Hepatic artery stenosis angioplasty and implantation of Wingspan neurovascular stent: A case report and discussion of stenting in tortuous vessels

BACKGROUND Hepatic artery stenosis is a complication of orthotopic liver transplant occurring in 3.1%-7.4%of patients that can result in graft failure and need for retransplantation.Endovascular therapy with angioplasty and stenting has been used with a high degree of technical success and good clinical outcomes,but tortuous hepatic arteries present a unique challenge for intervention.Suitable stents for this application should be maneuverable and conformable while also exerting adequate radial force to maintain a patent lumen.CASE SUMMARY Herein we report our experience with a neurovascular Wingspan stent system in a challenging case of recurrent hepatic artery stenosis and discuss the literature of stenting in tortuous transplant hepatic arteries.CONCLUSION Wingspan neurovascular stent is self-expanding,has good conformability,and adequate radial resistance and as such it could be added to the armamentarium of interventionalists in the setting of a tortuous and stenotic transplant hepatic artery.     

Isolated venous thrombosis: a new cause of acute graft failure in a non-piggyback liver transplant (case report)

A 46-year-old man was re-transplanted using standard technique for hepatic arterial thrombosis one month following orthotopic liver transplant. Postoperatively he deteriorated acutely with hypotension and disseminated intravascular coagulation. Angiography demonstrated a patent hepatic artery, portal vein and inferior vena cava but isolated thromboses in the right and middle hepatic veins. He was treated with transvenous intrahepatic porto-systemic shunt but subsequently died from sepsis and multiorgan failure. This vascular complication in the absence of outflow stenosis and with a normal prothrombotic screen is a previously undocumented cause of acute graft failure in a standard transplant without retrohepatic vena caval preservation. We present our case and discuss the relevant literature.     

Ischemic hepatitis secondary to hepatic artery steal in a patient with celiac artery stenosis and severe postural hypotension

Ischemic hepatitis, also known as hypoxic hepatitis or shock liver is defined as an acute, transient elevation of aminotransferase levels in the absence of any known causes. The pathogenesis is multifactorial. Many studies have suggested systemic hypotension as a major contributor to the pathogenesis of ischemic hepatitis but that alone is not enough to cause it. Celiac artery stenosis does not commonly cause clinically significant hepatic ischemia because of its rich collaterals. We present a case of a 78‐year‐old male with a background of severe orthostatic hypotension, who presented with elevation of liver enzymes due to hepatic artery steal precipitated by celiac artery stenosis. Clinical investigations showed elevated transaminases and unremarkable CT scan. Invasive celiac artery angiography showed a critical ostial lesion and it was stented. The liver enzymes peaked the day following stenting and normalized over the next 9 days. This confirmed clinically significant hepatic artery steal due to an ostial celiac artery stenosis. Relieving the celiac artery stenosis normalized the liver enzymes confirming the interdependence of the two components of this rare syndrome. Our report is the only report to our knowledge where classic hepatic artery steal and shock liver was demonstrated due to the rare combination of severe orthostatic hypotension and celiac artery ostial stenosis. © 2011 Wiley‐Liss, Inc.     

Hepatic gas gangrene following orthotopic liver transplantation: three cases treated with re-transplantation and a review of the literature

Abstract: Gas gangrene is a rare and devastating infectious process that can occur after liver transplantation, most often following hepatic artery thrombosis. We here report 3 cases of gas gangrene following orthotopic liver transplantation. Blood cultures were positive for Clostridium clostridiiforme in one case. In 2 other cases liver tissue from explanted specimens was positive for Enterobacter cloacae . Ultrasound demonstrated hepatic artery thrombosis and computed tomography imaging revealed diffuse liver necrosis with gas formation in each case. All 3 patients were successfully treated with a combination of antibiotics and emergent re-transplantation. We review previously published cases of gas gangrene after liver transplant and emphasize the importance of hepatic artery thrombosis in the development of this syndrome as well as the frequent involvement of non-clostridial organisms. Early diagnosis and aggressive combined medical and surgical treatment including re-transplantation are essential for successful treatment of these rare and catastrophic infections.     

