Journal List > J Korean Soc Transplant > v.25(3) > 1034343

J Korean Soc Transplant. 2011 Sep;25(3):176-183. English.
Published online September 30, 2011.  https://doi.org/10.4285/jkstn.2011.25.3.176
Copyright © 2011 The Korean Society for Transplantation
Hepatic Arterial Complications after Liver Transplantation: A Single-Center Experience
Keun Jeong Lee, M.D., Sang Tae Choi, M.D., Chung Min, M.D., Jung Nam Lee, M.D., Woon Ki Lee, M.D., Jeong-Heum Baek, M.D., Keon Kuk Kim, M.D., Jin Mo Kang, M.D. and Won Suk Lee, M.D.
Department of Surgery, Gacheon University Gil Hospital, Incheon, Korea.

Corresponding author : Sang Tae Choi, Department of Surgery, Gacheon University Gil Hospital, 1198 Guwol-dong, Namdong-gu, Incheon 405-760, Korea. Tel: +82-32-460-3244, Fax: +82-32-460-3247, Email: bcon1218@hanmail.net
Received July 22, 2011; Accepted August 27, 2011.

Abstract

Background

We wanted to explore performing hepatic arterial reconstruction in living donor liver transplantation (LDLT) using right lobe liver grafts and cadaveric liver transplantation (CLT) in a single center.

Methods

Thirty five LDLTs were performed from April 2005 to August 2009. The back wall support suture without twisting was used in most cases. A single RHA was anastomosed to the RHA in 24 patients, to the proper HA in 2 patients, to the RAHA in 4 patients, to the LHA in 2 patients and to an aberrant RHA arising from the SMA in 3 patients. The diameter of the donor RHA was between 1.5 mm and 3.0 mm (mean: 2.5 mm). In the 34 patients who underwent CLT, most of the arterial anastomoses were usually performed using two cuffs at the recipient HA and the GDA bifurcation and a branching point on the donor CHA with running and intermittent stay suture.

Results

The total incidence of HA complication was 4.34% (3/69): 1 HAT (2.85%) occurred in a case of LDLT and 2 HAS (5.88%) occurred in a case of CLT. HAT occurred in 1 recipient on the 1st day following LDLT and 2 HAS occurred in CLT recipients at one and two months, respectively, following LDLT.

Conclusions

HA complications occurred as a mild type of late complication and these complications might not be fatal in CLT. A low incidence of HAT can be achieved with using non-twisting method-guided microsurgical techniques for creating hepatic arterial anastomosis in LDLT. When early HAT occurs, early surgical reconstruction is mandatory for preventing the loss of the graft. Back wall sutures with only single needle suture might be a feasible method for HA microsurgical reconstruction.

Keywords: Hepatic artery; Thrombosis; Arterial occlusive disease; Liver transplantation

Introduction

Hepatic artery complication that occurred in liver transplantation is a potentially devastating problem. HAT developed 3~9% in even CLT(1, 2). when it occurred immediately, HAT may induced the graft failure, sepsis due to liver abscess, biliary stricture and leakage. Delayed, HAT presented with mild clinical symptoms such as cholangitis, altered liver function test(2, 3). It was initially suggested that surgical anastomosis technique was the most important risk factor for HAT. Attempting to reduce the incidence of HAT, we undertook a retrospective review of patients at our institution undergoing LDLT and CLT between April 2005 and August 2009, with the hepatic artery anastomosis performed by a single microvascular surgeon.

In this study, we intended to explore our experience in hepatic reconstruction and the management of hepatic artery complications following living donor and cadaveric liver transplantation over initial five years.

Materials and Methods

1) Recipient profile

Records were from a retrospectively collected database from April 2005 to August 2009. There were 34 adult CLTs and 35 LDLTs conducted at our center during this period. Male/female ratio was 51/18, the median age being 47 (range: 14~69) years. The indications for LT were HBV-associated cirrhosis (n=32), HBV-associated HCC (n=15), fulminant hepatic failure due to toxin (n=5), primary biliary cirrhosis (n=1), alcoholic liver cirrhosis (n=10), fulminant hepatic failure due to HAV (n=3), HCV(n=1), HAV and HBV co-infection (n=1). MELD score is mean 19.2 (6~42) in LDLT, mean 28.5 (10-50) in CLT. Right lobe without middle hepatic vein was used in most cases (n=33) except 2 case using right lobe with middle hepatic vein in LDLT.

