Hepatic artery angioplasty after liver transplantation: experience in 21 allografts

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.

Successful percutaneous transluminal angioplasty for hepatic artery stenosis in an infant undergoing living-related liver transplantation

A 1-yr-old girl underwent a living-related liver transplant, with reconstruction of hepatic artery of 2 mm in diameter under microscopy. She developed intestinal perforation requiring closure on day 4 post-transplant and suffered from hepatic artery stenosis (HAS) on post-transplant day 9. Conservative therapies, such as intravenous or transluminal administration of anti-coagulants, vasodilators or fluids, were unsuccessful and caused remarkable general edema and multiple arrhythmias as a result of increased preload. On day 15 post-transplant, because flow velocity was remarkably reduced (as shown by Doppler ultrasound) the patient underwent percutaneous transluminal angioplasty (PTA) using a kit for coronary angioplasty. The balloon catheter was inflated [first: 1.5 mm diameter, 4 atmospheric pressure (a.p.) for 30 seconds (s); second: 2.0 mm diameter, 4 a.p. for 30 s; third: 2.5 mm diameter, 10 a.p. for 30 s]. The stenosis was successfully dilated without any complication. The patient has been doing well with normal liver functions for 4 months after PTA. From this experience, PTA can be performed for HAS after liver transplantation, even in an infantile case, with a careful technique and a special device.

Endovascular treatment of hepatic venous outflow obstruction after living-donor liver transplantation

PURPOSE

To evaluate the effectiveness and safety of percutaneous interventional management of hepatic venous outflow obstruction after living-donor liver transplantation (LDLT).

MATERIALS AND METHODS

Percutaneous balloon angioplasty (n = 5) and stent placement (n = 22) were attempted in 27 patients with hepatic venous outflow obstruction. Patient follow-up included clinical and laboratory data collection, Doppler ultrasonography (US), hepatic venography, and computed tomography. The following parameters were documented retrospectively: technical success and complications, clinical improvement, and recurrence. Technical success was defined as elimination or successful reduction of pressure gradients across the stenosis and clinical success was defined as amelioration of presenting signs. Recurrence was defined as relapse of clinical signs with hepatic venous anastomotic restenosis on Doppler US.

RESULTS

Technical success was achieved in all patients. The mean pressure gradients across the stenoses before and after the procedure were 10.6 mm Hg +/- 6.4 (range, 3-39 mm Hg) and 2.4 mm Hg +/- 2.6 (range, 0-8 mm Hg), respectively (P < .001). Three of the five patients who underwent balloon angioplasty developed recurrent stenosis 1-5 weeks after the procedure. These patients underwent repeat balloon angioplasty, and two of them eventually underwent stent placement (n = 1) or surgical repositioning (n = 1) of the graft. Three of the 22 patients who underwent stent placement required a second stent placement procedure because of malpositioning, partial migration, and acute angulation. During the mean follow-up period of 49 weeks +/- 47 (range, 3-214 wk), clinical success was achieved in 20 of 27 patients (73%).

CONCLUSION

Percutaneous interventional management is an effective and safe adjunct for the treatment of hepatic venous outflow obstruction after LDLT.

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.

Feasibility and effectiveness of using coronary stents in the treatment of hepatic artery stenoses after orthotopic liver transplantation: preliminary report

OBJECTIVE

Our aim is to evaluate the feasibility, efficacy, and patency of using coronary stents for the treatment of hepatic artery stenosis after liver transplantation.

CONCLUSION

Hepatic artery stenosis after liver transplantation can be treated using coronary stents. The low rate of complication, high technical success, and 1-year patency rates are encouraging.

Interventional Radiology in the Pediatric Liver Transplant Patient

Liver transplantation now plays a major role in the treatment of end-stage liver disease in children. Reduced-size liver transplant surgical techniques have allowed increasing numbers of children to undergo liver transplantation. As more children are undergoing liver transplantation, there is a growing need for radiologic diagnosis of and intervention in post-transplantation complications in these patients.

Liver transplantation in the UK

INTRODUCTION

This paper provides a review of the practice of liver transplantation with the main emphasis on UK practice and indications for transplantation.

REFERRAL AND ASSESSMENT

This section reviews the process of referral and assessment of patients with liver disease with reference to UK practice.

DONOR ORGANS

The practice of brainstem death and cadaveric organ donation is peculiar to individual countries and rates of donation and potential areas of improvement are addressed.

OPERATIVE TECHNIQUE

The technical innovations that have led to liver transplantation becoming a semi-elective procedure are reviewed. Specific emphasis is made to the role of liver reduction and splitting and living related liver transplantation and how this impacts on UK practice are reviewed. The complications of liver transplan-tation are also reviewed with reference to our own unit. Immunosuppression:The evolution of immunosuppression and its impact on liver transplantation are reviewed with some reference to future protocols.

RETRANSPLANTATION

The role of retransplantation is reviewed.

OUTCOME AND SURVIVAL

The results of liver transplantation are reviewed with specific emphasis on our own experience.

FUTURE

The future of liver transplantation is addressed.

Treatment for accidental occlusion of the hepatic artery after hepatic resection: report of two cases

Two patients in whom accidental hepatic artery occlusion (HAO) occurred after hepatic resection (Hx) were reported. A 59-year-old female who underwent Hx for hepatocellular carcinoma with underlying liver cirrhosis developed HAO on postoperative day (POD) 14 and died of hepatic failure on POD 23. The autopsy findings showed multiple necrosis in the remnant liver and an extraluminal hematoma of the hepatic artery, suggesting an injury caused by Pringle's maneuver. The second case was a 53-year-old male who underwent Hx for cholangiocarcinoma without any underlying liver disease. He developed HAO on POD 6, and radiological studies indicated a pseudoaneurysma formation and severe stenosis of the hepatic artery. It was speculated that the cause of the HAO was intraluminal injury of the hepatic artery during an angiographic study conducted prior to Hx. Partial arterialization of the portal vein was performed, following which his liver function test results improved. In both cases, measuring the serum hepatocyte growth factor level and the hepatic vein oxygen saturation proved useful, not only for determining the degree of liver injury, but also for predicting the outcome after treatments for HAO. Furthermore, the partial arterialization of the portal vein for HAO after Hx may rescue the normal remnant liver.

Early complications after orthotopic liver transplantation

The cost and impact of early post-transplant complications continue to be high. Diagnosis and management involves a high index of suspicion, rapid diagnostic and therapeutic interventions, and elimination of technical problems. Preoperative assessment of the donor and recipient medical condition and meticulous attention to detail during the technical performance of OLTx are the mainstays in achieving a good outcome.