Intraoperative hepatic artery blood flow predicts early hepatic artery thrombosis after liver transplantation

Hepatic artery complications after orthotopic liver transplantation are associated with a high rate of graft loss and mortality (23% to 35%) because they can lead to liver ischemia. The reported incidence of hepatic artery thrombosis (HAT) after adult liver transplantation is 2.5% to 6.8%. Typically, these patients are treated with urgent surgical revascularization or emergent liver retransplantation. Since January 2007, we have recorded the postanastomotic hepatic artery flow after revascularization. The aim of this study was to assess the relationship between hepatic blood flow on revascularization and early HAT. Retrospectively, we reviewed perioperative variables from 110 consecutive liver transplantation performed at the Virgen del Rocío University Hospital (Seville, Spain) between January 2007 and October 2010. We evaluated the following preoperative (donor and recipient) and intraoperative variables: donor and recipient age, cytomegalovirus serology, ABO-compatibility, anatomical variations of the donor hepatic artery, number of arterial anastomoses, portal and hepatic artery flow before closure, cold ischemia time, and blood transfusion. These variables were included in a univariate analysis. Of the 110 patients included in the study, 85 (77.7%) were male. The median age was 52 years. ABO blood groups were identical between donor and recipient in all the patients. The prevalence of early HAT was 6.36% (7 of 110). Crude mortality with/without HAT was 22% versus 2% (P = .001), respectively. Crude graft loss rate with/without HAT was 27% versus 4% (P = .003), respectively. Early HAT was shown to be primarily associated with intraoperative hepatic artery blood flow (93.3 mL/min recipients with HAT versus 187.7 mL/min recipients without HAT, P < .0001). No retransplantation showed early HAT. In our experience, intraoperative hepatic artery blood flow predicts early HAT after liver transplantation.     

Effect of protocol Doppler ultrasonography and urgent revascularization on early hepatic artery thrombosis after pediatric liver transplantation

HYPOTHESIS: Protocol Doppler ultrasonography of the liver (DUSL) is useful for detecting early hepatic artery thrombosis (HAT). Urgent exploration based on DUSL findings and immediate revascularization of the liver may avoid HAT-related sequelae, namely, biliary complications and retransplantation after pediatric liver transplantation. DESIGN: Case-control study. SETTING: University hospital. PATIENTS: Group 1 included 96 liver transplantations performed in 75 pediatric patients from June 1, 1994, to August 31, 1999. Group 2 included 43 liver transplantations performed in 39 pediatric patients from September 1, 1999, to September 30, 2001. INTERVENTION: In group 1, DUSL was performed on the first posttransplantation day or on request. Angiographic confirmation of suggested HAT was treated with thrombolysis, angioplasty, or thrombectomy. In group 2, protocol DUSL was performed every 12 hours in the first week and every 24 hours in the second week. The suspicion of HAT warranted urgent surgery without the patient undergoing angiography. MAIN OUTCOME MEASURES: Incidence of HAT, biliary complications, and retransplantation. Graft and patient survival. Hospital stay, and number of admissions and operations after undergoing HAT. RESULTS: The incidence of HAT was 10.4% (10 of 96 transplantations) in group 1 and 7.0% (3 of 43 transplantations) in group 2. The incidence of biliary complications after HAT was 100% in group 1 and 0% in group 2 (P=.02). The incidence of retransplantation after HAT was 90.0% (9 of 10 patients) in group 1 and 0% in group 2 (P=.01). Of the 10 patients who experienced HAT in group 1, 5 patients underwent early retransplantation (mean length of time, 13.2 days). All 5 patients who did not undergo early retransplantation had biliary complications. Four of these 5 patients underwent retrasplantation at a later time (mean length of time, 687 days). In group 2, DUSL identified early HAT in 3 patients (7.0%). Emergent thrombectomy and arterial reconstruction were undertaken. All 3 (100%) have their original graft and are alive. None experienced biliary complications. One-year graft and patient survival is 72.0% and 84.0%, respectively, in group 1 and 80.0% and 85.0%, respectively, in group 2. Shorter hospital stay, fewer readmissions, and surgery after HAT were noted in group 2. CONCLUSIONS: Protocol DUSL detects early HAT and urgent revascularization based on DUSL can significantly reduce the incidence of biliary complication and graft loss requiring retransplantation in pediatric liver transplantation.     

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.     

