肝移植术后肝动脉血栓形成的溶栓治疗3例报道

目的 探讨肝移植术后肝动脉血栓形成的溶栓治疗价值。方法对50例同种异体肝移植病例，术后以彩色多普勒超声(CDI)定期监测肝动脉血流，怀疑肝动脉血栓形成(HAT)行动脉造影，确诊3例，即刻行介入溶栓治疗，经导管分别在20分钟内予尿激酶12．5万单位、30分钟内予尿激酶25万单位和肝素50mg，及4小时内注入尿激酶60万单位。结果3例溶栓治疗后，肝动脉均再通。1例因二次血栓形成再次溶栓成功。但均发生不同程度的腹腔内出血，1例保守治疗痊愈，1例经开腹手术止血后痊愈，另1例死于多器官功能衰竭。结论对怀疑HAT病例，应尽早行动脉造影。改进后的溶栓疗法有可能成为治疗HAT的可选择方法。     

成人肝移植术后早期肝动脉血栓形成的诊断与治疗

目的 探讨成人肝移植术后肝动脉血栓形成(hepatic artery thrombosis,HAT)的诊断与治疗,及其对患者预后的影响.方法 2007年6月至2010年10月我中心共实施成人尸体肝脏移植387例.术后采用床边彩色多普勒超声监测移植肝血流.疑有肝动脉血栓形成时,采用超声造影或肝动脉造影明确诊断,根据病情采用介入溶栓治疗、手术再血管化治疗及再次肝移植等治疗.结果 387例中术后共有10例患者发生HAT,发生率2.6％.发生HAT的中位时间为肝移植术后7(范围2～18)d.2例采用介入溶栓治疗,其中1例伴肝动脉狭窄放置支架,均痊愈;3例再次手术行肝动脉重建联合肝动脉局部溶栓治疗,其中1例术后再次出现HAT,死亡;2例行再次肝移植,痊愈;3例出现肝内脓肿,严重感染,肝功能恶化死亡.死亡率为40％(4/10).结论 肝移植术后常规彩色多普勒超声监测肝动脉血流是早期发现HAT的关键,超声造影及肝动脉造影可明确诊断;及时采用介入溶栓、手术再血管化及再次肝移植等治疗虽然可减少患者死亡,但预防HAT发生更为重要.     

Intraarterial thrombolytic treatment for hepatic artery thrombosis immediately after living donor liver transplantation

Hepatic artery thrombosis (HAT) following living donor liver transplantation (LDLT) remains one of the major causes of graft failure and mortality in liver transplant recipients. This complication requires early diagnosis and revascularization to avoid graft loss. We have reported herein two cases of successful urokinase intraarterial thrombolytic treatment for HAT in the immediate postoperative period after LDLT. Significant elevation of liver transaminases was noted 6 and 4 hours after LDLT and HAT confirmed by three-dimensional computed tomogram and angiogram. Both patients were treated successfully with intraarterial thrombolysis using an urokinase infusion (a total dose of 200,000 to 250,000 IU over 20 to 25 minutes) immediately after HAT was confirmed. One patient underwent laparotomy and bleeder ligation owing to hepatic arterial anastomotic site bleeding after thrombolysis. These two patients remain in good condition without any ischemic graft sequelae at 7 and 8 months follow-up. In conclusion, intraarterial thrombolysis using an urokinase infusion could be considered as one of the treatment modalities of acute HAT following LDLT even in the immediate postoperative period.     

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目的 探讨原位肝移植术后肝动脉血栓形成的诊治经验。方法 总结３４例原位肝移植术后的临床资料,结合文献,分析肝移植术后肝动脉血栓形成的诊断和不同治疗方法的结果。结果 本组肝动脉血栓形成发生率为８．８％（３／３４）,３例均经彩超检查诊断,例１术后第５７天死于上消化道出血,经尸检证实,例２和例３经肝动脉造影证实后给予动脉内溶栓,球囊扩成形及放置血管内支架等介入治疗,病人分别在术后第１８,６５天死于感染和     