2) Surgical technique

Hepatic arterial reconstruction was performed under the magnified scope of 3.5 times or 5~10 times zoom magnification using an operating microscope (Olympus, Tokyo, Japan), completed by end-to-end anastomosis method between donor hepatic artery and recipient hepatic artery with interrupted sutures. In LDLT, conventional twisting method that turns over the hepatic artery was used in early 2 cases. After having difficulty in twisting too short donor hepatic artery, the back wall first suture without twisting can be done in the other case (n=33) by using nylon microsuture with single needle (prolene 9/0, Ethicon, Voerderstedt, Germany). Initial sutures can be done at the deepest and most difficult points in posterior wall, located in the farthest away from operator. Another stitch was placed from the outer side of healthy donor arterial wall to the inner side of recipient arterial wall which was liable to make the intimal dissection during dissection. The subsequent sutures were placed forward or backward on either side adjacent to the previous suture. After the posterior wall suture finished, anterior wall suture could be done with intermittent suture. The suture method guaranteed the good operation field and the secure intimal adjustment and prevented the intimal dissection and further hepatic arterial complication. This suture method does not require turning over the hepatic artery. It takes a less time to anastomosis, there is a little change to intimal damage and tension may occur during turning the short hepatic artery.

Most arterial anastomosis in CLT was usually performed using the cuff at the recipient hepatic artery and gastroduodenal artery bifurcation and a branching point on the donor common hepatic artery with intermittent stay suture and a running suture using prolene 7/0 (Ethicon, Voerderstedt, Germany) under the magnified scope of 3.5 times. In 2 case of young recipient, donor celiac trunk anastomosis to supraceliac aorta was used for arterial reconstruction. Anastomosis between the recipient and graft HA was resolved by cutting both arterial ends obliquely to adjust the length in 5 cases.

3) Statistics

Statistical analysis was performed using SPSS, version 14.0 (Statistical Package for the Social Sciences, Chicago, U.S.A.). Survival curves were calculated using Kaplan-Meier analysis to compared survivals among groups. The chi-square test was used to compare the frequency of the complication.

Results

In the 35 patients who underwent LDLT, all single donor right hepatic arteries were anastomosed; to right hepatic artery in 24 patients, to proper hepatic artery in 2 patients, to right anterior hepatic artery in 4 patients, to left hepatic artery in 2 patients, to aberrant right hepatic artery arising from superior mesenteric artery in 3 patients. The diameter of donor right hepatic artery is between 1.5 mm and 3.0 mm (mean 2.5 mm).

In the 34 patients who under CLT, most arterial anastomosis was usually performed using a Carrel patch at the recipient hepatic artery and gastroduodenal artery bifurcation and a branching point on the donor common hepatic artery or common hepatic artery and gastroduodenal bifurcation with intermittent stay suture and a running suture except 4 cases (between the recipient and graft HA after cutting both arterial end obliquely to adjust the length). Anastomosed arterial feature and complication were summarized in Table 1.


Table 1
Anastomosed arterial feature and complication
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The total incidence of HA complication was 4.34% (3/69), 1 HAT (2.85%) occurred in only LDLT, 2 HAS (5.88%) in CLT (1 case occurred in non-anastomosis site). HAT occurred at 1st day following LDLT which were revascularized with autogenous saphenous vein between right gastroepiploic artery anastomosed to donor right hepatic artery and recipient abdominal aorta 1 day postoperatively, 2 HAS occurred one and two month following CLT (mean 52.6 months), no symptom was presented. HAT was identified by serial US, CT and angiography. HAS was found accidentally by routine CT. No death related to hepatic artery complications occurred.

Hepatic arterial complication developed in 3 (4.34%) of 69 patients, as summarized in Table 2.


Table 2
Clinical data from 3 patients with hepatic arterial complication after liver transplantation
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1) Hepatic artery thrombosis (Fig. 1)


Fig. 1
Ischemic necrosis followed by hepatic artery stenosis. CT shows ischemic necrosis followed by hepatic arterial thrombosis, which occurred at segment VI at 1st postoperation day. Hepatic angiography show arterial vasospam ans thrombus occurred at the right gastroepiploic artery (A, B). Hepatic flow can be preserved after jump graft by using great saphenous vein from supraceliac aorta to right gastroepiploic artery (C). The ischemic necrosis portion show relatively good parenchymal regeneration and duct dilatation in 7 months later (D, E).
Click for larger image

One patient was identified with HAT at the first post-operative day. He suffered from HBV related hepatocellular carcinoma and transarterial chemoembolization (TACE) twice preoperatively. His hepatic artery flow in common hepatic artery proved to be minimal in operative field, because of intimal damage after TACE. Right hepatic artery of donor was anastomosed to the right gastroepiploic artery of the recipient. Thrombosis occurred at the site of right gastroepiploic artery, demonstrated arterial vasospasm and thrombus in angiography. Jump graft by using great saphenous vein from supraceliac aorta to right gastroepiploic artery was performed in end-to-side arterial anastomosis.

