Treatment of early hepatic artery thrombosis after liver transplantation

Hepatic artery vasospasm masquerading as early hepatic artery thrombosis in progressive familial intrahepatic cholestasis 3: a case report

Post-liver transplant (LT) hepatic artery vasospasm is a vascular complication that is not well recognized and its incidence is not known. As a possible sequela to vasospasm, hepatic artery thrombosis is the second major cause of allograft failure after primary nonfunction and its reported incidence is 2.9% in adults and 8.3% in pediatric LT. Lacuna in knowledge regarding early hepatic artery vasospasm post-LT makes it a difficult condition to diagnose and treat, as the initial ischemic insult on graft can have devastating consequences. We report a case of pediatric progressive familial intrahepatic cholestasis type 3-related chronic liver disease who underwent cadaveric orthotopic LT and postoperatively developed fever, worsening hypotension, and elevated liver enzymes with an absence of arterial flow in intrahepatic branches on Doppler ultrasound. Suspecting early hepatic artery thrombosis, the patient was re-explored and the graft hepatic artery was found to be in a state of vasospasm. Following the infusion of intra-arterial papaverine, urokinase, and intravenous nicorandil, there was an improvement in blood flow. The patient responded well and was discharged on postoperative day 23 with normal liver enzymes.

Patency rates of hepatic arterial resection and revascularization in locally advanced pancreatic cancer

BACKGROUND

Arterial resection (AR) for pancreatic adenocarcinoma is increasingly considered at specialized centers. We aimed to examine the incidence, risk factors, and outcomes of hepatic artery (HA) occlusion after revascularization.

METHODS

We included patients undergoing HA resection with interposition graft (IG) or primary end-to-end anastomoses (EE). Complete arterial occlusion (CAO) was defined as "early" (EO) or "late" (LO) before/after 90 days respectively. Kaplan-Meier and change-point analysis for CAO was performed.

RESULTS

HA resection was performed in 108 patients, IG in 61% (66/108) and EE in 39% (42/108). An equal proportion (50%) underwent HA resection alone or in combination with celiac and/or superior mesenteric artery. CAO was identified in 18% of patients (19/108) with arterial IG least likely to occlude (p=0.019). Hepatic complications occurred in 42% (45/108) and correlated with CAO, symptomatic patients, venous resection, and postoperative portal venous patency. CAO-related operative mortality was 4.6% and significantly higher in EO vs LO (p = 0.046). Median CAO occlusion was 126 days. With change-point analysis, CAO was minimal beyond postoperative day 158.

CONCLUSION

CAO can occur in up to 18% of patients and the first 5-month post-operative period is critical for surveillance. LO is associated with better outcomes compared to EO unless there is inadequate portal venous inflow.

Bivalirudin for the prevention of hepatic artery thrombosis in pediatric liver transplantation

BACKGROUND

Early hepatic artery thrombosis (HAT) after liver transplantation is a serious complication that frequently results in graft loss and the need for retransplantation. Although studies have reported on various operative and endovascular treatment approaches, pharmacologic strategies for the prevention or management of HAT are not well defined. Patients with blood clotting disorders, those with a contraindication to heparin, and those who have previously developed HAT represent unique challenges in management.

METHODS

We present the case of a 9-month-old male with a hypercoagulable state who developed early HAT after two liver transplants, despite the use of postoperative therapeutic heparin infusion.

RESULTS AND CONCLUSION

The patient successfully underwent a third liver transplant using intraoperative and postoperative bivalirudin infusion, a direct thrombin inhibitor. Rotational thromboelastometry (ROTEM) was used to guide anticoagulation and blood product administration in the perioperative period. At 1.5 years post-transplant, the patient has good graft function with patent hepatic vasculature. This case demonstrates the innovative use of bivalirudin anticoagulant therapy and viscoelastic methodologies to improve outcomes in hypercoagulable liver transplant recipients.

Hepatic artery reconstruction in pediatric liver transplantation: Experience from a single group

BACKGROUND

The reconstruction of hepatic artery is a challenging part of the pediatric liver transplantation procedure. Hepatic artery thrombosis (HAT) and stenosis are complications which may result in ischemic biliary injury, causing early graft lost and even death.

METHODS

Two hundred and fifty-nine patients underwent liver transplantation in 2017 in a single liver transplantation group. Among them, 225 patients were living donor liver transplantation (LDLT) and 34 deceased donor liver transplantation (DDLT).

RESULTS

In LDLT all reconstructions of hepatic artery were microsurgical, while in DDLT either microsurgical reconstruction or traditional continuous suture technique was done depending on different conditions. There were five (1.9%) HATs: four (4/34, 11.8%) in DDLT (all whole liver grafts) and one (1/225, 0.4%) in LDLT (P = 0.001). Four HATs were managed conservatively using anticoagulation, and 1 accepted salvage surgery with re-anastomosis. Until now, 3 HAT patients remain in good condition, whereas two developed biliary complications. One of them needed to be re-transplanted, and the other patient died due to biliary complications.