The Long‐Term Outcome of Hepatic Artery Thrombosis After Liver Transplantation in Children: Role of Urgent Revascularization

Hepatic artery thrombosis (HAT), one of the most severe complications of pediatric orthotopic liver transplantation (OLT), often compromises graft and/or child survival. Of 590 OLT performed in 516 children over a 20‐year period, 45 were complicated by early HAT, during the first 2 weeks after transplantation. Systematic Doppler ultrasonographic detection of HAT allowed successful surgical revascularization in 19 instances, resulting in a 20‐year graft survival rate of 77% versus 24% of cases when revascularization was not attempted or failed. A combination of surgical emergency revascularization, biliary interventional radiology, biliary surgery and/or retransplantation resulted in an 80% 20‐year patient survival rate, identical to that of transplanted children who did not experience early HAT. The majority of long‐term survivors with their initial graft had normal liver tests, no biliary dilation on ultrasonography and minimal or moderate fibrosis on liver histology. A failed attempt at revascularization did not significantly alter patient survival. Despite these encouraging results, for the children and their parents to overcome the entire process in terms of reoperations, repeated radiological interventions, number of hospitalizations and emotional stress, remains an ordeal of such magnitude that it justifies renewed efforts to progress in the prevention of this complication.     

Acute hepatic artery thrombosis in pediatric liver transplantation: surgical thrombectomy and in situ fibrinolysis]

In pediatric liver transplantation, hepatic artery thrombosis usually leads to graft loss, early due to hepatic necrosis when it occurs during the first week following the transplant procedure, or later due to biliary complications. Liver retransplantation is the usual attitude. However, urgent surgical hepatic arterial thrombectomy to restore the blood flow can be successful when early diagnosis is made with Doppler ultrasound examination and angiography. Four hepatic arterial thrombectomies were performed as an emergency with additional intra-hepatic arterial fibrinolytic treatment, in three children, 1.5, 3 and 5.5 years of age. Mean duration between the first signs of hepatic artery thrombosis and thrombectomy was 16 hours. None of the children had an urgent liver retransplantation. A complete success was obtained in one case, with normal liver function tests and patent hepatic artery on the Doppler ultrasound examination at the present time. In the two other cases, hepatic artery thrombosis recurred, in spite of repeated thrombectomy in one case; following this attempt complications of hepatic artery thrombosis occurred in the two patients: ischemic necrosis of the left lobe (1 case), biliary leak (1 case) and stenosis of the common bile duct (2 cases). A complete success in one case and a partial success in the two others lead us to advocate urgent thrombectomy and in situ fibrinolytic treatment when early diagnosis of hepatic artery thrombosis is made.     

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.     

肝移植术后肝动脉血栓形成的预防

目的 探讨肝移植术后肝动脉血栓形成(hepatic artery thrombosis,HAT)的预防.方法 2004年1月至2007年12月我院器官移植科共实施596例成人尸肝移植,自2005年开始采取综合措施预防HAT形成,包括术中重建变异肝动脉,受体肝动脉条件不好的患者采取供体肝动脉与受体腹主动脉搭桥,动脉吻合全部采用显微缝合技术,术后常规监测移植肝血流,对肝动脉峰值流速低于40 cm/s的患者行抗凝治疗.比较2004年实施的181例肝移植患者(A组)与2005-2007年实施的415例肝移植患者(B组)HAT发生情况.结果 A组共有8例患者出现HAT,发生的中位时间为术后11 d(3～41 d),3例表现为急性肝功能恶化,3例表现为胆漏,1例表现为肝脓肿,1例无明显临床症状.B组共有6例患者出现HAT,发生时间为术后8 d(1～21 d),3例表现为急性肝功能恶化,1例表现为胆漏,2例无明显临床症状.B组患者HAT发生率明显低于A组(1.44%vs4.42%,X~2=4.86,P=0.027).A组3例行再次肝移植,共死亡5例,B组3例行肝动脉重建联合肝动脉局部溶栓治疗,2例患者康复出院,1例患者因严重感染、肾功能衰竭死亡.3例患者接受再次肝移植.结论 肝动脉血栓形成是肝移植术后的严重并发症,术中采用显微缝合方式,注意重建变异肝动脉,术后严密监测,及时抗凝治疗可以有效预防肝动脉血栓形成.     

Presence of multiple bile ducts in the liver graft increases the incidence of biliary complications in pediatric liver transplantation.

