Modified technique for aortic cross‐clamping during liver donor procurement

Undue tension on the donor vessels during organ procurement is associated with intimal dissection, which can form the nidus for the thrombosis of the hepatic artery (HA) and graft loss. According to the US OPTN database, 143 grafts were discarded in the last 15 yr due to vascular damage during procurement. The most common technique to expose the supraceliac aorta is dissection between the left lateral segment of the liver and the esophagus–stomach. In obese donors, due to restricted space and in pediatric donors where the vessels are very delicate and this space is very small, the replaced or accessory left HA(R/A LHA) is prone to damage if approached conventionally. We describe a technique for the exposure of the supraceliac aorta in which the aorta is approached from the left side behind the gastroesophageal junction that does not require division of the gastrohepatic ligament. From May 2007 to May 2013, 104 liver procurements were performed. Eighty‐nine (85.6%) were adults, and 15 (14.4%) were pediatric donors. Twenty‐three (22.1%) had R/A LHA. No donor organ suffered any damage. One adult recipient with R/A LHA suffered HA thrombosis not related to it. In summary, this technical modification offers improved safety during cadaveric procurement and increases the ease.     

腹腔镜肝左外叶供肝获取术中供肝血管影像学解剖特征及其临床意义

目的探讨腹腔镜肝左外叶供肝获取术中供肝血管的影像学解剖特征及临床意义。方法采用回顾性描述性研究方法。收集2016年10月至2018年12月复旦大学附属华山医院收治的39例活体肝移植供者的临床资料;男10例,女29例;年龄为(31±7)岁。同时收集39例活体肝移植受者的临床资料;男26例,女13例;年龄为8个月(4~68个月)。供者术前常规行腹部增强X线计算机体层摄影术检查、三维血管重建判断供肝血管解剖情况。供者均施行腹腔镜肝左外叶供肝获取术。观察指标:(1)术前影像学检查三维血管重建情况。(2)手术情况。(3)随访情况。采用门诊方式对受者进行随访,了解受者肝移植后并发症情况。随访时间截至2019年10月。正态分布的计量资料以±s表示,组间比较采用t检验。偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。结果(1)术前影像学检查三维血管重建情况。39例供者术前影像学检查三维血管重建显示肝动脉和肝静脉解剖学特征包括:①肝动脉情况为11例供者存在肝中动脉,其中5例起始于肝右动脉,3例起始于肝右动脉和肝左动脉汇合处,3例起始于肝左动脉。2例供者肝左动脉解剖变异,均存在副肝左动脉,起始于胃左动脉。26例供者无肝中动脉,肝左动脉无解剖变异。②肝静脉情况:9例供者肝左静脉和肝中静脉分别汇入下腔静脉。7例供者存在肝左静脉左上缘支。23例供者肝左静脉与肝中静脉共干汇入下腔静脉。(2)手术情况。①39例供者均成功施行腹腔镜肝左外叶供肝获取术,手术时间为(160±32)min,术中出血量为(142±74)mL。②11例有肝中动脉供者中,8例为肝左动脉优势型,留取肝左动脉用于肝移植术中肝动脉吻合重建,3例肝中动脉起始于肝左动脉,留取肝左动脉和肝中动脉共干用于肝移植术中肝动脉吻合重建。2例肝左动脉解剖变异供者中,1例为副肝左动脉优势型,1例为肝左动脉优势型,分别留取副肝左动脉和肝左动脉用于肝移植术中肝动脉吻合重建。其余26例供者留取肝左动脉用于肝移植术中肝动脉吻合重建。③39例供者中,11例术中行肝左静脉优先入路,28例术中行非肝左静脉优先入路。肝左静脉优先入路供者手术时间和术中出血量分别为(147±22)min和(110±44)mL,非肝左静脉优先入路供者上述指标分别为(169±33)min和(154±81)mL,两者上述指标比较,差异均有统计学意义(t=4.19,2.81,P<0.05)。(3)随访情况。39例受者均获得术后10个月的随访,随访期间未出现肝动脉吻合口出血、狭窄,以及由肝动脉供血不良引起的缺血性胆管损伤和胆道狭窄等并发症,也未出现肝静脉流出道狭窄相关并发症。结论腹腔镜肝左外叶供肝获取术前影像学检查三维血管重建可发现肝中动脉和肝左动脉解剖变异,指导手术入路的选择。腹腔镜肝左外叶供肝获取术对于符合条件的供者推荐采用肝左静脉优先入路,可缩短手术时间、减少术中出血量。     