CONCLUSIONS

Microsurgical technique significantly improves the reconstruction of hepatic artery in pediatric liver transplantation. The risk for arterial complications is higher in DDLT. Conservative therapy can achieve good outcome in selected HAT cases.

Catheter directed hepatic artery thrombolysis following liver transplantation. Case report and review of the literature

Hepatic artery thrombosis is the most frequent vascular complication following orthotopic liver transplantation, and often results in biliary complications, early graft loss and death. Surgical revascularization and retransplantation are considered the mainstay of treatment. However, intraarterial endovascular therapy is an alternative that has shown low morbidity and mortality, thereby avoiding the need for retransplantation. We describe a case of orthotopic liver transplantation complicated with hepatic artery thrombosis that was successfully treated with endovascular therapy.

Antithrombin III in the prevention of thrombotic complications in high risk patients undergoing liver transplantation

Introduction. Recent studies have indicated an increased incidence of thrombotic vascular complications after liver transplantation. The reasons may be associated with surgical technique and “unbalanced” hemostasis in patients with diffuse liver diseases. The imbalance is determined by the deficiency of physiological procoagulants and anticoagulants due to a reduced protein-synthesis function of the liver in chronic hepatocyte injury. At the same time, 90% of all spontaneous antithrombin activity is associated with antithrombin III.

Aim. The aim of the study was to evaluate the efficacy of using antithrombin III concentrate in liver transplant patients.

Material and methods. A retrospective study included 46 patients undergoing liver transplantation who had nonocclusive thrombosis in the portal vein system prior to surgery and postoperative venous or arterial thrombosis.

Results. The treatment results were compared between the group with antithrombin III concentrate and the control group in patients with portal vein thrombosis before surgery and postoperative venous or arterial thrombosis; the antithrombin III activity dynamics in the early postoperative period was assessed; the incidence of infectious, and vascular complications and the mortality rates were analyzed.

Conclusion. The antithrombin III concentrate administration during liver transplantation and in the postoperative period contributes to a rapid normalization of antithrombin III activity in blood, the decrease in mortality and in the incidence of infectious and thrombotic complication rates.

Marked Decrease in Urgent Listing for Liver Transplantation Over Time: Evolution of Characteristics and Outcomes of Status-1 Liver Transplantation

BACKGROUND

Approximately 5% of liver transplants annually are performed urgently with "status-1" designation. This study aims to determine if the demand, characteristics, and outcome for status-1 liver transplantation has changed over time.

METHODS

We used the Scientific Registry of Transplant Patients (2003-2015) to characterize 2352 adult patients who underwent 2408 status-1 liver transplants and compared them between Era1 (2003-6/2009) and Era2 (7/2009-2015).

RESULTS

Overall, there were fewer liver transplants performed with the status-1 designation in Era2 than Era1 (1099 vs 1309). Although the number of urgent liver transplants was relatively constant with successive years, the proportion transplanted with status-1 designation decreased markedly over time. Era2 patients were older (43.2 years vs 41.7 years, P = 0.01) and less likely be ABO-incompatible (1.1% vs 2.4%, P = 0.01) or retransplant (77 vs 124, P = 0.03). In terms of disease etiology, the largest group was "acute liver failure (ALF), nonspecified" (43.4%). There was no difference in proportion with drug-induced liver injury (DILI), but the subset of herbal/dietary supplements increased in Era2 (1.3% vs 0.46%, P = 0.04). Survival was increased in Era2 in the overall cohort and for patients with autoimmune disease (P < 0.05), despite longer waiting times for this etiology (186 days vs 149 days). DILI or nonspecified ALF had shorter waiting times, and 90% were transplanted within 7 days.

CONCLUSIONS

Liver transplantation for the most urgent indications (status-1) is decreasing while survival remains excellent. Fewer incidences of ALF are classified as indeterminate, mostly as a result of increasing awareness of autoimmune hepatitis and DILI as causes of the syndrome.

Common hepatic artery thrombosis after iatrogenic injury in pancreaticodudenectomy operation, unexpected course

INTRODUCTION

Pancreatic resection is the only effective treatment with prolonged survival in operable pancreatic cancer and peri-ampullary cancer; it is also a procedure of significant morbidity and complications. Vascular injury is one of the most serious intraoperative complications.

PRESENTATION OF CASE

We report here a case of common hepatic artery injury during pancreaticodudenectomy followed by complete thrombosis after its repair. As common hepatic artery is the only arterial blood supply of the liver, acute liver failure and necrosis were the usual course. Surprisingly liver enzymes and bilirubin start to improve in post operatively due to small hardly detected accessory left and middle hepatic artery.

DISSCUSSION AND CONCLUSION

Although hepatic artery is the only arterial supply of the liver, occasionally small accessory arteries may give significant arterial blood supply. In such a situation liver enzymes act as surrogate markers to assess the sufficiency of this flow to the liver.

