肝移植术后急性肝动脉血栓形成的介入治疗

目的评价用血管内介入放射学技术治疗原位肝移植后急性肝动脉血栓形成(HAT)的安全性和疗效。方法对10例肝移植后早期发生急性HAT患者进行了介入治疗。10例均表现为术后转氨酶、胆红素进行性增高。HAT发生于移植术后16h～10d(平均4.5d),Doppler超声波检查提示HAT,经血管造影证实。血管内介入技术有肝动脉内留置导管持续低剂量溶栓和肝动脉内支架置入术,同时经静脉给予低剂量肝素。肝动脉内溶栓期间间隔6～12h复查超声波。结果10例均表现为肝固有动脉完全阻塞。溶栓治疗成功8例。复查血管造影显示肝固有动脉有血流通过,肝内动脉分支显影,肝功能明显改善。肝动脉内留置导管时间为12h～9d(平均4.8d)。8例溶栓成功的患者均存在肝固有动脉吻合口处狭窄,其中7例狭窄程度>90%,进行肝动脉血管内支架置入术。溶栓治疗失败2例,1例于溶栓开始后12h发生腹腔内出血,行急诊开腹探查,发现肝动脉吻合口出血,随即再次吻合;1例留置导管溶栓7d后未能开通肝动脉阻塞,但向肝脏供血的侧支建立、肝功能有所改善,未作进一步治疗。8例治疗成功者术后随访4～20个月(中位值12个月),一般情况良好,复查超声波显示肝动脉血流通畅。结论血管内介入放射学技术是治疗肝移植后早期急性HAT的有效方法,有较高的安全性。     

11例肝移植术后肝动脉血栓形成的观察与护理

肝动脉血栓(Hepatic artery thrombosis,HAT)形成是肝移植术后最常见的血管并发症,也是导致术后移植物功能丧失和患者死亡的主要原因之一[1],发生率为3%~9%。HAT一旦发生,绝大多数情况下终将导致移植肝脏功能丧失,被迫接受再次肝移植。2002年4月~2006年6月,我院694例同种异体原     

False-negative duplex Doppler studies in children with hepatic artery thrombosis after liver transplantation

Recent reports describe formation of collateral vessels in children who have hepatic artery thrombosis after liver transplantation. This led us to reevaluate the role of duplex Doppler imaging in this population. Among 135 pediatric liver transplant patients, 20 had arteriography for suspected hepatic artery thrombosis. Duplex and/or color Doppler imaging was performed in 13 of these children. The Doppler examination failed to show hepatic artery signals in five patients. Arteriography showed hepatic artery thrombosis in all five. In three of these, subsequent Doppler examinations showed reappearance of arterial Doppler signals. Arteriography confirmed the interval development of collaterals. Hepatic artery signals were found on the Doppler examinations of the remaining eight patients. Four had normal arteriograms, but the remaining four had hepatic artery thrombosis with collateral formation. Patients with hepatic artery thrombosis and collateral circulation tended to have increased diastolic flow (decreased resistive index). In addition, early scans clearly identified patients with complete thrombosis before collateral formation. On the basis of our preliminary experience, a child with a liver transplant and a clinical history strongly suggestive of hepatic artery compromise should have arteriography despite an apparently normal Doppler examination.     

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

Hepatic artery stenosis and thrombosis represent dangerous complications of liver transplantation because the associated mortality and morbidity rates are high. In the past, repeat transplantation was considered the first-choice therapy; however, new surgical and interventional revascularization techniques have been suggested recently. Although extensive experience has been acquired with percutaneous transluminal angioplasty (PTA) and fibrinolysis techniques, only sporadic cases of stent placement in the hepatic artery of a transplanted liver have been reported, and no long-term results of this technique are available. In this study, seven stents (five Wallstents and two Palmaz stents) were positioned in four patients (two with stenoses and two with thromboses). Stent placement was performed in three cases after PTA and fibrinolysis, whereas primary stent placement was performed in the fourth. In all cases, technical success was achieved. During 18-25 months of follow-up, all stents proved patent and no patient required another transplantation. Although experience is still limited, the authors' experience indicates that placement of a stent in the hepatic artery in cases of stenosis or thrombosis yields good medium-term success, improving the results obtained by fibrinolysis and PTA and consequently enabling the graft to survive and avoiding the need for repeat transplantation.     