成人间活体肝移植肝动脉重建方法和并发症的处理

目的 探讨成人间活体肝移植的肝动脉重建和并发症处理的经验.方法 自2002年1月至2006年7月,共施行50例成人间右半肝活体肝移植.在供受者间肝动脉的重建中,供者右肝动脉与受者右肝动脉吻合24例,与受者肝固有动脉吻合12例,与受者左肝动脉吻合3例,与受者肝总动脉吻合2例,与受者肠系膜上动脉发出的副右肝动脉吻合2例,与受者肝总动脉自体大隐静脉间置搭桥3例.受者腹主动脉与供者右肝动脉自体大隐静脉搭桥2例,用保存的尸体髂血管行受者腹主动脉与供者右肝动脉搭桥2例.供者肝动脉直径1.5～2.5 mm,采用显微外科技术在3.5倍手术放大镜和5～10倍手术显微镜下完成肝动脉重建.结果 50例成人间右半肝活体肝移植中,有2例(4%)分别于术后1d、7d发生肝动脉血栓形成,立即采用自体大隐静脉从肾下腹主动脉至供者右肝动脉搭桥术,恢复供肝血流,痊愈出院.1例术后1.5个月后发生肝动脉血栓形成,随访期无临床症状未行处理.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.围手术期未有与肝动脉并发症有关的死亡病例.全部病例获得随访,随访时间2～52个月(中位随访时间9个月),1年实际生存率为92%.结论 选择恰当的肝动脉重建方式和应用显微外科技术可显著降低肝动脉并发症,及时处理肝动脉并发症是保证供肝存活的关键.     

An extremely uncommon variation of left hepatic artery around the esophagus: a case report

Abstract:  An extremely rare case of a replaced left hepatic artery (LHA) around the esophagus in a deceased multi-organ donor is reported. The liver could not be harvested unless either of the LHA or the esophagus was transected. This is the second report of a LHA off the left gastric artery with such a peculiar course around the esophagus. Whether to cut the artery or the hollow viscus in such a situation is controversial; nevertheless, a surgeon must precisely identify all the extrahepatic arteries during liver harvest, to prevent injuries that might result in compromised complete arterialization of the graft.     

Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation

Shirouzu Y, Ohya Y, Hayashida S, Asonuma K, Inomata Y. Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation.
Clin Transplant 2011: 25: 625–632. © 2010 John Wiley & Sons A/S. Abstract: Background: Hepatic outflow block is one of the major complications leading to severe graft dysfunction after left lobe living donor liver transplantation (LDLT). Methods: Medical records of 46 recipients of a left lobe LDLT were reviewed. The method of outflow reconstruction and post‐transplant morphological changes of hepatic veins were investigated. The subjects were followed up until September 2008, with a median follow‐up period of 2.0 yr (range: 0.5–5.9 yr). Results: There were no multiple outflow tracts to be reconstructed, and the median caliber of the single orifices with or without venoplasty was 32.0 mm. The difference between the angle of hepatic veins to the sagittal plane measured on computed tomography was calculated for pre‐operative donors and post‐operative recipients a month after LDLT. Both left and middle hepatic veins showed a significantly greater change in angle than the right hepatic vein. Both left and middle hepatic veins more frequently showed a nearly flat wave form on Doppler study one month after LDLT. In the 46 recipients of left lobe grafts, three developed outflow block (6.5%). Conclusions: The middle and left hepatic veins tend to distort and stretch during graft regeneration. These characteristics seem to be associated with outflow disturbances.     

Pediatric Liver Transplantation Using Reduced and Hyper‐Reduced Left Lateral Segment Grafts: A 10‐Year Single‐Center Experience