A liver donor with double hepatic artery aneurysm: a saved graft

The shortage of organs and the increasing median age of deceased donors for orthotopic liver transplantation stimulate transplant centres to accept grafts that otherwise would have been discarded due to severe vascular abnormalities. We encountered a donor with two arterial aneurysms and a left accessory hepatic artery: an arterial aneurysm of the common hepatic artery and a left accessory hepatic artery arising from a second aneurysm of the left gastric artery(Michels type V). A complex reconstruction was created to transplant the liver. Multiple arterial anastomosis was made and the hepatic inflow of the transplanted liver restored. Although the procedure increased the risk of hepatic artery thrombosis, one more organ supposed to be discarded was saved.     

First successful case of simultaneous liver and kidney transplantation for patients with chronic liver and renal failure in Japan

Establishment of a preferential liver allocation rule for simultaneous liver and kidney transplantation (SLK) and revisions of laws regarding organ transplants from deceased donors have paved the way for SLK in Japan. Very few cases of SLK have been attempted in Japan, and no such recipients have survived for longer than 40 days. The present report describes a case of a 50‐year‐old woman who had undergone living donor liver transplantation at the age of 38 years for management of post‐partum liver failure. After the first transplant surgery, she developed hepatic vein stenosis and severe hypersplenism requiring splenectomy. She was then initiated on hemodialysis (HD) due to the deterioration of renal function after insertion of a hepatic vein stent. She was listed as a candidate for SLK in 2011 because she required frequent plasma exchange for hepatic coma. When her Model for End‐stage Liver Disease score reached 46, the new liver was donated 46 days after registration. The reduced trisegment liver and the kidney grafts were simultaneously transplanted under veno‐venous bypass and intraoperative HD. The hepatic artery was reconstructed prior to portal reconstruction in order to shorten anhepatic time. Although she developed subcapsular bleeding caused by hepatic contusion on the next day, subsequent hemostasis was obtained by transcatheter embolization. Thereafter, her recovery was uneventful, except for mild rejection and renal tubular acidosis of the kidney graft. This case highlights the need to establish Japanese criteria for SLK.     

Acute portal vein thrombosis after liver transplant presenting with subtle ultrasound abnormalities:A case report and literature review

BACKGROUND Portal vein thrombosis(PVT) after liver transplantation(LT) is an uncommon complication with potential for significant morbidity and mortality that transplant providers should be cognizant of.Recognizing subtle changes in postoperative ultrasounds that could herald but do not definitively diagnose PVT is paramount.CASE SUMMARY A 30-year-old female with a history of alcohol-related cirrhosis presented with painless jaundice and received a deceased donor orthotopic liver transplant.On the first two days post-operatively,her liver Doppler ultrasounds showed a patent portal vein,increased hepatic arterial diastolic flows,and reduced hepatic arterial resistive indices.She was asymptomatic with improving labs.On postoperative day three,her resistive indices declined further,and computed tomography of the abdomen revealed a large extra-hepatic PVT.The patient then underwent emergent percutaneous venography with tissue plasminogen activator administration,angioplasty,and stent placement.Aspirin was started to prevent stent thrombosis.Follow-up ultrasounds showed a patent portal vein and improved hepatic arterial resistive indices.Her graft function improved to normal by discharge.Although decreased hepatic artery resistive indices and increased diastolic flows on ultrasound are often associated with hepatic arterial stenosis post-LT,PVT can also cause these findings.CONCLUSION Reduced hepatic arterial resistive indices on ultrasound can signify PVT post-LT,and thrombolysis,angioplasty,and stent placement are efficacious treatments.     