Hepatic artery thrombosis after liver transplantation: radiologic evaluation

Hepatic artery thrombosis after liver transplantation is a devastating event requiring emergency retransplantation in most patients. Early clinical signs are often nonspecific. Before duplex sonography (combined real-time and pulsed Doppler) capability was acquired in October 1984, 76% of all transplants in this institution referred for angiography with a clinical suspicion of hepatic artery thrombosis had patent arteries. In an effort to reduce the number of negative angiograms, CT, real-time sonography, and pulsed Doppler have been evaluated as screening examinations to determine which patients need angiography. Of 14 patients with focal inhomogeneity of the liver architecture detected by CT and/or real-time sonography, 12 (86%) had hepatic artery thrombosis, one had slow arterial flow with hepatic necrosis, and one had a biloma with a patent hepatic artery. In 29 patients undergoing duplex sonography of the hepatic artery, six (21%) had absence of a Doppler arterial pulse. All six had abnormal angiograms: Four had thrombosis, one had a significant stenosis, and one had slow flow with biopsy-proven ischemia. Of 23 patients with a Doppler pulse, two had hepatic artery thrombosis at surgery. However, real-time sonography demonstrated focal inhomogeneity in the liver in both cases. Our data demonstrate that pulsed Doppler of the hepatic artery combined with real-time sonography of the liver parenchyma currently is the optimal screening test for selecting patients who require hepatic angiography after liver transplantation. A diagnostic algorithm is provided.     

Management of hepatic artery steno-occlusive complications after liver transplantation

Steno-occlusive disease (arterial obstructive disease) of the transplant hepatic artery is a collective term that can be used to include hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks. The latter 2 can be referred to collectively as arterial anatomical defects. This chapter details the angiographic techniques and definitions required to make an accurate angiographic diagnosis of these arterial transplant complications. In addition, the chapter focuses on detailed technical aspects of the endoluminal management of these arterial complications. The chapter discusses the role and technical results of endoluminal management of these arterial complications and, when possible, the lesion morphologies most amenable to endoluminal management.     

Collateral transformation of the hepatic artery after liver transplantation

OBJECTIVE: A high rate of false-negative sonographic examinations for evaluation for hepatic artery thrombosis in the setting of collateral artery vessel formation has been documented. Subacute hepatic artery compromise with collateral vessel formation can be subclinical, and we believe that this phenomenon may occur more commonly than currently appreciated. CONCLUSION: We discuss two cases of subacute hepatic artery compromise with collateral artery vessel formation that were prospectively diagnosed in July 2007 by sonography and confirmed by angiography. We refer to this phenomenon as "collateral transformation of the hepatic artery."     

Management of nonocclusive hepatic artery complications after liver transplantation

Nonocclusive arterial disease represents less than 5% of posttransplant arterial complications. Nonocclusive arterial complications are classified into (1) nonocclusive diminished flow in the hepatic artery, (2) arteriovenous fistulae, (3) pseudoaneurysms, and (4) arterial rupture. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. Transcatheter embolization is the main mode of minimal invasive management of these uncommon complications. Other minimal invasive methods have been described such as stent placement or direct percutaneous embolization/thrombosis. The article discusses the presentation, etiology, types, treatment indications, and various modes of minimal invasive therapy used to manage these complications.     

Cholangiographic findings in hepatic artery occlusion after liver transplantation

Because the hepatic artery provides the only blood supply to the biliary tree of a liver allograft, posttransplantation arterial occlusion may result in a biliary complication. Cholangiograms were reviewed retrospectively in 31 transplant patients who had proved complete or partial occlusions of the hepatic artery (thrombosis in 29 and marked stenosis in two). Cholangiograms were abnormal in 26 (84%). The most common abnormality, seen in 16 patients, was nonanastomotic contrast leakage from the donor intra- or extrahepatic bile ducts. Strictures of the donor biliary tree occurred in 14 patients, four of whom also had a nonanastomotic bile leak. In 12 of the 14, the strictures were nonanastomotic. Other findings included poor filling of the intrahepatic bile ducts, generalized donor ductal dilatation and irregularity, and intraductal filling defects. Sixteen (89%) of 18 transplants with nonanastomotic contrast leakage had occlusions of the hepatic artery. Of 21 transplants with nonanastomotic strictures, 12 (57%) had occlusions of the hepatic artery. Only two (10%) of 20 transplants with biliary anastomotic strictures had arterial occlusion. We conclude that liver transplant recipients who exhibit nonanastomotic contrast leakage or nonanastomotic strictures on cholangiography should be evaluated for occlusion of the hepatic artery as the probable cause.     