原位肝移植术后动脉并发症的诊断与治疗

目的 探讨肝移植术后动脉并发症的早期诊断与治疗方法。方法 回顾性分析本院180例次原位肝移植术后动脉并发症的监测、诊断与处理。结果 动脉并发症发生率为5．0％(9／180)，其中肝动脉血栓形成(HAT)5例，肝动脉狭窄(HAS)3例，腹腔动脉狭窄1例。8例动脉造影证实，1例尸检证实。彩色多普勒超声(CDI)的诊断敏感度和特异度分别为88．9％和95．9％；术中超声(IOUS)的敏感度、特异度，阳性预测值和阴性预测值分别为100％，96．0％，66．7％和100％。3例患者接受介入治疗、3例接受再血管化手术、2例分别接受再次肝移植和非手术治疗。3例治愈，6例死亡。结论CD1是监测动脉并发症的首选方法；IOUS有助于术中的早期诊断。HAS和HAT治疗应首选再血管化或再次肝移植；介入溶栓的疗效不佳；个别患者可尝试非手术治疗。     

An Orthotopic Liver Transplantation Patient Survived Without Hepatic Artery Flow Due to Thrombosis: A Case Report

BackgroundHepatic artery thrombosis (HAT), a serious complication after orthotopic liver transplantation, almost always leads to morbidity and mortality without urgent revascularization or retransplantation, especially if HAT occurs within a few days after transplantation.Case PresentationHerein we describe a case report of an orthotopic liver transplantation patient surviving without hepatic artery flow due to HAT on postoperative day 1. Reanastomosis, thrombectomy, and intra-arterial thrombolysis were performed, but only retrograde arterial flow by Doppler ultrasound, not by angiography, could be demonstrated in the hepatic artery. This case report is in compliance with the Declaration of Helsinki and the Declaration of Istanbul.ConclusionBased on the evidence from this patient, we believe that patients with failed revascularization can experience a long-term survival with conservative treatment. Retransplantation should be evaluated based on laboratory findings because graft function in individual patients can recover.     

Maintenance of the celiac trunk with the left-sided liver allograft for in situ split-liver transplantation

BACKGROUND: It has been shown that in situ split-liver transplantation (SLT) expands the cadaveric donor pool, decreases recipient waiting time, and decreases pretransplant morbidity. However, the technique as previously described requires a microvascular left hepatic artery anastomosis. In an attempt to decrease the incidence of hepatic artery thrombosis and to increase collaboration among transplant teams, in the current report, we describe a modification of the in situ SLT technique that maintains the celiac trunk with the left-sided liver allograft. METHODS: Twelve in situ split-liver procurements resulted in 24 segmental liver allografts; 11 right trisegments, 11 left lateral segments, 1 right lobe, and 1 left lobe. The common bile duct and main portal vein were maintained with the right-sided liver allograft in all cases. The right hepatic artery was divided, and the celiac trunk was maintained with the left-sided liver allograft in nine cases. In one case the left hepatic artery was divided and the celiac trunk was maintained with the right-sided allograft. Two of the 12 donors had a completely replaced left hepatic artery originating from the left gastric artery, which was divided at its origin from the celiac trunk. When the celiac trunk was maintained with the left-sided allografts, arterial reconstruction of the right-sided allograft was performed with an external iliac arterial interposition graft. Nineteen of the 24 split-liver allografts were transplanted at our center. The remaining five liver allografts were shared with regional liver transplant centers. RESULTS: In this series, 1-year actuarial patient and allograft survival rates are 100% and 96%, respectively. Hepatic artery thrombosis (HAT) did not occur in any patient receiving a left-sided split allograft in which the celiac trunk or left gastric artery was maintained; in addition, HAT did not occur in any of the right-sided allografts. HAT did occur immediately after transplantation in the one patient who was transplanted with a left lateral segment without the celiac trunk. This allograft was salvaged by early thrombectomy and interposition grafting. One patient required retransplantation, owing to portal vein thrombosis. Hepatic venous outflow obstruction did not occur in any of the patients. Two patients required reexploration in the posttransplant period because of arterial anastomotic site bleeding, and one of the left lateral segment allograft recipients had a cut-surface bile leak, which was managed nonoperatively. All of the patients are alive and well, including the five patients who received their transplants at other centers, with a median follow-up of 10 months (range, 1-27 months). CONCLUSIONS: In summary, our data demonstrate that maintaining the celiac trunk with the left-sided allograft in SLT provides excellent early survival results with low complication rates. This technical modification obviates the need for a left hepatic artery microvascular anastomosis and should lower the incidence of hepatic artery thrombosis in the small-caliber left hepatic artery. We have also shown that this technique allows sharing among liver transplant centers without compromise in patient or allograft survival rates. It is hoped that this modification in SLT will increase the number of livers split, and will promote sharing among transplant centers to truly optimize the number of liver allografts available from the cadaveric pool.     

