Treatment of post-liver transplant hepatic artery pseudoaneurysm with balloon angioplasty after failed stent graft placement

Systematic review of extrahepatic hepatic artery pseudoaneurysm following adult liver transplantation: Risk factors and treatment modalities

Hepatic artery pseudoaneurysm (HAP) is a rare vascular complication following liver transplantation (LTx) with treatment choice frequently driven by institutional experience. Approximately, 10% of hepatic grafts are lost from this complication, requiring re-transplantation and placing further demand on the already present organ shortage. Secondly, patients with HAP can present with catastrophic bleeding, with reported mortality of up to 78%. We aim to identify risk factors associated with HAP and assess the survival benefit of different treatment modalities used (endovascular and open surgical techniques). Early detection may facilitate semi-elective management of this condition. A systematic search was performed in PubMed, Medline and Embase up to 1 October 2023. Case series with ≥5 patients focusing on adult patients who developed extrahepatic pseudoaneurysm following LTx were included. A total of 11 studies were pooled, comprising of 118 patients with survival data available in 61 patients. The most common presentation was haemorrhagic shock or luminal haemorrhage (75.5%). Bile leak was documented in 66.7% (28/42), 15.2% (18/118) associated foregut pathologies and 28.6% (14/49) of microbiology cultures grew a fungal organism. Flow preserving strategies (stenting, revascularization) trended towards better survival at 120 months compared to non-flow preserving strategies (embolization, HAL); however, this was not statistically significant following log rank (Mantel-Cox) analysis (P 0.169). Any patient following LTx presenting with haemorrhagic shock or luminal bleeding needs HAP excluded urgently. HAP management is complex, requiring careful consideration of patient specific presentation, anatomic factors and associated pathologies.

Endovascular Reconstruction of the Hepatic Arterial System for the Management of Mycotic Pseudoaneurysm in a Liver Transplant Patient

BACKGROUND

Hepatic artery pseudoaneurysm is a rare but very morbid complication after liver transplant. Treatment options include ligation or endovascular embolization, followed by revascularization. We describe a new endovascular approach by stent exclusion in a high-risk patient.

RESULTS

A 62-year-old male who received a second liver transplant after failed allograft presented with hemobilia and was diagnosed with a hepatic artery pseudoaneurysm in the setting of infection. Given his hostile abdomen, an endovascular approach was sought. We excluded the mycotic pseudoaneurysm with multiple covered stent grafts extending from the common hepatic artery to the right and left hepatic arteries. He was discharged with long-term antibiotics. On his 6-month follow-up visit, his stent was patent and hepatic function was stable.

CONCLUSIONS

Endovascular stent-graft placement for management of hepatic artery pseudoaneurysm after liver transplant should be considered as a lower morbidity alternative to surgical repair, even in the setting of infection.

Interval Magnetic Resonance Imaging: an Alternative to Guidelines for Indeterminate Nodules Discovered in the Cirrhotic Liver

BACKGROUND

Current guidelines for the management of indeterminate nodules discovered on surveillance imaging recommend alternate imaging modality or biopsy. This study evaluates the use of short interval MRI rather than immediate CT or biopsy.

METHOD

This retrospective cohort study examines outcomes of 111 patients with indeterminate nodules reviewed by a single institution's Liver Tumor Board 2011-2016. Analysis was focused on outcomes stratified by management decision.

RESULTS

The tumor board recommended biopsy or immediate repeat CT imaging in 13 (12%), 3-month interval MRI in 64 (58%) and 6-month interval MRI for 34 (30%) patients. Twenty-eight (29%) patients in the interval MRI subgroups were diagnosed with hepatocellular carcinoma (HCC) during the period of follow-up, and 21 (75%) of these were located within the original indeterminate nodule. The median time to diagnosis was 6.5 months. Twenty-three (82%) were eligible for potentially curative therapy at the time of HCC diagnosis. Delay in HCC diagnosis was not the reason for inability to provide potentially curative therapy in any patient.

CONCLUSION

This study supports the judicious use of interval MRI at 3 or 6 months in patients with liver cirrhosis and an indeterminate liver nodule rather than immediate CT scan or biopsy.

Early Detection of a Hepatic Artery Pseudoaneurysm After Liver Transplantation Is the Determinant of Survival

BACKGROUND

Hepatic artery pseudoaneurysm (PA) after liver transplantation (LT) is a rare but potentially fatal complication. Among a series of 50 patients of LT, we experienced 3 such cases. Some authors also have reported cases of PA, either intrahepatic or extrahepatic. The aim of this study was to investigate the important factors that affect the treatment outcome.

METHODS

Three patients were presented. To analyze the factors, not only our patients but also the patients with PA reported in the literature (including 10 case series and 23 case reports) were enrolled for analysis. The possible factors probably affecting the survival were compared statistically, including age, sex, clinical manifestation as bleeding (including gastrointestinal bleeding, hemobilia, or intra-abdominal bleeding), treatment (with embolization or surgical exploration or stent), diagnosis establishment before or after bleeding, and so forth.

RESULTS

From univariate analysis, the significant factors that affect survival are sex (female) (P = .036), stent treatment (P = .006), and early detection (P = .036), whereas age (P = .493) and presentation with hemorrhage (P = .877) are not significant factors. However, according to multivariate analysis, stent treatment has a borderline significance (P = .056).

CONCLUSIONS

Early detection of such a life-threatening complication is a key determinant of survival. "Early" does not refer to early postoperative days but means the detection prior to the rupture of the pseudoaneurysm. Postoperative imaging studies such as computed tomographic scan or magnetic resonance cholangiopancreatography early and periodically to follow up the graft status is recommended, especially for those who had received other interventions before or after the liver transplantation.

Iatrogenic-related transplant injuries: the role of the interventional radiologist

As advances in surgical techniques and postoperative care continue to improve outcomes, the use of solid organ transplants as a treatment for end-stage organ disease is increasing. With the growing population of transplant patients, there is an increasing need for radiologic diagnosis and minimally invasive procedures for the management of posttransplant complications. Typical complications may be vascular or nonvascular. Vascular complications include arterial stenosis, graft thrombosis, and development of fistulae. Common nonvascular complications consist of leaks, abscess formation, and stricture development. The use of interventional radiology in the management of these problems has led to better graft survival and lower patient morbidity and mortality. An understanding of surgical techniques, postoperative anatomy, radiologic findings, and management options for complications is critical for proficient management of complex transplant cases. This article reviews these factors for kidney, liver, pancreas, islet cell, lung, and small bowel transplants.

Surgical and endovascular treatment of hepatic arterial complications following liver transplant

Vascular complications after liver transplantation increase post-operative morbidity and contribute to the incidence of retransplantation. Vascular complications comprise arterial, caval, and portal venous pathology, with the majority of complications being arterial in etiology, including anastomotic stricture, pseudoaneurysm, and thrombosis. There are two major therapeutic options for the treatment of these arterial complications: endovascular intervention and surgery. The former includes intra-arterial thrombolysis, embolization, percutaneous transluminal angioplasty, and stent placement. The latter includes thrombectomy, reanastomosis, and retransplantation. Although surgical treatment has been considered the first choice for management in the past, advances in endovascular intervention have increased and make it a viable therapeutic option following orthotopic liver transplantation. This review focuses on the role of surgical and endovascular therapy in the management of hepatic arterial complications after liver transplantation.