肝移植术后非闭塞性肝动脉低灌注的研究进展

肝移植术后非闭塞性肝动脉低灌注（NHAHP）在临床上并不少见,通常发生于肝移植术后的30 d内;NHAHP会导致移植肝缺血、损伤,甚至失功能。NHAHP的发生机制尚不完全明确,可能有以下多种机制共同参与：脾动脉盗血、门静脉高灌注、及其所致的肝动脉血流反应性降低、肝动脉血流阻力指数增加等。NHAHP的临床表现和实验室检查均缺乏特异性。虽然DSA是诊断NHAHP的金标准,但其为有创检查,只用于需要腔内介入治疗的患者;彩色多谱勒血流图联合超声造影是目前首选的影像学检查手段。脾动脉主干栓塞是治疗NHAHP的首选方法,其安全有效,能够迅速改善NHAHP。     

肝移植术后肝动脉早期血栓形成的介入放射学处理

目的总结肝移植术后早期肝动脉血栓形成的介入处理经验。方法我院502例肝移植术后临床上疑有肝动脉并发症的32例患者行肝动脉造影检查,证实肝动脉主干内血栓形成(HAT)20例。对该20例患者采用经肝动脉内导管持续性尿激酶溶柃治疗及PTA和内支架植入术。结果本组HAT发生率为3.98%(20/502),发生存术后2～19d,中位时间为4.5d,20例血栓形成部位均化于肝动脉吻合口处,其中5例溶栓过程中使用球囊扩张,3例使用支架,2例出现吻合口出血而使用弹簧圈作栓塞和带膜内支架。20例均经介入溶栓治疗后获肝动脉再通。溶栓疗程2～11d,平均2.5d。结论经肝动脉内尿激酶持续性溶栓及PTA和内支架治疗效果良好,可作为肝移植术后HAT的重要治疗手段。     

Role of contrast-enhanced ultrasound in decision support for diagnosis and treatment of hepatic artery thrombosis after liver transplantation

Objective

To assess role of contrast-enhanced ultrasound (CEUS) in decision support for diagnosis and treatment of hepatic artery thrombosis (HAT) after liver transplantation.

Materials and methods

Between January 2005 and January 2011, 605 patients underwent liver transplantation in our medical center. All the liver transplant recipients received Doppler ultrasound scanning and CEUS examination was performed in 45 patients with suspected HAT on Doppler ultrasound. Sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were determined based on the results from angiography, surgery and clinical follow-up.

Results

Fourteen HATs, including one late HAT, were diagnosed by CEUS. Twelve HAT cases were confirmed by angiographic and/or surgical findings, while the late HAT and other 31 patients with negative CEUS finding were confirmed by the clinical follow-up. There was a false positive HAT diagnosed by CEUS in which angiography revealed a patent hepatic artery. The sensitivity, specificity, accuracy, positive predict value and negative predictive value of CEUS in diagnosing HAT were 100%, 96.9%, 97.8%, 92.9% and 100%, respectively. In our series of 605 liver transplants, the incidence and mortality of HAT was 2.2% (13/605) and 53.8% (7/13), respectively.

Conclusions

Our study demonstrates the important role of CEUS in decision support for diagnosis and treatment of HAT after liver transplantation. When HAT is suspected by Doppler ultrasound, CEUS shall immediately be performed to elucidate its nature. A negative CEUS finding shall avoid invasive angiography. Such as, CEUS may alter the clinical workflow on HAT detection after liver transplantation.     