320排CT检查技术对肝移植术后肝动脉并发症的诊断价值

目的 探讨320排CT中采用高浓度低剂量对比剂对移植肝动脉并发症的临床诊断价值.方法 58例肝移植术后患者,分A、B两组,对比剂分别为碘350g/L(27例)和370g/L(31例);均采用320排CT扫描机,对比剂流速均为6 ml/s,总剂量50 ml,采用动态容积扫描模式,扫描参数:X线管转速0.5 s/r,层厚0.5 mm,管电流100～250 mA,管电压100 kV.利用4D DSA成像软件,测量纯肝动脉的达峰时间、达峰CT值;记录肝移植组患者的身高和体质量.选取最佳纯肝动脉期的图像,进行容积(VR),最大密度投影(MIP),多层面图像重建(MPR).应用SPSS10.0统计分析软件,根据不同数据资料进行非参数检验,χ~2检验或t检验.结果 (1)肝移植A组,B组间的年龄、性别、身高、体质量和人体质量指数间比较,差异均无统计学意义,A组、B组间肝动脉达峰时间分别为(19.71±3.11)s、(20.06±3.67)s,两者间差异无统计学意义(P＞0.05);B组肝动脉达峰CT值、达峰绝对CT值分别为451.39±113.16、412.06±112.30,与A组的396.26±89.46、357.59±87.54相比,差异具有统计学意义(t值分别为-2.036、-2.038,P值均＜0.05);(2)移植肝动脉成像:肝动脉吻合口假性动脉瘤2例,肝动脉吻合口轻度、中度、重度狭窄、闭塞分别为13例、5例、9例、1例;肝动脉吻合口处多发中重度狭窄4例,肝动脉吻合口病变发生率为58.6%(34/58),肝动脉闭塞及重度狭窄者伴有肝门部侧支动脉形成6例,肝动脉-门静脉瘘及肝动脉迂曲各12例,肝内动脉小分支开放8例,其他包括15例伴有肝内动脉小分支稀疏,3例供受体肝动脉管径粗细不一致.结论 320排CT低剂量对比剂的4D DSA成像可获得准确的移植肝动脉纯动脉期图像,对肝移植术后肝动脉病变的诊断具有安全、无创、准确的优点,可作为肝移植术后对肝动脉并发症进行随访的有效手段.     

Trasplante hepático y renal en la enfermedad poliquística hepatorrenal

ObjectiveTo evaluate the results of isolated liver and combined liver and kidney transplantation in a retrospective series of 32 patients with hepatorenal liver and kidney disease.Materials and methodsA retrospective observational study that enrolled patients with polycystic liver disease (PLD) and polycystic liver and kidney disease (PLKD) who were evaluated for transplantation between January 1999 and December 2019 at Hospital Clínic de Barcelona [Clinical Hospital of Barcelona].ResultsWe included a total of 53 patients enrolled, 32 (60.3%) had indication for transplantation, of which 12 received a single liver transplant and 20 received a double liver and kidney transplant. The mean age was 52 years and 83.9% of the recipients were women. The main indication for liver transplantation was disabling symptomatic hepatomegaly (93.5%). Among the postoperative complications, in the combined liver and kidney transplant group, hepatic artery thrombosis in one case and renal artery thrombosis in other were detected. In both groups there was one case of inferior vena cava lesion. Three patients presented acute cellular rejection responding to corticosteroids and one presented humoral rejection which was treated with plasmapheresis. During the follow-up period of 80 (27-121) months, the liver transplant survival rate was 100% and the kidney transplant survival rate was 90%. Two patients in the combined liver and kidney transplant group died (one due to cardiovascular causes and the other due to intestinal adenocarcinoma).ConclusionsIsolated liver transplantation or combined liver and kidney transplantation in selected patients with polycystic disease yields excellent results, with few complications, very good transplant survival and excellent patient survival (93.8%).     