肝移植术后肝动脉狭窄的介入治疗七例

目的评价介入技术治疗原位肝移植后肝动脉狭窄(HAS)的效果。方法对原位肝移植术后发生HAS的7例患者进行介入治疗,4例于移植术后7~20d发生肝脏缺血并发症,3例于移植术后3~6d发生HAS。介入治疗方法有肝动脉内留置导管持续给予低剂量尿激酶进行溶栓和肝动脉内支架置入术。结果3例为肝动脉吻合口狭窄,狭窄程度>70%;4例为肝固有动脉完全阻塞,经肝动脉内留置导管溶栓3~7d后开通,但均存在肝动脉吻合口狭窄,狭窄程度>90%。7例肝动脉内置入支架均成功,术后2周肝功能明显改善,未发生与介入治疗相关的并发症。术后随访4~18个月,一般情况良好,超声波复查,显示肝动脉血流通畅。结论血管内支架置入术是治疗原位肝移植后HAS的一种安全、有效的方法。     

Stent placement in pediatric patients with hepatic artery stenosis or thrombosis after liver transplantation

Hepatic artery stenosis (HAS) and thrombosis (HAT) after orthotopic liver transplantation remain significant causes of graft loss. Postoperative HAT follows approximately 5% to 19% of orthotopic liver transplantation. It is seen more frequently in pediatric patients. In the past, repeat transplantation was considered the first choice for therapy. Recently, interventional radiological techniques, such as thrombolysis, percutaneous transluminal angioplasty, or stent placement in the hepatic artery, have been suggested, but little data exist related to stent placement in the thrombosed hepatic artery during the early postoperative period in pediatric patients. Between March 2000 and March 2005, percutaneous endoluminal stent placement was performed in seven pediatric liver transplant patients. HAT or HAS initially diagnosed in all cases by Doppler ultrasound then confirmed angiographically. We intervened in four cases of hepatic artery stenosis and three cases of hepatic artery occlusion. Stents were placed in all patients. Three ruptures were seen during percutaneous transluminal angioplasty of the hepatic artery using a covered coronary stents on the first, fifth day, or 17th postoperative day. In one patient, dissection of the origin of the common hepatic artery developed owing to a guiding sheath, and a second stent was placed to cover the dissected segment. The other two hepatic artery stents remained patent. In one stent became occluded at 3 months after the intervention with no clinical problems. Follow-up ranged from 9 to 40 months. In conclusion, early and late postoperative stent placement in the graft hepatic artery was technically feasible.     

活体肝移植术后早期肝动脉血栓形成的诊断与治疗

目的探讨活体肝移植术后早期肝动脉血栓形成的诊断与治疗。方法2006年9月至2009年8月天津市第一中心医院单一外科组共实施110例活体肝移植,移植术后7d内每日用彩色多普勒超声(彩超)监测肝动脉血流,怀疑肝动脉血栓形成行肝动脉造影或腹部CT检查,确诊者予介入治疗或手术治疗。结果该组3例术后5～6d发生肝动脉血栓,肝动脉血栓发生率2.7%(3/110)。其中1例再次手术行肝动脉取栓,术后血流正常;2例行介入治疗,放置支架,术后1例再次血栓形成,1例血流流速偏低,2例均发生胆道并发症,但肝功能正常。3例均存活。结论术后早期用彩超监测对肝动脉血栓的诊断至关重要,及时手术取栓或介入放置支架效果良好。     

