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

Endovascular therapies for hepatic artery stenosis post liver transplantation

PURPOSE

To evaluate primary patency at 12 months after endovascular therapies in hepatic artery stenosis.

METHODS

A retrospective review of all endovascular interventions for hepatic artery stenosis (HAS) after liver transplantation that occurred between June 2013 and November 2020 was performed at a single institution in France. Follow up occurred from 1 month to 4 years (median 15 months). The treatment consisted of dilation with a balloon or stent. We analyzed short-term (technical success and complications) and long-term outcomes (liver function, arterial patency, graft survival at 12 months (GS), and reintervention). We also compared percutaneous balloon angioplasty (PBA) with stent placement. PBA alone was used if < 30% residual stenosis of the hepatic artery was achieved. Stenting was performed if there was greater than 30% residual stenosis and in the case of complications (dissection or rupture).

RESULTS

A total of 18 stenoses were suspected on the basis of routine surveillance duplex ultrasound imaging (peak systolic velocity > 200 cm/s, systolic accelerating time > 10 ms and resistive index < 0.5), all of which were confirmed by angio CT, but only 17 were confirmed by angiography. Seventeen patients were included (14 males, mean age 57 years; and three females, mean age 58 years). Interventions were performed in 17 cases (95%) with PBA only (5/17), stent only (5/17) or both (4/17). Immediate technical success was 100%. Major complications occurred in 1 of 17 cases (5.8%), consisting of target vessel dissection. The analysis of the three (groups PBA only, stent only or both) showed the same procedural success (100%), GS (100%) and normal liver function after the procedures but different rates of complications (20% vs. 0% vs. 0%), arterial patency at 12 months (60% vs. 80% vs. 85%) (p = 0.4), early stenosis (40% vs. 80% vs. 0%) or late stenosis (60% vs. 20% vs. 100%) and requirement for reintervention (40% vs. 20% vs. 14%) (p = 0.56).

CONCLUSION

This study suggests that PBA, stent, or both procedures show the same primary patency at 12 months. It is probably not a definitive answer, but these treatments are safe and effective for extending graft survival in the context of graft shortages.

Understanding Local Hemodynamic Changes After Liver Transplant: Different Entities or Simply Different Sides to the Same Coin?

Liver transplantation is an extremely complex procedure performed in an extremely complex patient. With a successful technique and acceptable long-term survival, a new challenge arose: overcoming donor shortage. Thus, living donor liver transplant and other techniques were developed. Aiming for donor safety, many liver transplant units attempted to push the viable limits in terms of size, retrieving smaller and smaller grafts for adult recipients. With these smaller grafts came numerous problems, concepts, and definitions. The spotlight is now aimed at the mirage of hemodynamic changes derived from the recipients prior alterations. This article focuses on the numerous hemodynamic syndromes, their definitions, causes, and management and interconnection with each other. The aim is to aid the physician in their recognition and treatment to improve liver transplantation success.

Management of early hepatic artery thrombosis following living-donor liver transplantation: feasibility, efficacy and potential risks of endovascular therapy in the first 48 hours post-transplant-a retrospective cohort study

This retrospective cohort study aims to review our 18-year experience with early hepatic artery thrombosis (e-HAT) following living-donor liver transplantation (LDLT), as well as to assess the feasibility, efficacy and potential risks of endovascular management of e-HAT in the first 48 hours (hrs) post-LDLT. Medical records of 730 patients who underwent LDLT were retrospectively reviewed. In all cases who had developed e-HAT, treatment modalities employed and their outcomes were evaluated. Thirty-one patients developed e-HAT(4.2%). Definite technical success and 1-year survival rates of surgical revascularization[11/31 cases(35.5%)] were 72.7% & 72.7%, whereas those of endovascular therapy[27/31 cases(87.1%)] were 70.4% & 59.3%, respectively. Endovascular therapy was carried out in the first 48hrs post-transplant in 9/31 cases(29%) [definite technical success:88.9%, 1-year survival:55.6%]. Four procedure-related complications were reported in 3 of those 9 cases(33.3%). In conclusion, post-LDLT e-HAT can be treated by surgical revascularization or endovascular therapy, with comparable results. Endovascular management of e-HAT in the first 48hrs post-LDLT appears to be feasible and effective, but is associated with a relatively higher risk of procedure-related complications, compared to surgical revascularization. Hence, it can be reserved as a second-line therapeutic option in certain situations where surgical revascularization is considered futile, potentially too complex, or potentially more risky.

Hepatic artery stenosis angioplasty and implantation of Wingspan neurovascular stent: A case report and discussion of stenting in tortuous vessels

BACKGROUND

Hepatic artery stenosis is a complication of orthotopic liver transplant occurring in 3.1%-7.4% of patients that can result in graft failure and need for re-transplantation. Endovascular therapy with angioplasty and stenting has been used with a high degree of technical success and good clinical outcomes, but tortuous hepatic arteries present a unique challenge for intervention. Suitable stents for this application should be maneuverable and conformable while also exerting adequate radial force to maintain a patent lumen.