肝移植术后并发症与介入治疗一、肝动脉血栓形成

肝移植术(LT)后并发症的有效处理很大程度上决定手术的成败。LT后肝动脉血栓形成(HAT)可直接导致移植肝坏死、胆汁瘤与肝功能衰竭。及早发现并明确诊断对预后至关重要,多普勒超声可作为首选的普查方式,CTA、MRA及血管造影可以进一步明确诊断。肝动脉血栓形成后局部溶栓简便易行,与球囊扩张、支架置入技术联合应用通常取得较好的疗效,同时需寻求规范化诊疗方案;血管重建术与加压舱治疗也是有效方法,不得已时,肝脏再移植仍是重要的最后治疗措施。     

肝移植术后肝动脉狭窄的介入治疗

目的 对介入方法治疗肝移植术后肝动脉狭窄的价值进行初步的探索。方法 1998年9月至2001年11月进行的200例肝移植病人中术后18例发生肝动脉狭窄、闭塞，对18例病人行球囊扩张与内支架置入术的资料进行回顾和总结。结果 15例病人成功进行了介入治疗，其中单纯球囊扩张治疗13例，内支架治疗2例，3例病人介入治疗失败。治疗成功的15例病人中7例愈后良好，8例愈后不良。结论 介入方法治疗肝移植术后肝动脉狭窄具有微创、安全、有效的优点，可作为治疗移植术后肝动脉狭窄的首选治疗手段。但早期诊断、早期治疗是影响治疗愈后的重要因素。     

The use of coronary stent in hepatic artery stenosis after orthotopic liver transplantation

PURPOSE: This retrospective study was undertaken to evaluate the effectiveness of coronary stent placement in hepatic artery stenosis after orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Of 430 consecutive adult orthotopic liver transplant recipients between November 2003 and September 2005, 17 had hepatic artery stenosis (HAS). Fourteen of them underwent coronary stent placement in the HAS. The technical results, complications, hepatic artery patency and clinical outcome were reviewed. RESULTS: Technical and immediate success was 100%. After a mean follow-up of 159.4 days (range, 9-375 days), all patients obtained patent hepatic arteries except 2 patients occurred hepatic artery restenoses at 26 and 45 days after stent placement, respectively. Kaplan-Meier curve of patency showed cumulated stent patency at 3, 6, and 12 months of 78%, 58% and 45%, respectively. During the follow-up, 8 patients survived, 5 died of septic multiple-organ failure, 1 received retransplantation because of refractory biliary infection. Hepatic artery dissection induced by a guiding catheter occurred in one patient and was successfully treated with a coronary stent. CONCLUSION: Hepatic artery stenosis after OLT can be successfully treated with coronary stent placement with low complication rate and an acceptable 1-year hepatic artery patency rate.     

Abdominal sonography after hepatic transplantation: results in 36 patients

Hepatic transplantation was performed in 46 patients over a 2-year period at the University of Minnesota. Thirty-six of these patients subsequently underwent 166 sonographic examinations of the upper abdomen. Forty-three examinations were performed within 2 weeks of transplantation, 47 between 2 and 8 weeks after transplantation, and 76 more than 8 weeks after transplantation. The sonograms were reviewed retrospectively and correlated with the available clinical and histopathologic data. Diffuse, nonspecific parenchymal abnormalities were seen in 27 patients. Focal regions of parenchymal abnormality seen in four patients were associated with abscess and infarction. Moderate to severe biliary dilatation was seen in seven patients with biliary obstruction diagnosed by percutaneous or T-tube cholangiography. Obstruction was seen most commonly in children who had undergone cholecystojejunostomy biliary reconstruction, and it required radiologic or surgical intervention. Routine sonographic assessment of the upper abdominal vasculature showed thrombosis of the portal vein in two cases, thrombosis of the inferior vena cava in one case, thrombosis of the donor aorta in three cases. Focal intraabdominal fluid collections were identified in 14 patients and represented hematomas in all but one. Free peritoneal fluid was detected in 19 patients. Sonography was used to guide percutaneous aspiration of abdominal fluid and to guide fine-needle puncture for percutaneous transhepatic cholangiography. Upper abdominal sonography provides a noninvasive means of evaluating and confirming a wide spectrum of complications that can follow hepatic transplantation. Because clinical and laboratory findings often are nonspecific in these patients, sonographic detection of focal parenchymal abnormalities, biliary dilatation, and vascular compromise is especially valuable.