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目的 探讨肝移植术中肝动脉重建的手术技巧和肝动脉早期栓塞后的治疗选择.方法 回顾性分析第二军医大学附属东方肝胆外科医院2003年4月至2006年3月159例次原位肝移植术和3例活体肝移植术中肝动脉重建的经验,比较不同口径的肝动脉吻合时间;早期动脉栓塞后施行介入溶栓治疗的效果.结果 直径≥3mm动脉(120例)的平均吻合时间明显短于直径＜3mm的动脉(42例,P＜0.05);3例活体肝移植动脉重建时间分别是89min、120min和34min.2例(1.2%)术后早期并发肝动脉栓塞(HAT),1例介入溶栓治疗后肝动脉恢复血流,1例溶栓失败,急诊施行肝动脉-腹主动脉搭桥术后肝动脉恢复血流.结论 小口径肝动脉重建难度大,活体肝移植应采用显微外科重建,合理的吻合技术可减少术后HAT的发生;早期HAT需合理选择治疗措施.     

彩色多普勒超声在肝移植术后肝动脉并发症的应用价值

目的　探讨彩色多普勒超声 (CDI)监测肝移植术后肝动脉并发症的应用价值。方法　术后连续CDI检查监测 180次原位肝移植。监测指标包括肝门部及肝内肝动脉左、右分支的峰值速度 (HAV) ,加速度 (HAAC) ,加速时间 (SAT) ,阻力指数 (RI) ,观察有无血流信号中断、侧支循环形成、肝内有无梗死灶和肝内、外胆管改变等。结果　 8例病人经选择性动脉造影证实为动脉并发症 (血栓形成 5例 ,肝动脉狭窄 3例 )。CDI表现有 :RI降低 <0 5 (8/ 8) ,SAT延长 >0 0 8s(6 / 8) ,HAAC降低<30 0cm/s2 (6 / 8) ,HAV降低 <4 0cm/s(7/ 8) ,肝内胆管扩张、回声改变等 (4 / 8) ,肝内梗死灶 (2 / 8) ,肝内外动脉血流信号消失 (2 / 8) ,肝门部侧支循环形成 (1/ 8)。CDI对动脉并发症诊断的敏感度和特异度分别为 87 5 % (7/ 8)和 95 3% (16 4 / 172 )。结论　CDI可有效监测肝移植术后肝动脉并发症并对其治疗有一定的指导作用。RI、SAT、HAAC、HAV是CDI诊断肝动脉并发症的敏感指标 ,联合应用可以提高CDI的诊断特异度。     

Endovascular management of early hepatic artery thrombosis after living donor liver transplantation

To study the feasibility of endovascular management of early hepatic artery thrombosis (HAT) after living‐donor liver transplantation (LDLT) and to clarify its role as a less invasive alternative to open surgery. A retrospective review of 360 recipients who underwent LDLT. Early HAT developed in 13 cases (3.6%). Diagnosis was performed using Doppler, CT angiography, and digital subtraction angiography. Intra‐arterial thrombolysis (IAT) was performed using streptokinase or tPA. In case of underlying stricture, PTA was attempted. If the artery did not recanalize, continuous infusion was performed and monitored using Doppler US. Initial surgical revascularization was successful in 2/13 cases. IAT was performed in 11/13 cases. The initial success rate was 81.8% (9/11), the failure rate was 18.2% (2/11). Rebound thrombosis developed in 33.3% (3/9). Hemorrhage developed after IAT in 2/11 cases (18.2%). Definite endovascular treatment of HAT was achieved in 6/11 cases (54.5%) and definite treatment (surgical, endovascular or combined) in 9/13 cases (69%). (Follow‐up 4 months–4 years). Endovascular management of early HAT after LDLT is a feasible and reliable alternative to open surgery. It plays a role as a less invasive approach with definite endovascular treatment rate of 54.5%.     

肝移植术后急性肝动脉闭塞的介入治疗

目的评价介入医学在诊断和治疗肝移植术后急性肝动脉闭塞中的作用.方法对7例原位肝移植术后急性肝动脉闭塞病例的诊断和介入治疗过程进行了回顾性分析.结果 59例肝移植术后血管造影证实存在肝动脉闭塞7例,其中多普勒超声发现5例;经导管溶栓治疗,7例肝动脉闭塞中5例部分或全部开通,对其中4例进行了血管内支架植入治疗,经1～13个月随访,肝动脉血流通常,避免了再次肝移植.结论血管造影对肝移植后肝动脉并发症的诊断具有重要价值,介入手段是处理肝移植术后急性肝动脉闭塞的有效方法.     