Few studies have examined the long‐term outcomes and prognostic factors associated with pediatric living living‐donor liver transplantation (LDLT) using reduced and hyper‐reduced left lateral segment grafts. We conducted a retrospective, single‐center assessment of the outcomes of this procedure, as well as clinical factors that influenced graft and patient survival. Between September 2000 and December 2009, 49 patients (median age: 7 months, weight: 5.45 kg) underwent LDLT using reduced (partial left lateral segment; n = 5, monosegment; n = 26), or hyper‐reduced (reduced monosegment grafts; n = 18) left lateral segment grafts. In all cases, the estimated graft‐to‐recipient body weight ratio of the left lateral segment was more than 4%, as assessed by preoperative computed tomography volumetry, and therefore further reduction was required. A hepatic artery thrombosis occurred in two patients (4.1%). Portal venous complications occurred in eight patients (16.3%). The overall patient survival rate at 1, 3 and 10 years after LDLT were 83.7%, 81.4% and 78.9%, respectively. Multivariate analysis revealed that recipient age of less than 2 months and warm ischemic time of more than 40 min affected patient survival. Pediatric LDLT using reduced and hyper‐reduced left lateral segment grafts appears to be a feasible option with acceptable graft survival and vascular complication rates.     

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目的：分析10例活体肝移植术中的血管变异，总结其外科处理经验，进一步提高手术成功率，减少并发症。方法：2001年1月至12月，行活体肝移植10例，其中左半肝8例，左外叶1例，右半肝1例，供肝者均为其母，经术中B超及胆管造影以确定肝切线。供体单支肝动脉分支与受体肝动脉吻合，两支肝动脉分别与受体肝左、右动脉吻合。门静脉分支与受体门静脉主干吻合。供体肝静脉与受体下腔静脉行端侧吻合。胆管重建均采用肝管分支与受体胆总管端端吻合，置T管引流。结果：10例活体肝移植，1例因肝动脉血栓形成，术后5天需次肝移植；1例发生排斥；其余8例均康复出院，5例已上学。结论：活体肝移植术中血管重建技术是其重要环节，术前和术中了解供受体解剖变异并正确处理，可减少术后血管和胆道的并发症。     

Anatomical and technical aspects of hepatic artery reconstruction in living donor liver transplantation

BACKGROUND: We describe our experience with arterial reconstruction in living donor liver transplantation (LDLT) focusing on anatomic and technical aspects. METHODS: From June 1994 to February 2003, 132 grafts were implanted in 130 LDLT recipients including 1 re-transplant and 1 dual graft transplantation. Donor and recipient records were retrospectively reviewed. Anatomical variations in graft arteries were classified as: Type I, single pedicle with (Ia) or without (Ib) aberrant artery (left hepatic artery (HA) from left gastric artery or right HA from superior mesenteric artery); Type II, double pedicles with (IIa) or without (IIb) aberrant artery; Type III, equal to or greater than 3 pedicles. Statistical analyses were carried out using Mann-Whitney U-test. RESULTS: There were 72 male and 58 female recipients. The median age at transplantation was 3 years (range, 0.5 to 61). In left grafts, there were 34 Type Ia, 6 Type Ib, 33 Type IIa, 13 Type IIb, and 3 Type III; whereas in right grafts, there were 35 Type Ia, 6 Type Ib, 1 Type IIa, and 1 Type IIb. Two-in-one (2-in-1) segmental resection technique in graft HA harvest was carried out whenever there were tiny arteries supplying the donor graft. All HA reconstructions were done under microvascular techniques. There was no donor mortality and 1 recipient in-hospital mortality. There was no graft or patient loss due to HA occlusion. Donor complications included 3 biloma, 1 bile leak, 1 biliary stricture, and 1 late intestinal obstruction secondary to postoperative adhesions that were all successfully managed by non-operative interventions, except the biliary stricture that needed a revision to Roux-en-Y hepatico-jejunostomy. The 1-year and 5-year recipient survivals were 98% and 94%, respectively. CONCLUSIONS: Successful HA reconstruction can be safely carried out in LDLT recipients and live donors with multiple graft arteries using the 2-in-1 segmental resection of donor HA under microvascular techniques.     

活体肝移植22例临床分析

目的 总结开展活体肝移植的临床经验,探讨进一步提高活体肝移植疗效的措施.方法 回顾性分析我院22例活体肝移植供受体的临床资料,总结术前评估过程、手术方法和术后并发症的情况.结果 本组获取的供肝移植物包括左外叶2例、左半肝6例、扩大左半肝1例、右半肝5例和扩大右半肝8例.所有供体术后恢复顺利,未出现严重并发症.22例受体中成年患者13例,儿童患者9例.围手术期发生并发症8例,包括严重腹腔感染1例,肝功能恢复不良合并伤口感染1例,腹腔内出血继发肝动脉血栓形成1例,此3例患者最终均因多器官功能衰竭死亡.1例肝功能衰竭的患儿术后因心肺功能衰竭死亡.另外发生胆漏2例,顽固性腹水1例,右下肢深静脉血栓形成1例,均通过保守疗法治愈.18例受体病愈出院.手术后期发生胆道吻合口狭窄3例,行PTCD并留置支撑管治疗,Oddi括约肌失迟缓引起的梗阻性黄疸1例,行内镜下十二指肠乳头括约肌切开术治疗.此4例患者病情稳定,肝功能均已恢复正常.结论 选择合适的供体、掌握关键的手术技术,才能使供受体都获得良好的预后.     