Continuing management of liver transplant patients after discharge

The management of liver transplant patients after discharge is a complex balance between immunosuppression and the side-effects and toxicity of such medications. The Queensland Liver Transplant Service (QLTX) has performed 72 transplants in 67 patients; 49 patients (73%) are alive. The actuarial 1-year survival rate is 72%. Death after the first year in patients transplanted for benign HBsAg negative disease has not occurred. The most common technical complications are biliary stenosis and hepatic artery thrombosis. Long-term immunosuppression is with cyclosporin and low dose prednisolone. Regular trough cyclosporin levels and liver function tests are vital. The most limiting side-effect of cyclosporin is nephrotoxicity. Constant vigilance, aggressive investigation, and management of pyrexia and biochemical liver dysfunction by the primary care physician in consultation with the transplant team will ultimately determine long-term outcome. The principles and important details of the management of these patients by the QLTX are presented as a guide to referring practitioners.     

Iliac artery stenosis causing post-renal transplant hypertension: successful management by percutaneous angioplasty and stent implantation

Atherosclerotic occlusion of the native iliac arteries and/or transplant renal artery is a major cause of post-transplant hypertension. Iliac artery stenosis mimics renovascular hypertension and may cause renal dysfunction in transplant recipients. We report a case of a 61-year-old renal transplant recipient with native bilateral iliac artery stenoses and coronary artery disease. He presented with severe hypertension and was managed successfully with angioplasty and stenting of native iliac arteries.     

冠状动脉支架放置术治疗肝移植术后肝动脉狭窄

目的评价肝移植术后肝动脉狭窄时冠状动脉支架应用的可行性和有效性。方法2003年11月至2005年9月,14例肝移植术后肝动脉狭窄患者接受肝动脉冠状动脉支架放置术治疗,其中早期治疗10例,延迟治疗4例。总结肝动脉冠状动脉支架放置术的技术结果、肝动脉通畅及患者临床转归等情况。结果冠状动脉支架放置术成功率达100％。中位随诊146d(9～345 d),2例患者分别于术后26 d和45 d出现再狭窄,其余患者肝动脉均保持通畅；10例早期介入治疗的患者中,2例分别于术后9 d和30 d死于败血症性多器官功能衰竭,1例患者由于反复胆道感染于术后147 d接受再次肝移植,其余患者术后肝功能指标正常且无症状生存。4例延迟治疗的患者中,1例生存至今已345 d,但肝功能反复出现异常,其余3例死于肝脓肿和胆道感染导致的多器官功能衰竭。结论肝动脉冠状动脉支架放置术可以成功治疗肝移植术后肝动脉狭窄,早期介入治疗是取得良好的临床疗效的关键。     

Magnetic resonance venography and liver transplant complications

Hepatic vein stenosis is a rare but serious complication following liver transplantation.Multiple modalities can be utilized to image the hepatic vasculature.Magnetic resonance venography(MRV)provides certain advantages over ultrasound,computed tomography angiography and digital subtraction venography.MRV utilizes the same imaging principles of magnetic resonance angiography in order to image the venous system.Blood pool contrast agents,specifically gadofosveset trisodium,allow for steady state imaging up to 1 h following injection,with improved visualisation of vital venous structures by utilising delayed steady state imaging.Additionally,the inherent physics properties of magnetic resonance imaging also provide excellent soft tissue detail and thus help define the extent of complications that often plague the post-liver transplant patient.This case report describes the use of gadofosveset trisodium in a patient with hepatic venous stenosis following liver transplantation.Initial venography failed to outline the stenoses and thus MRV using a blood pool contrast agent was utilised in order to delineate the anatomy and plan a therapeutic endovascular procedure.     

Celiac artery aneurysm associated with atherosclerotic common hepatic artery stenosis

Celiac artery aneurysms are rare vascular lesions and represent 4% of all splanchnic aneurysms. Media degeneration and atherosclerosis are the most common underlying etiologic factors. The risk of rupture and the associated mortality rate are 13% and 40% respectively. In contrast, elective repair carries a low mortality rate of 5%. Most of celiac artery aneurysms are asymptomatic and in the past nearly 80% of the cases were diagnosed when ruptured. Recently, there is an increased recognition of all splanchnic aneurysm types, probably because of better diagnostic techniques. We report a case of celiac artery aneurysm with severe atherosclerotic stenosis of the common hepatic artery. We performed, through a midline supraumbilical laparotomy, extended partial aneurysmectomy and common hepatic artery ostium endarterectomy. For the closure we used Dacron patch. The uncomplicated postoperative patient's course, with no evidence of liver dysfunction and excellent patency of the common hepatic artery, suggests that this technique offered good results and minimized the perioperative risk.     