2) Hepatic artery stenosis (Fig. 2)


Fig. 2
Hepatic angiography showing arterial kicking and stenosis. Hepatic angiography show arterial kicking and stenosis at the anastomosis of CHA in CLT. The kicking of anastomosis site was revised by ballooning and stenting (A, B). Intimal dissection and stenosis in non-anastomotic site was relieved by ballooning and stenting (C, D).
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Among the CLT patient, one patient was found with common hepatic artery stenosis during checking the commputed tomography, suspicious of acute rejection. Intimal dissection and stenosis in the recipient artery (not the anastomosis) was revealed in conventional angiography, balloon and coronary stent insertion was done. One patient's commputed tomography showed 7 mm sized contrast filling around vascular structure in right hepatic artery can not rule out pseudoaneurysm, proved to be kicking of common hepatic artery anastomosis site in angiography. This stenosis was revised by ballooning and stenting.

Discussion

Hepatic artery thrombosis (HAT) after liver transplantation is a potentially life threatening complication(1). HAT presently complicates 3~9% of all CLTs (4, 5). Reconstruction of the hepatic artery is more difficult and challenging issue especially in living donor liver transplantation (LDLT), compared to CLT. The incidence of arterial thrombosis has been reduced dramatically from 25% without a microscope to 0~3.8% with a microscope(6-8). The technique of microsurgical hepatic artery reconstruction has contributed greatly to a reduced incidence of HAT and HAS. Technical failure of the reconstruction usually leads to re-transplantation or even death, and the procedure is complicated by anatomical variation, vascular consistency, and the hemodynamic situation of the recipients during the operation. Hepatic artery reconstruction is one of the key steps for LDLT. In a hospital launching liver transplantation, initial patient loss could make transplantation impossible to proceed with the operation if patient loss occurred because of the arterial complication. Initial failure will almost lead to the cessation of transplantation at launching hospitals. Therefore, transplantation surgeons were assisted by plastic surgeons that had many micorosurgical experiences in the beginning of liver transplantation operation. Recently transplantation surgeons themselves have performed hepatic artery anastomosis in most transplant centers. Proper anastomotic vessel choice via microsurgical technique in hepatic arterial reconstruction would reduce significantly the incidence of hepatic artery complications and provide an excellent graft survival following LDLT. The recipient's hepatic artery is located deep in the abdominal cavity and the operative field is limited and movable during ventilation(4-6), the intimal damage may be more severe, and the usable vessel grafts are limited. Because of the short and small hepatic artery, size discrepancy between the graft and recipient hepatic arteries, poor arterial pathologic state such as intimal dissection and reconstruction of hepatic arteries is a challenge to surgeons in LDLT(9, 10). Hepatic arterial complications including thrombosis, stenosis and aneurysm formation are life-threatening in LDLT by causing graft failure and irreversible biliary damage(9-11). So these early experiences have been accumulated, several techniques have attempted to improve the success rate. Recently many centers have designed new technique in order to reduce the arterial damage and complication which happens in operation(12-14). Other methods such as the fish-mouth method, funnelization method, or end-to-side anastomosis were not used in this study; sometimes it is dangerous to use the conventional twist reconstruction technique, because it may require turning over a damaged, short artery, some reports support a back wall support suture technique with double needle suture instead of conventional rotating method. There are a little literatures comparing conventional method with the back wall suture method. Some studies reported the advantage of the back wall method(15, 16). Using back wall support suture under microsurgical reconstruction, they could minimize the artificial injuries of hepatic arteries and improve the survival rate of the post liver transplantation by reducing hepatic artery thrombus(15-17).

In our study, all anastomoses were carried out by one transplant surgeon using atraumatic microvascular techniques in 5~10 times zoom magnification using an operating microscope during the reconstructions in LDLT, 3.5 times under the magnified scope in CLT. Only 1 case of HAT in recipients occurred which was in the 35 incipient patients following LDLT. Surgical techniques have been known as major factor for hepatic artery thrombosis. The key points in hepatic artery reconstruction included selecting a reciprocal stump location for arterial reconstruction: a thicker and healthy arterial stump in the recipient was chosen for the first anastomosis(18). When separating the arteries from surrounding structures, it is important to preserve plenty of soft tissue around the artery. The patient's liver condition such as fibrosis, ascite and coagulopathy influenced by primary disease could make it more difficult.