肝中动脉的影像学解剖特点与活体供肝移植的相关性

目的 探讨在活体供肝移植中逐步受到重视的肝中动脉的解剖特点,以指导临床活体供肝移植的成功开展.方法 分析70例研究对象的64排螺旋CT资料,重点观察肝中动脉的解剖特点及变异情况.结果 肝中动脉在肝门部从其起源动脉发出后,走行于肝外,然后逐渐转至脐裂内门脉矢状部内侧,发出分支,主要供应肝4段.70例研究对象中,有49例(70%)存在肝中动脉.其中肝中动脉发自肝右动脉29例,占所有肝中动脉(n=49)的59.2%;发自肝左动脉17例,占34.7%;发自其它动脉3例(肝右前动脉、胃十二指肠动脉、肝固有动脉各1例),占6.1%.结论 肝中动脉的存在率高达70%,术前了解其解剖变异情况对于活体供肝移植手术方案的制定有重要指导作用.     

Living Donor Liver Transplantation Using Dual Grafts from Two Donors: A Feasible Option to Overcome Small‐for‐Size Graft Problems?

Living donor liver transplantation (LDLT) between adults inevitably implies two potential risks associated with a small-for-size graft for the recipient and small remnant liver for the donor. To overcome these problems, LDLT using dual grafts from two independent donors can be a solution, in which sufficient graft volume can be obtained while preserving donor safety. We present a case of LDLT that was managed successfully by using right and left lobe dual grafts from two donors. The recipient was a large-size male with hepatitis C cirrhosis complicated by multiple hepatocellular carcinomas (HCCs). The first donor donated a right lobe graft and the second donor donated a left lobe plus caudate lobe graft with the middle hepatic vein. Graft function was excellent throughout the course without evidence of small-for-size syndrome. In conclusion, LDLT using dual grafts can be justified in a selected case to avoid small-for-size graft problems without increasing independent donor risks.     

Relevance of HLA compatibility in living donor liver transplantation: the double‐edged sword associated with the patient outcome

HLA compatibility in living donor liver transplantation (LDLT) seems relevant to the acceptability of graft livers because LDLT recipients often share most or some part of HLAs with the respective donors. This study retrospectively investigated whether HLA compatibility affected the outcome of LDLT. Three hundred ninety LDLTs were performed in this hospital, and 346 pairs of HLAs (HLA‐A, B, DR) were retrieved from the medical record between October 1996 and March 2011. The dates of the deaths were censored when a recipient apparently died of or was retransplanted by other causes than graft failure because of host‐versus‐graft (HVG) response to purely analyze the outcomes of LDLT in view of HVG response. The relationship between HLA compatibility and graft‐versus‐host disease (GVHD) was also analyzed. No recipients with recipient‐against‐donor HLA mismatch (R→D MM) 0 experienced graft failure by HVG response. On the other hand, three of five recipients with “R→D MM 0” together with “donor‐against‐recipient MM 3” died of fatal GVHD. HLA compatibility in LDLT not only affected the long‐term acceptance of graft livers but also the risk of fatal GVHD.     

Regeneration and outcome of dual grafts in living donor liver transplantation

In living donor liver transplantation (LDLT), the essential aims are to provide an adequate graft volume to the recipient and to keep a sufficient remnant liver volume in the donor. In some instances, these aims cannot be met by a single donor and LDLT using dual grafts from two donors is a good solution. From 2002 to 2009, five recipients in our hospital received dual graft LDLT. Two recipients received one right lobe and one left lobe grafts; the other three received two left lobe grafts. The mean final liver regeneration rate was 91.2%. Left lobe graft atrophy in the long term was observed in recipients who received a right and a left lobe grafts. The initial bigger volume graft in all recipients was noted to have better regeneration than the smaller volume grafts. Portal flow and bilateral grafts volume size discrepancy were considered as two major factors influencing graft regeneration in this study. We also noted that the initial graft volume correlated with portal flow in the separate grafts and finally contribute to individual graft regeneration. Because of compensatory hypertrophy of the other graft, recipients who experienced atrophy of one graft did not show signs of liver dysfunction.     