肝移植术后肝动脉狭窄的治疗

目的探讨肝移植术后肝动脉狭窄的治疗。方法连续503例肝移植中出现15例肝动脉狭窄,根据临床表现、动态肝功能和彩色多普勒检查、CT动脉成像、选择性肝动脉造影诊断。结果术后早期出现肝动脉狭窄10例,2例合并肝动脉血栓形成,再移植3例,介入治疗7例,其中动脉支架植入5例,球囊扩张溶术后6天肝功能衰竭死亡1例,支架植入术后9天肝功能衰竭死亡1例。1月后发现肝动脉狭窄5例,介入治疗均行肝动脉支架植入,1例支架植入术后186天因胆道感染死亡。结论根据肝动脉狭窄程度、发生时间、移植肝功能状态和病人情况选择治疗措施。再移植是治疗肝移植术后肝动脉狭窄的有效方法。肝动脉支架植入可挽救移植肝,改善移植肝功能,延长移植肝发挥功能以等再次肝移植。     

肝移植术后肝动脉并发症的治疗

目的 探讨肝移植术后肝动脉并发症治疗方式与时机的选择.方法 总结2003年10月至2007年3月中山大学附属第三医院肝脏移植中心25例肝移植术后肝动脉并发症的临床资料,分析介入溶栓、经皮腔内血管成形(PTA)、支架植入和再次肝移植对肝动脉并发症预后的影响.结果 本组患者肝移植术后肝动脉血栓形成(hepatic artery thrombosis,HAT)5例,2例患者因肝功能衰竭行再移植治疗,术后均存活;3例接受介入溶栓治疗后,1例肝功能恢复正常,1例死亡,1例再次出现HAT,并再次移植术后因多器官功能衰竭死亡.术后1个月内出现肝动脉狭窄(hepatic arterystenosis,HAS)者12例,因肝功能衰竭行再移植2例;支架植入10例(治疗后因胆道缺血性改变行再移植4例);6例再移植患者存活4例,因颅内出血和感染死亡2例.术后1个月后出现HAS者8例,行肝动脉支架植入5例,肝功能好转.因胆道缺血性改变接受再移植1例.另外2例行保守治疗,情况稳定未作处理.结论 肝移植术后肝动脉并发症的治疗应根据并发症采用个体化的治疗方案.HAT的治疗以再次肝移植为主,HAS以介入治疗为主,一旦出现胆道缺血性改变,应及时行再次肝移植.     

Vascular complications after living donor liver transplantation: a Brazilian, single-center experience

Background

In living donor liver transplantation (LDLT), vascular complications are more frequently seen than in deceased donor transplantation. Early arterial, portal vein, or hepatic vein thromboses are complications that can lead to graft loss and patient death. The aim of this study was to assess the incidence, treatment, and outcome of vascular complications after LDLT in a single Brazilian center.

Methods

Between December 2001 and December 2010, we performed 130 LDLT. Sixty-four recipients were children (27 weighing <10 kg).

Results

Nine recipients had vascular complications. Hepatic artery thrombosis (HAT) occurred in 4 (3.1%), portal vein thrombosis (PVT) in 3 (2.3%), and hepatic vein thrombosis (HVT) and hepatic arterial stenosis (HAS) in 1 (0.8%) patient each. Complications were identified by Doppler and confirmed by angiography or angiotomography. Patients with HAT were listed for retransplantation. One died before retransplant. Two children were submitted to retransplantation; one is still alive, with neurologic sequelae. One adult with HAT was retransplanted with a deceased donor graft and is doing well 58 months after surgery. Two patients with PVT died as a consequence of graft malfunction. In the other case, portal vein arterialization was performed, but patient died 11 months posttransplant. HVT was detected after cardiac reanimation and was treated with an endovascular stent. This patient died 3 months after LDLT. HAS was diagnosed after liver abscess development and was successfully treated by endovascular angioplasty. No recurrence was observed after 22 months. Follow-up ranged from 9 to 117 months.

