例存在脾动脉盗血综合征导致肝总动脉供血不足,3例肝总动脉纤细,4例肝总动脉壁薄弱或分层。重建后肝动脉平均血流为(315±178)mL/min。术后2例受者分别因肝脏流出道和胆管吻合口狭窄导致黄疸,其余受者移植肝功能恢复良好。1例受者术后2个月出现肝动脉血栓形成,继发肝脓肿,半年后因多脏器功能衰竭死亡。其余7例受者随访至2018年11月均存活,肝动脉均通畅,无狭窄或血栓形成。 结论当供、受者常规肝动脉端端吻合无法实施时,应用供者髂动脉行腹主动脉搭桥重建移植肝动脉是一种可行的肝动脉重建方法。     

Two-step hepatic artery reconstruction for a hepatic artery lacking in length for the use of a microclamp in living donor liver transplantation

IntroductionWe describe successful two-step hepatic artery reconstruction in a patient whose graft site hepatic artery was too short for the use of a microclamp in living donor liver transplantation.Presentation of caseA 57-year-old woman was diagnosed as having hepatitis C and liver cirrhosis. Her 26-year-old son was the living liver donor. The living donor underwent right lobectomy. The dissected graft hepatic artery was too short for the use of a microclamp. The recipient right hepatic artery was cut and used as an arterial graft. The graft right hepatic artery was sutured to the right hepatic artery of the arterial graft and the graft posterior branch of the right hepatic artery was sutured to the middle hepatic artery of the arterial graft. After reconstruction of the portal vein and hepatic vein was completed, anastomosis was performed between the graft right hepatic artery and right hepatic artery. The patency of the vessels was checked using color Doppler ultrasonography for 1 week postoperatively. No postoperative complications involving blood flow of the hepatic artery were observed.DiscussionIn our case, the recipient hepatic artery was cut and used as an arterial graft. Although the number of anastomotic sites of the hepatic artery increased, we could perform hepatic artery reconstruction safely and easily.ConclusionTwo-step hepatic artery reconstruction is a useful method in cases where the recipient hepatic artery does not have enough length.     

Utility of Doppler Ultrasonography in Liver Transplantation With Celiac Axis Compression Syndrome: A Case Report

BackgroundCeliac axis compression syndrome (CACS) blocks adequate hepatic arterial flow and is a risk factor for hepatic artery thrombosis after liver transplantation. We report a case of living donor liver transplantation in a 65-year-old Brazilian male with liver cirrhosis of Child-Pugh class C and hepatocellular carcinoma caused by hepatitis C virus infection.ResultsThe patient underwent living donor liver transplantation using the graft of his 34-year-old daughter. Stenosis of the celiac artery was detected on preoperative computed tomography (CT), and CACS was suspected. Maintaining blood supply through the hepatic artery to prevent potential graft loss is essential in liver transplantation. A decrease in common hepatic artery (CHA) flow due to CACS could disturb graft blood supply or lead to hepatic artery thrombosis. In this case, we confirmed CACS through dynamic CT and used intraoperative Doppler ultrasonography (US) to plan the surgical procedure. Three types of hepatic artery reconstruction have been described in liver transplantation for CACS, namely the release of the median arcuate ligament (MAL), aorto-hepatic graft reconstructions, and reconstruction preserving the gastroduodenal artery (GDA) without MAL release. We found that clamping the GDA completely abolished hepatic inflow, but clamping the CHA did not change the hepatic inflow. Therefore, we performed arterial reconstruction without division of the GDA. The patient's postoperative course was good, with excellent hepatic artery flow, as assessed by Doppler US.ConclusionsPreoperative dynamic CT evaluation, adequate preparation of surgical procedures, and intraoperative evaluation by Doppler US is recommended in liver transplantation patients with CACS.