Outcome of partial reconstruction of multiple hepatic arteries in pediatric living donor liver transplantation using left liver grafts

Partial liver grafts used in living donor liver transplantation (LDLT) may have multiple hepatic artery (HA) stumps. This study was designed to validate the safety of partial reconstruction of multiple HAs in pediatric LDLT cases. From January 2000 to June 2014, 136 pediatric LDLT recipients were categorized into three groups: single HA group (Group 1, n = 74), multiple HAs with total reconstruction group (Group 2, n = 23), and multiple HAs with partial reconstruction group (Group 3, n = 39). Partial reconstruction was performed only when there was pulsatile back‐bleeding after larger HA reconstruction and sufficient intrahepatic arterial flow was confirmed by Doppler ultrasound (DUS). There was no significant difference in biliary complication rate, artery complication rate, patient survival, and graft survival among these groups. Risk factor analysis revealed that the presence of multiple HAs and partial reconstruction of multiple HAs were not risk factors of biliary anastomosis stricture. In conclusion, partial reconstruction of HAs during pediatric LDLT using a left liver graft with multiple HA stumps does not increase the risk of biliary anastomosis stricture or affect graft survival when intrahepatic arterial communication is confirmed by pulsatile back‐bleeding and DUS.     

Impact of Human T Cell Leukemia Virus Type 1 in Living Donor Liver Transplantation

Human T cell leukemia virus type 1 (HTLV‐1) is an endemic retrovirus in southwestern Japan, which causes adult T cell leukemia (ATL) or HTLV‐1 associated myelopathy in a minority of carriers. Here, we investigated the impact of HTLV‐1 status in living donor liver transplantation (LDLT). Twenty‐six of 329 (7.9%) HTLV‐1 carriers underwent primary LDLT. One recipient negative for HTLV‐1 before LDLT received a graft from an HTLV‐1 positive donor. Eight donors were HTLV‐1 positive. Twenty‐seven recipients (13 male and 14 female; mean age 52.5 years) were reviewed retrospectively. ATL developed in four recipients who ultimately died. The intervals between LDLT and ATL development ranged from 181 to 1315 days. Of the four ATL recipients, two received grafts from HTLV‐1 positive donors and two from negative donors. The 1‐, 3‐ and 5‐year HTLV‐1 carrier survival rates were 91.3%, 78.3% and 66.3%, respectively. Fulminant hepatic failure as a pretransplant diagnosis and a pretransplant MELD score ≥ 15 was identified as risk factors for ATL development in this study (p = 0.001 and p = 0.041, respectively). In conclusion, LDLT can be performed for HTLV‐1 positive recipients. However, when fulminant hepatic failure is diagnosed, LDLT should not be performed until further studies have revealed the mechanisms of ATL development.     

Impact of live donor age (>or=50) on liver transplantation

BACKGROUND: The question of whether donor age negatively impacts recipient outcome in adult-to-adult living donor liver transplantation (LDLT) is rarely discussed. The aim of this study was to evaluate the impact of older donor age (50 years or older) on recipient outcomes in adult-to-adult LDLT. METHODS: LDLT data were retrospectively evaluated from our 299 LDLT cases in 297 recipients, which were divided into 2 groups: a younger group (group Y, donor age<50, n=237) and an older group (Group O, donor age>or=50, n=62). Clinical parameters of both recipients and donors were comparable between groups. RESULTS: There was no difference between the groups in patient survival or postoperative complications of either donors or recipients. In recipients, graft regeneration was significantly impaired in Group O. Graft function, including protein synthesis and cholestasis, was comparable between the 2 groups. CONCLUSION: Although the regeneration capacity of aged grafts was impaired, the function of grafts from older donors was comparable to that of those from younger donors. There was no difference in the clinical outcomes between the groups.     