原位肝移植术后肝脓肿的诊断和治疗

目的 探讨原位肝移植术(OLT)后肝脓肿的病因、诊断、治疗和预防措施。方法自1993年1月至2003年6月，本中心共行OLT274例，术后并发肝脓肿6例(2．2％)。患者主要临床表现有发热、寒战、腹痛、身目黄染、肝功能损害、低蛋白血症、贫血、白细胞及中性粒细胞比例增高等。诊断主要根据临床表现及超声或CT检查。治疗方法主要包括脓肿抽吸引流、清除胆泥．抗炎和支持治疗。结果6例中2例治愈，3例放弃再次肝移植术，2例死于严重全身感染，治愈率为33．3％。结论OLT后肝脓肿病因较复杂，可能与肝动脉血栓或狭窄、甲基强的松龙冲击治疗、胆管炎症和介入治疗等有关。OLT后肝脓肿的预后较差．应加强预防措施防止其发生。     

Hepatic involvement in a liver transplant recipient with disseminated cryptococcosis

Abstract: Cryptococcosis occurs primarily in immunocompromised patients such as organ transplant recipients. Central nervous system and pulmonary infections are documented most frequently; hepatic involvement is rarely reported. We report a case of early hepatic cryptococcosis in a 54-year-old male liver transplant recipient. Two weeks after orthotopic liver transplant, he was readmitted with fever, malaise, diarrhea, and progressive pulmonary infiltrates. On admission, liver-associated enzymes were decreased from those at discharge after transplantation. Blood and bronchoalveolar lavage cultures were positive for Cryptococcus neoformans . Despite treatment with amphotericin B and flucytosine, the patient developed both marked cholestasis and transaminase elevation. A liver biopsy performed 22 days after admission revealed numerous yeast-like organisms in hepatic sinusoids consistent with C. neoformans . Despite treatment, the patient died 55 days after admission and 66 days after transplantation. Our case illustrates hepatic involvement of cryptococcal infection within the first month following transplantation.     

Use of a mechanical thrombectomy device to recanalize a subacutely occluded aortohepatic bypass after orthotopic liver transplantation.

PURPOSE: To report the use of a rotational thrombectomy device for recanalization of a thrombosed hepatic artery bypass graft in an orthotopic liver transplant (OLT). CASE REPORT: Six months after a second OLT in a 52-year-old man, an iliac conduit used for an aortohepatic bypass became occluded, interrupting arterial supply to the liver transplant. The 8-F Straub Rotarex system was used to successfully remove clot from the bypass graft, avoiding embolization to the hepatic arteries. The recanalized conduit has remained patent for 1 year with the patient on an anticoagulation regimen. CONCLUSIONS: The Rotarex thrombectomy system may be considered an alternative to other percutaneous interventions for the treatment of occluded bypass conduits supplying a liver transplant.     

Diagnosis and management of hepatic artery in-stent restenosis after liver transplantation by optical coherence tomography:A case report