We studied the impact of multiple bile duct anastomosis on the development of biliary complications after liver transplantation in children. A total of 101 patients received a primary liver transplant and were divided into 2 groups: those with a single bile duct (n = 77) and those with multiple bile ducts (n = 24). Mean follow-up was 39.8 +/- 20.8 months. A total of 27 patients presented with biliary complications (26.7%), 18 patients (18.7%) presented with early complications (12 leaks and 6 strictures), and 9 patients (8.9%) had late strictures. Hepatic artery thrombosis (HAT) and multiple bile ducts were significant risk factors for the development of biliary complications, and the presence of multiple bile ducts was an independent risk factor. Patients with multiple bile ducts had a significantly greater incidence of total biliary complications compared to those with single ducts. Patients with multiple ducts had a higher incidence of leaks when compared to those in the single duct group, but the incidence of strictures, both early and late, was similar in both groups. One-year patient and graft survivals were not statistically different in the 2 groups. In conclusion, the presence of more than one bile duct in the graft is an independent risk factor for the development of biliary complications after pediatric liver transplantation.     

再次肝移植治疗移植肝失功的经验分析

目的 总结再次肝移植治疗移植肝失功的临床经验。方法 回顾分析1993年4月至2005年4月期间施行的9例再次肝移植受者临床资料。再次肝移植的原因包括肝动脉血栓（2／9）,门静脉血栓（1／9）,胆道并发症（6／9）;9例再次肝移植均为尸肝移植,3例采用经典原位肝移植,6例采用背驮式肝移植,6例采用Roux-en-Y胆肠内引流,1例供受体门静脉间用供体脾静脉搭桥,1例供体肝动脉与供体腹主动脉之问用供体脾动脉搭桥。结果 全组无手术死亡,5例术后未出现并发症,1例术后门静脉吻合口狭窄,3例术后6个月内死亡。结论 首次肝移植后由于胆道和血管并发症导致移植肝失功是再次肝移植的主要适应证,不失时机地进行再次肝移植是治疗移植肝失功惟一有效的方法。     

原位肝移植术后肝动脉血栓形成的诊断和治疗

目的探讨原位肝移植术后肝动脉血栓形成的诊断与治疗。方法回顾性分析我科1996年10月至2004年3月施行的98例次原位肝移植术．其中8例原发性肝癌患者术前有多次TACE史。结果本组病例仅术前有多次TACE史的患者发生肝动脉血栓5例,均经选择性血管造影证实。3例、1例和1例受者分别接受介入溶栓、再血管化手术和再次肝移植。与肝动脉栓塞有关的死亡率为60％(3／5)。结论术前多次TAcE史是移植术后发生肝动脉血栓的高危因素。彩色多普勒超声是监测血管并发症的首选方法。再血管化手术或再次肝移植是治疗肝动脉血栓的有效方案。     

Hepatic allograft rescue following arterial thrombosis. Role of urgent revascularization

Hepatic artery thrombosis is a continuing source of morbidity and mortality following orthotopic liver transplantation. The cornerstone of therapy has been urgent retransplantation that is limited by organ availability. For this reason we developed a policy of urgent revascularization for allograft rescue. Hepatic artery thrombosis developed following 15 transplants of which 11 underwent urgent rearterialization. The diagnosis was made a mean of 4.8 days (range 1-10) following transplantation. Duplex ultrasonography was diagnostic in all patients and confirmed by angiography in 4 (36%). Three patients with hepatic artery thrombosis were identified following screening ultrasonography and were clinically unsuspected. Upon reexploration, a specific technical reason for hepatic artery was found in 4 patients (36%). Twelve arterial revascularization procedures were performed in 11 patients including: thrombectomy alone (n = 4); revision of anastomosis with thrombectomy (n = 5); and thrombectomy with placement of vascular conduit (n = 3). Following revascularization, 8 patients maintained hepatic artery patency. Three patients eventually required retransplantation secondary to biliary sepsis. Biliary tract complications developed in 6 patients, at a mean of 23 days following revascularization and included: breakdown of the biliary anastomosis (n = 4); stricture (n = 1); and sludge formation (n = 1). The overall graft and patient survival are 74% and 82% respectively, with a mean follow-up of 6.8 months. Hepatic allograft rescue with the use of urgent revascularization following hepatic artery thrombosis appears to be an effective means of either avoiding retransplantation or providing a bridge until a suitable donor becomes available.     