Living Donor Liver Transplantation for Neonates Using Segment 2 Monosubsegment Graft

The prognosis of liver transplantation for neonates with fulminant hepatic failure (FHF) continues to be extremely poor, especially in patients whose body weight is less than 3 kg. To address this problem, we have developed a safe living donor liver transplantation (LDLT) modality for neonates. We performed LDLTs with segment 2 monosubsegment (S2) grafts for three neonatal FHF. The recipient age and body weight at LDLT were 13–27 days, 2.59–2.84 kg, respectively. S2 or reduced S2 grafts (93–98 g) obtained from their fathers were implanted using temporary portacaval shunt. The recipient portal vein was reconstructed at a more distal site, such as the umbilical portion, to have the graft liver move freely during hepatic artery (HA) reconstruction. The recipient operation time and bleeding were 11 h 58 min–15 h 27 min and 200–395 mL, respectively. The graft‐to‐recipient weight ratio was 3.3–3.8% and primary abdominal wall closure was possible in all cases. Although hepatic artery thrombosis occurred in one case, all cases survived with normal growth. Emergency LDLT with S2 grafts weighing less than 100 g can save neonates with FHF whose body weight is less than 3 kg. This LDLT modality using S2 grafts could become a new option for neonates and very small infants requiring LT.     

活体肝移植治疗终末期肝病

目的 探讨活体肝移植(1iving donor liver transplantation,LDLT)供、受者术前评估和手术方式的选择.方法 回顾性分析1995年1月至2007年10月我中心95例LDLT患者的临床资料.良性终末期肝病92例,其中Wilson病45例;肝脏恶性肿瘤3例.结果 供肝切取不带肝中静脉右半肝31例,带肝中静脉右半肝3例,带肝中静脉左半肝51例,不带肝中静脉左半肝或左外叶10例.所有供者术后顺利恢复,均未出现严重并发症.受者随访1～86个月,良性终末期肝病受者1、3、5年累积生存率分别为89%(82例)、78%(71例)和73%(67例),其中Wilson病受者1、3、5年累积生存率分别为92%(42例)、89%(40例)和76%(34例).3例肝脏恶性肿瘤患者死亡2例,1例长期生存.供、受者铜代谢均恢复正常.结论 建立供者安全保障体系是LDLT开展的先决条件,选择合理的手术方式是提高受者生存率的关键.亲体肝移植是治疗Wilson病的有效手段.     

Branch patch reconstruction in living donor liver transplantation: arterialization of grafts with replaced type arteries

We developed a hepatic arterialization technique in living donor liver transplantation. The technique was indicated in patients with a left graft from donors with a right hepatic artery originated from superior mesenteric artery or a right graft from donors with a left hepatic artery from left gastric artery. The donor common hepatic and gastroduodenal arteries were split. On the recipient side, left and right hepatic arteries or branches of the right hepatic artery were split, received patch plasty, and anastomosed with the graft arteries under loupe observation. Livers from 25 donors were procured (16 right livers and 9 left livers) using this technique. There were no vascular complications in the donors. Three recipients died due to infectious disease with arterial patency. The remaining 22 recipients survived without hepatic arterial thrombosis. In limited situations, this technique can be adapted for living donor liver transplantation without increasing donor complications.     

The impact of meticulous management for hepatic artery thrombosis on long‐term outcome after pediatric living donor liver transplantation*

Abstract: To analyze the risk factors in the development of hepatic artery thrombosis (HAT) and assess the impact of our perioperative management for HAT on the long‐term outcome after pediatric living donor liver transplantation (LDLT), we reviewed 382 patients under 12 yr of age who underwent 403 LDLT from January 1996 to December 2005. One‐ and 10‐yr patient survival rates were 78% and 78% in the patients with HAT (27 patients; 6.7%), and 84% and 76% in the patients without HAT, respectively (p = n.s.). Univariate analysis showed gender (female), body weight (lower), and graft‐to‐recipient weight ratio (higher) were significant risk factors in the patients with HAT (p < 0.05). Patients with Doppler ultrasound signal loss of the hepatic artery (HA) accompanied by an increase of liver enzymes underwent thrombectomy and reanastomosis (S‐group, n = 13), and patients with a weak HA signal underwent anticoagulant therapy (M‐group, n = 13). One patient underwent re‐LDLT. One‐ and five‐yr patient survival rates were 83% and 83% in the S‐group, and 77% and 77% in the M‐group (p = n.s.). The incidence of biliary complications in the S‐group (58%) was significantly higher than that of the M‐group (15%). For a successful long‐term outcome, the early detection of HAT and prompt medical and surgical intervention are crucial to minimize the insult of HAT.