BACKGROUND Percutaneous transluminal angioplasty and stenting represent an effective treatment for hepatic artery stenosis after liver transplantation. In the first year after stenting, approximately 22% of patients experience in-stent restenosis, increasing the risk of artery thrombosis and related complications, and 50% experience liver failure. Although angiography is an important tool for diagnosis and the planning of therapeutic interventions, it may raise doubts, especially in small-diameter arteries, and it provides low resolution rates compared with newer intravascular imaging methods, such as optical coherence tomography(OCT).CASE SUMMARY A 64-year-old male developed hepatic artery stenosis one year after orthotropic liver transplantation and was successfully treated with percutaneous transluminal angioplasty with stenting. Five months later, the Doppler ultrasound results indicated restenosis. Visceral arteriography confirmed hepatic artery tortuosity but was doubtful for significant in-stent restenosis(ISR) and intrahepatic flow reduction. To confirm ISR, identify the etiology and guide treatment, OCT was performed. OCT showed severe stenosis due to four mechanisms: Focal and partial stent fracture, late stent malapposition, in-stent neointimal hyperplasia, and neoatherosclerosis.CONCLUSION Intravascular diagnostic methods can be useful in evaluating cases in which initial angiography results are not sufficient to provide a proper diagnosis of significant stenosis, especially with regard to ISR. A wide range of diagnoses are provided by OCT, resulting in different treatment options. Interventional radiologists should consider intravascular diagnostic methods as additional tools for evaluating patients when visceral angiography results are unclear.     

Late acute celiac and hepatic artery thrombosis with portal vein thrombosis resulting in hepatic infarction 12 years post orthotopic liver transplantation

Hepatic artery thrombosis (HAT) is relatively infrequent, but possibly a devastating complication of orthotopic liver transplantation (OLT). It often requires urgent retransplantation. Two main forms of HAT are recognized as early and late HAT (diagnosis within or after 30 days following LT). Early HAT typically results in graft failure. Late HAT features biliary obstruction, cholangitis, and hepatic abscess formation. We report here the case of a patient of Wilson’s disease who presented twelve years post-liver transplant symptoms typical of acute HAT and hepatic infarction. On diagnostic imaging, celiac axis and hepatic artery were thrombosed, resulting in ischemic necrosis of the left hepatic lobe. The resulting sepsis and transient hepatic insufficiency were managed conservatively, and repeat OLT was avoided. The patient remains stable more than one year later. To the best of our knowledge this case report is unique in the literature for the unusually long interval between OLT and late acute HAT, as well as celiac and portal vein occlusion. The acute presentation of sub massive hepatic necrosis is also uncharacteristic of late HAT and more typical of acute HAT. This report describes our experience in managing this and a literature review of the topic.     

Extrahepatic collaterals and liver damage in embolotherapy for ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery

AIM： To evaluate the effects of extrahepatic collaterals to the liver on liver damage and patient outcome after embolotherapy for the ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery.
METHODS： We reviewed 9 patients who underwent transcatheter arterial embolization （TAE） for the ruptured hepatic artery pseudoaneurysm following major hepatobiliary pancreatic surgery between June 1992 and April 2006. We paid special attention to the extrahepatic arterial collaterals to the liver which may affect post-TAE liver damage and patient outcome.
RESULTS： The underlying diseases were all malignancies, and the surgical procedures included hepatopancreatoduodenectomy in 2 patients, hepatic resection with removal of the bile duct in 5, and pancreaticoduodenectomy in 2. A total of 11 pseudoaneurysm developed： 4 in the common hepatic artery, 4 in the proper hepatic artery, and 3 in the right hepatic artery. Successful hemostasis was accomplished with the initial TAE in all patients, except for 1. Extrahepatic arterial pathways to the liver, including the right inferior phrenic artery, the jejunal branches, and the aberrant left hepatic artery, were identified in 8 of the 9 patients after the completion of TAE. The development of collaterals depended on the extent of liver mobilization during the hepatic resection, the postoperative period, the presence or absence of an aberrant left hepatic artery, and the concomitant arterial stenosis adjacent to the pseudoaneurysm. The liver tolerated TAE without significant consequences when at least one of the collaterals from the inferior phrenic artery or the aberrant left hepatic artery was present. One patient, however, with no extrahepatic collaterals died of liver failure due to total liver necrosis 9 d after TAE.
CONCLUSION： When TAE is performed on ruptured hepatic artery pseudoaneurysm, reduced collateral pathways to the liver created by the primary surgical procedure and a short postoperative interval may lead to an unfavorable ou