Vascular complications after pediatric liver transplantation from the living donors

Early arterial or portal vein thrombosis is a complications that can lead to graft loss and patient death or need of immediate retransplantation. The aim of the study was to assess the incidence, causes, treatment, and outcome of vascular thrombosis after living related donor liver transplantation (LRdLTx). Between 1999 and 2004 71 LRdLTx were performed in children aged from 6 months to 10 years. Vascular thrombosis was found in 12 recipients. Hepatic artery thrombosis (HAT) occurred in 4 (5.6%), portal vein thrombosis (PVT) in 8 (11.2%) cases. HAT occurred 5 to 8 days, PVT 1 to 22 days after LTx. Diagnosis of vascular thrombosis was confirmed by routine Doppler ultrasound examination. Thrombectomy was successful in one patient with HAT and in three patients with PVT. Venous conduit was performed in one patient with PVT after second thrombosis. Two children developed biliary strictures as a late complication of HAT and required additional surgical interventions. Two children with PVT developed portal hypertension with esophageal bleeding, which required surgical intervention; one another underwent endoscopic variceal ligation for grade III varices. Follow-up ranged from 7 to 60 months. One patient died as a result of HAT after retransplantation due to multiple intrahepatic abscesses 2 months after first transplant. Any risk factors of vascular thrombosis that can be controlled should be avoided after transplantation. Routine posttransplant Doppler examination should be performed at least twice a day within 7 to 14 posttransplant days. Immediate thrombectomy should be always carried out to avoid late complications and even mortality.     

Treatment of early hepatic artery thrombosis after liver transplantation

Introduction

Early hepatic artery thrombosis remains one of the major causes of graft failure and mortality in liver transplant recipients. It is the most frequent severe vascular complication after orthotopic liver transplantation (OLT) accounting for >50% of all arterial complications. Most patients need to be considered for urgent liver retransplantation.

Materials and Methods

Among 911 OLTs in 862 from 1989 to 2011, we observed 23 cases (2.6%) of acute early hepatic artery thrombosis. Seventeen patients were qualified immediately for liver retransplantation, and 6 underwent endovascular therapies, including intra-arterial heparin infusion or percutaneous transluminal angioplasty with stent placement.

Results

Among patients who were assigned to early liver retransplantation, 11/17 survived with 3 succumbling due to postoperative complications, including 1 portal vein thrombosis, and 3 succumbling on the waiting list. All patients who underwent endovascular therapy survived with an excellent result obtained in 1 who underwent treatment <24 hours after arterial thrombosis. In 2 patients we achieved a satisfactory result not requiring retransplantation, but 3 patients assigned to endovascular treatment >24 hours after arterial thrombosis needed to be reassigned to liver retransplantation because of poor results of endovascular treatment.

Conclusions

Endovascular treatment efforts should be made to rescue liver grafts through urgent revascularization depending on the patient's condition and the interventional expertise at the transplant center, reserving the option of retransplantation for graft failure or severe dysfunction.     

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。     

肝移植术后肝内弥漫性胆管狭窄的治疗和预防

目的 探讨肝移植术后肝内弥漫性胆管狭窄的治疗及预防措施.方法 回顾性分析北京市器官移植中心2002年1月至2007年12月收治的21例肝移植术后肝内胆管弥漫性及肝内外多发性狭窄患者的临床资料.同时自2006年1月开始进行前瞻性研究,采用尿激酶灌注无心跳尸体供肝,预防肝内弥漫性胆管狭窄的发生.结果 21例患者中16例行再次肝脏移植,其余5例患者在等待供肝过程中因肝功能衰竭死亡.16例再次肝移植患者中14例治愈,患者健康状况良好,肝功能正常,2例死于围手术期真菌感染.尿激酶灌注组肝内弥漫性胆管狭窄的发生率1.4%,非尿激酶灌注组肝内弥漫性胆管狭窄的发生率5.9%,两组比较差异有统计学意义(x2=5.98,P<0.05).结论 再次肝移植是治疗难治性胆管狭窄的有效方法.对无心跳尸体供肝常规采用尿激酶两次灌洗方案能有效降低肝内胆管弥漫性狭窄的发生率.     