Nonvascular post-liver transplantation complications: from US screening to cross-sectional and interventional imaging

Orthotopic liver transplantation is becoming an increasingly routine procedure for a variety of benign and malignant diseases of the liver and biliary system. Continued improvements in surgical techniques and post-transplantation immunosuppression regimens have resulted in better graft and patient survival. A number of potentially treatable nonvascular complications of liver transplantation are visible at imaging, and accurate diagnosis of these complications allows patients to benefit from potential treatment options. Biliary complications include stricture (anastomotic and nonanastomotic), leak, biloma formation, and development of intraductal stones. Pathologic conditions, including hepatitis C infection, hepatocellular carcinoma, hepatic steatosis, and primary sclerosing cholangitis, may recur after liver transplantation. Transplant patients are at increased risk for developing de novo malignancy, including post-transplantation lymphoproliferative disorder, which results from immunosuppression. Patients are also at increased risk for systemic infection from immunosuppression, and patients with hepatic artery and biliary complications are at increased risk for liver abscess. Transplant recipients are typically followed with serial liver function testing; abnormal serum liver function test results may be the first indication that there is a problem with the transplanted liver. Ultrasonography is typically the first imaging test performed to try to identify the cause of abnormal liver function test results. Computed tomography, magnetic resonance imaging, angiography, and/or cholangiography may be necessary for further evaluation. Accurately diagnosing nonvascular complications of liver transplantation that are visible at imaging is critically important for patients to benefit from appropriate treatment.

Anticoagulation and antiplatelets as prophylaxis for hepatic artery thrombosis after liver transplantation

Hepatic artery thrombosis (HAT) is the most serious vascular complication after liver transplantation. Multiple risk factors have been identified to impact its development. Changes in haemostasis associated with end stage liver disease and the disturbance of the coagulation and anticoagulation cascades play an important role in development of this lethal complication. Early recognition and therapeutic intervention is mandatory to avoid its consequences. Pharmacological prophylaxis, by the use of antiplatelet or anticoagulant agents, is an important tool to reduce its incidence and prevent graft loss. Only a few studies have shown a clear benefit of antiplatelet agents in reducing HAT occurrence, however, these studies are limited by being retrospective and by inhomogeneous populations. The use of anticoagulants such as heparin is associated with an improvement in the outcomes mainly when used for a high-risk patients like living related liver recipients. The major concern when using these agents is the tendency to increase bleeding complications in a setting of already unstable haemostasis. Hence, monitoring of their administration and careful selection of patients to be treated are of great importance. Well-designed clinical studies are still needed to further explore their effects and to formulate proper protocols that can be implemented safely.

Impact of hepatic arterial hemodynamics in predicting early hepatic arterial thrombosis in pediatric recipients younger than three yr after living donor liver transplantation

We used Doppler US to evaluate the changes in hepatic arterial hemodynamics that occur following LDLT in pediatric recipients, with a view to assessing the utility of these parameters in predicting early HAT. A retrospective review of 144 pediatric recipients (73 males, 71 females) who underwent routine Doppler US in the first week after LDLT was undertaken, and changes in hepatic arterial hemodynamics were assessed. The HARI and HAPSV were compared in patients with early HAT (defined as occurring in the first postoperative week) and a control group, and the utility of these parameters in predicting early HAT after LDLT was determined. A total of 11 pediatric recipients experienced early HAT, being diagnosed on average four and a half days after LDLT. HARI and HAPSV values were significantly different between the early HAT group and controls. HARI values <0.6 on the day before the onset of early HAT were able to predict HAT development with a sensitivity of 81.8% and specificity of 95.2%. This provides evidence for routine Doppler US examination in these patients and supports consideration of more intensive anticoagulation in these high-risk patients.

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.

A meta-analysis of complications following deceased donor liver transplant

BACKGROUND

Liver transplantation is a complex surgery associated with high rates of postoperative complications. While national outcomes data are available, national rates of most complications are unknown.

DATA SOURCES

A systematic review of the literature reporting rates of postoperative complications between 2002 and 2012 was performed. A cohort of 29,227 deceased donor liver transplant recipients from 74 studies was used to calculate pooled incidences for 17 major postoperative complications.

CONCLUSIONS

This is the first comprehensive review of postoperative complications after liver transplantation and can serve as a guide for transplant and nontransplant clinicians. Efforts to collect national data on complications, such as through the National Surgical Quality Improvement Program, would improve the ability to provide patients with informed consent, serve as a tool for individual center performance monitoring, and provide a central source against which to measure interventions aimed at improving patient care.

Current concepts in pediatric liver transplantation

Liver transplantation is the definitive treatment for end-stage liver disease in both children and adults. Advances over the last 2 decades have resulted in excellent patient and graft survival rates in what were previously cases of fatal disorders. These developments have been due to innovations in surgical technique, increased surgical experience, refinements in immunosuppressive regimens, quality improvements in intraoperative anesthetic management, better understanding of the pathophysiology of the liver diseases, and better preoperative and postoperative care. Remarkably, the use of split-liver and living-related liver transplantation surgical techniques has helped mitigate the well-recognized national organ shortage. This review will discuss the major aspects of pediatric liver transplantation as it pertains to indication for transplantation, recipient selection and listing for orthotopic liver transplantation, pre-orthotopic liver transplantation care of children, optimal timing of orthotopic liver transplantation, surgical technical considerations, postoperative care and complications, and patient and graft survival outcomes.