Conclusion

Pediatric patients are more prone to develop vascular complications after LDLT. Long-term survival was statistically lower for recipients with vascular complications (33.3% vs 77.7%; P = .008).     

肝移植后肝动脉血栓形成的危险因素及防治措施

目的探讨肝移植后肝动脉血栓形成的好发因素及其防治措施。方法收集国内、外近年来关于肝移植后肝动脉血栓形成的好发因素及防治方面的文献并作一综述。结果肝移植后肝动脉血栓形成的好发因素有第五因子莱顿、受体的代谢性肝脏疾病和受体的性别、肝移植中Roux-en-Y法胆管重建术的应用、病毒感染等方面;防治措施主要有早期诊断、检测激活蛋白C抵抗性与预防性应用抗凝剂、改进肝动脉重建的方法、高压氧疗法、经导管持续溶栓治疗、再次肝移植等方面。结论肝移植后肝动脉血栓形成的好发因素及其防治措施的研究对改善肝移植患者的预后有指导作用。     

原位肝移植术中肝动脉变异及术后肝动脉血栓形成的处理

目的探讨肝移植术中肝动脉变异及术后肝动脉血栓形成的处理。方法统计2000年8月至2002年12月期间进行肝移植术的67例次供、受者肝动脉的变异情况；分析肝动脉的重建方式，探讨肝动脉变异与手术后肝动脉血栓形成的关系、肝动脉血栓形成的危险因素及肝动脉血栓形成后的处理。结果67例次供者肝脏和65例受者肝脏共出现肝动脉变异12例次，发生频率最高的为右肝动脉起源于肠系膜上动脉(5例)及左肝动脉起源于胃左动脉(3例)。肝动脉的重建方式如下：供者及受者肝总动脉与胃十二指肠动脉分叉处成型后吻合58例；腹主动脉与肝动脉搭桥2例；利用变异的肝动脉分支吻合7例。手术后发生肝动脉血栓形成3例，均经腹股沟处股动脉插管行肝动脉溶栓治疗，此3例患者中死亡1例。结论避免变异的肝动脉损伤、选择适当的肝动脉吻合方式可以保证移植肝脏的动脉血供。肝动脉血栓形成与肝动脉变异无关。作为肝动脉血栓形成后的保守治疗方法，肝动脉内溶栓治疗有可能避免2次移植。     

Arterial steal syndrome after orthotopic liver transplantation

Arterial steal syndrome after orthotopic liver transplantation (OLT) is characterized by arterial hypoperfusion of the graft, which is caused by a shift in blood flow into the splenic or gastroduodenal arteries. In this report, we present mechanisms by which this syndrome caused ischemia in our patients. Steal was suspected by elevated levels of liver enzymes and the results of Doppler ultrasonography and computed tomographic angiography; it was confirmed by celiac angiography. Patients with established hepatic arterial thrombosis before angiography were excluded from this study. Steal was treated by embolization with a coil or by placement of an endoluminal narrowing stent. Ten patients at our institution (seven men and three women; mean age, 24.7 +/- 11 years; range, 6 to 40 years) exhibited biochemical evidence of liver ischemia and graft failure at 1 to 170 days after having undergone orthotopic liver transplantation. Nine of those patients had splenic steal, and one had both splenic and left gastric artery steal syndrome. None of the patients had gastroduodenal artery steal syndrome. The eight patients with splenic steal syndrome and the patient with both splenic and left gastric steal syndrome were treated by transcatheter occlusion with a coil. The remaining patient with splenic steal syndrome was treated with an endoluminal narrowing stent placement. All patients improved clinically within 24 hours after treatment, exhibiting significant changes in their biochemical and radiological parameters. Follow-up ranged from 1 to 22 months (mean, 6.7 +/- 6.6 months). One patient died from sepsis 1 month after having undergone coil embolization. He had no vascular anomalies at the time of death. We conclude that steal is a significant problem after OLT. Embolization and stenting are minimally invasive and successful treatments for steal, usually resulting early clinical improvement.