Continuous transcatheter arterial thrombolysis for early hepatic artery thrombosis after liver transplantation

Early hepatic artery thrombosis (HAT) after orthotopic liver transplantation remains a significant cause of graft loss and patient death. The most effective treatment approach is still controversial. The purpose of this study was to assess the effect of continuous transcatheter arterial thrombolysis in the treatment of early HAT. Routine posttransplant color Doppler imaging (CDI) was performed to monitor hepatic artery blood flow. HAT was confirmed by arterial angiography in suspected cases. HAT was identified in 8 patients (8/287, 2.8%) which occurred on days 2 to 19 (mean, 5.2 days) after liver transplantation. Patients with HAT were treated with continuous transcatheter arterial thrombolysis using urokinase. Successful revascularization through thrombolysis was obtained in all eight cases. One patient died of a pulmonary infection at 2 months after liver transplantation. Another patient underwent retransplantation because of resistant allograft rejection and recurrence of HAT 6 months after the first operation, but died from multiple system organ failure 2 months later. The other six patients remained in good health during the follow-up period of 3 to 27 months. Our results demonstrate that CDI is an effective method to monitor the occurrence of early HAT after liver transplantation. Furthermore, continuous transcatheter arterial thrombolysis with urokinase could be a rational therapeutic approach to rescue the allograft following early HAT diagnosis confirmed by arterial angiography.     

Survival and outcome after hepatic artery thrombosis complicating pediatric liver transplantation

BACKGROUND/PURPOSE: Hepatic artery thrombosis (HAT) represents a significant cause of graft loss and mortality after pediatric orthotopic liver transplantation (OLT). The incidence and etiology of this complication have been investigated in detail but relatively little is known about outcome. METHODS: A review was conducted of all children with confirmed HAT complicating OLT during a 10-year period (1990 through 1999) in a single center. HAT was established by angiography or at operation in all cases. RESULTS: From a consecutive series of 400 pediatric OLTs, there were 31 (7.8%) instances of HAT in 29 children of median age 3.8 years (range, 8 days to 16 years). Twenty-four (83%) are alive after a median follow-up of 3.6 years. Fourteen cases occurred after transplantation of whole grafts and 17 after reduced or split livers. Of the 18 episodes resulting in retransplantation, there were 5 deaths and 2 second episodes of HAT; surviving children are alive with good graft function. Of the 13 episodes managed without retransplantation, 4 patients underwent attempted early revascularisation of the graft, which was successful in 2, and the remainder initially were treated conservatively. All 13 children are alive after a median follow-up of 4.1 years (range, 0.6 to 5.8), but 5 required radiologic or surgical intervention for biliary or septic complications; biochemical liver function is normal in 8, mildly abnormal in 3, and poor in 2. Retransplantation was less likely in those who had received reduced or split grafts (7 of 17) compared with those who had received whole grafts (11 of 14), but this difference just failed to reach statistical significance (chi(2) = 3.01, 0.1 > P > .05). CONCLUSIONS: Using a selective policy of retransplantation, revascularisation, and conservative treatment, 83% of children survived HAT complicating OLT. Approximately 40% of children with HAT survived without retransplantation. J Pediatr Surg 36:888-891.     

Hepatic artery thrombosis resulting in gas gangrene of the transplanted liver.

Early hepatic artery thrombosis after orthotopic liver transplantation results in massive injury to hepatocytes and the bile duct epithelium. In the fulminate form, impaired liver synthetic function is expressed by encephalopathy and coagulopathy. Ischemic bile duct injury is associated with the disruption of the biliary anastomosis, bile duct strictures, and intrahepatic bilomas. The inability of the liver macrophages to clear translocated portal blood intestinal pathogens results in persistent bacteremia and sepsis. The major radiologic finding is the radiographic evidence of gas gangrene of the liver graft. Early recognition and correct interpretation of the radiologic findings, immediate removal of the liver graft, and placement of the patient on venous-venous bypass or total hepatic devascularization while a new liver is being procured and retransplantation are the only hope for survival.     

再次肝移植治疗移植肝失功能22例报告

目的 总结再次肝移植治疗移植肝失功能的临床经验。方法 回顾分析2004年1月至2006年6月期间中山大学附属第三医院施行22例再次肝移植受者的临床资料，结合文献加以讨论。再次肝移植的原因分别为移植术后胆道并发症（12例）、移植术后肝癌复发（4例）、肝动脉栓塞（2例）、肝动脉狭窄（2例）以及乙肝复发（2例）。再次移植率为3．62％，供肝植入均采用改良背驮式肝移植技术。结果 全组无手术死亡，8例随访至今分别存活21、14、8、3个月各1例，12、1个月各2例；14例存活2周到28个月不等。首次肝移植术后8～30d行再次肝移植病人围手术期病死率最高，为66．7％；1年内死亡10例，主要死亡原因为感染（60％）。结论 再次肝移植是移植肝失功能的惟一有效的治疗方法，正确掌握手术时机及适应证，钻研手术技巧，合理的个体化免疫抑制方案以及围手术期有效的抗感染治疗是提高再次肝移植病人存活率的关键。