To minimize the incidence of intimal dissection and injury, careful division and preparation of recipient artery are necessary. When donor artery diameter is too small, isolation of smaller hepatic artery could be possible by dividing the deep recipient liver parenchyma to overcome the size discrepancy. Intimal damage and injury of hepatic artery usually occurs during dissection proximally to visualize smaller diameter of hepatic artery. In the case of intimal dissection, recipient hepatic artery is not suitable for reconstruction, some studies have been reported various applications by using splenic artery, right gastroepiploic artery and interposition graft between common hepatic artery and donor hepatic artery or between CHA and abdominal aorta, instead of dissected hepatic artery. Some reports suggested graft interposition increased the risk of HAT(19). Mostly, direct end to end anastomosis was simplest way to avoid the size mismatching and make larger anastomosis decreased risk for thrombosis theoretically. From the view of this, donor's cuff between right hepatic artery and cystic artery will be good option to anastomose with larger recipient's hepatic artery, as possible (Fig. 3).


Fig. 3
Schematic drawing of the microvascular anastomosis. Schematic drawings show the microvascular anastomosis. The recipient and graft artery are clamped without twisting. The first suture is placed at upper and posterior wall at most deep portion of two arteries (A), and hepatic artery cuff by using cystic attery to overcome size discrepancy (B).
Click for larger image

Some reports have provided the convenience and usefulness about hepatic artery anastomosis by using microsuture with double-arm needle(17). Initially, we must distress ourselves about the amount safe anastomosis of pressure hepatic arteries with previous single arm needle suture, having no idea of the new instrument and surgical product. While some cases of much shorter hepatic artery were difficult to use the conventional rotating method, we used the back wall suture with not rotation but fixed method. Because recipient artery tends to be more intimal dissection or damaged than healthy donor artery, each stitch was placed from the outer side of donor artery to the inner side of recipient artery with single needle, could make it distinct to penetrate the full thickness of poor recipient's arterial wall and attach the both arterial intimas.

It is more important to adjust arterial course and axis in hepatic arterial anastomosis, even if some tortuous or enough long in LDLT. While CHA in CLT has so thicker and larger diameter that approximate length detached arteries is more important compared with LDLT. Inapproximate lengthy anastomosis between donor and recipient artery without detaching from the recipient's hepatoduodenal ligament enough distally causes the kicking and stenosis under the natural position of whole liver.

Hepatic arterial kicking and stenosis in CLT may be more frequent than LDLT. Released liver may compress the anastomosis of length hepatic artery, the liver retracted to obtain visual field during arterial anastomosis.

In the case of early HAT, several methods, including re-transplantation, urgent revascularization, or revision of anastomosis, have been performed to avoid irreversible damage of the allograft(20-22). In our study, one recipients underwent urgent revascularization immediately after HAT was confirmed on the 1st day after LDLT, and were subsequently cured with satisfactory liver function. We performed hepatic reconstruction between RHA and RGEPA in HAT patient suspicious of inflow insufficiency after repeated TACE. CT show ischemic necrosis followed by hepatic arterial thrombosis, which occurred at segment VI at 1st day postoperatively day. Hepatic angiography show arterial vasospasm and thrombus occurred at the right gastroepiploic artery. In emergency operation, we anastmosed celiac axis and right gastroepiploic artery by using the great saphenous vein without aorta clamping. Celiac axis is more better inflow than abdominal aorta, no need to clamp the aorta and high blood pressure cause the GSV to tear after finishing direct anastomosis to aorta. Right gastroepiploic artery was anastomosed with donor hepatic artery is better distal conduit could be possible to anastomose in end-to-side fashion with larger GSV. It is difficult to anastomose the short and small donor hepatic artery to larger GSV directly. Therefore we anastomosed interposed right gastroepiploic artery to GSV by end to side fashion after checking anastomosis security between epiploic artery and donor hepatic artery. This patient didn't receive thrombolytic and anticoagulant therapy with monitoring of coagulation status, and thereafter HA inflow returned to normal. The majority of late hepatic complication occurred to only CLT, presented with no specific symptom. Patient with stenosis was treated with balloon angioplasty and endoluminal stent placement (4, 16). The stenosis proximal part from anastomosis site was found on the other patient. However, no death was associated with vascular complications. Late HAT, which occurred after the first postoperative month, can be well tolerated, and portal flow can support the liver until the collateral circulation has developed(23). Stent insertion after balloon angioplasty was performed for the patient in our study with late HAT. Liver function test results and general condition were good. However, long-term results of late HAT patients will require further research.

Conclusion

Careful preoperative evaluation and intraoperative microsurgical technique for hepatic artery reconstructions are the keys to prevent vascular complications following LDLT. Immediate surgical intervention is required for acute vascular complications, whereas late complications remain asymptomatic and may be treated by balloon angioplasty and endovascular stent placement.

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