CASE SUMMARY

Herein we report our experience with a neurovascular Wingspan stent system in a challenging case of recurrent hepatic artery stenosis and discuss the literature of stenting in tortuous transplant hepatic arteries.

CONCLUSION

Wingspan neurovascular stent is self-expanding, has good conformability, and adequate radial resistance and as such it could be added to the armamentarium of interventionalists in the setting of a tortuous and stenotic transplant hepatic artery.

Complications after endovascular treatment of hepatic artery stenosis after liver transplantation

BACKGROUND

Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis (HAT) and a subsequent 30% to 50% risk of graft loss. Although endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment, the potential risks of these interventions are poorly described.

METHODS

A retrospective review of all endovascular interventions for HAS after liver transplantation between August 2009 and March 2016 was performed at a single institution, which has the largest volume of liver transplants in the United States. Severe HAS was identified by routine surveillance duplex ultrasound imaging (peak systolic velocity >400 cm/s, resistive index <0.5, and presence of tardus parvus waveforms).

RESULTS

In 1129 liver transplant recipients during the study period, 106 angiograms were performed in 79 patients (6.9%) for severe de novo or recurrent HAS. Interventions were performed in 99 of 106 cases (93.4%) with percutaneous transluminal angioplasty alone (34 of 99) or with stent placement (65 of 99). Immediate technical success was 91%. Major complications occurred in eight of 106 cases (7.5%), consisting of target vessel dissection (5 of 8) and rupture (3 of 8). Successful endovascular treatment was possible in six of the eight patients (75%). Ruptures were treated with the use of a covered coronary balloon-expandable stent graft or balloon tamponade. Dissections were treated with placement of bare-metal or drug-eluting stents. No open surgical intervention was required to manage any of these complications. With a median of follow-up of 22 months, four of eight patients (50%) with a major complication progressed to HAT compared with one of 71 patients (1.4%) undergoing a hepatic intervention without a major complication (P < .001). One patient required retransplantation. Severe vessel tortuosity was present in 75% (6 of 8) of interventions with a major complication compared with 34.6% (34 of 98) in those without (P = .05). In the complication cohort, 37.5% (3 of 8) of the patients had received a second liver transplant before intervention compared with 12.6% (9 of 71) of the patients in the noncomplication cohort (P = .097).

CONCLUSIONS

Although endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery and prior retransplantation were associated with a twofold to threefold increased risk of a major complication. Acute vessel injury can be managed successfully using endovascular techniques, but these patients have a significant risk of subsequent HAT and need close surveillance.

Endovascular Mechanical Thromboaspiration of Right Hepatic Arterial Thrombosis After Liver Transplantation

A 56-year-old male Patient presented 27 days after a liver transplantation (LT) with fever and hyperbilirubinemia. He underwent CT examination resulting in a diagnosis of right hepatic artery (HA) occlusion with hepatic bilomas. Once placed a long right femoral 6F introducer at the origin of the HA, a 0.014" guidewire was advanced over the thrombus, in a segmental branch. A 4MAX (Penumbra, Alameda, USA) catheter was advanced and withdrawn under constant aspiration until complete clot removal was achieved. Follow-up CT and D-US assessments at 12 months demonstrated regular HA patency and bilomas reduction. Endovascular thromboaspiration is an effective strategy in cases of E-HAT after LT.

Doppler Characteristics of Recurrent Hepatic Artery Stenosis

OBJECTIVES

We sought to assess midterm sonographic findings in patients after stenting for hepatic artery stenosis.

METHODS

Thirty-nine hepatic artery stent procedures were performed for hepatic artery stenosis after liver transplantation between September 2009 and December 2013. Thirty cases were technically successful and met the minimum follow-up time (76 days, defined by earliest diagnosed stenosis). Routine ultrasound surveillance was obtained on all patients, and statistical analysis of the findings in the patency and restenosis groups was performed.

RESULTS

Of the 30 cases, restenosis occurred 9 times in 6 patients. Mean follow-up was 677 days. Mean time to restenosis was 267 days. Five cases (56%) were identified within the first 6 months after stent placement. Four cases (44%) were recognized in the second year after stent placement. Prior to the sonographic diagnosis of restenosis, the mean resistive indices of the main (.64 versus .57, P < .0001), left (.63 versus .54, P < .0001), right anterior (.60 versus .52, P < .0001), and right posterior (.60 versus .53, P = .001) hepatic artery branches differed among patency and restenosis groups, respectively. The mean peak systolic velocity also differed significantly between the 2 groups: 254 cm/sec in patients with eventual restenosis versus 220 cm/sec in patients without restenosis (P = .02).

CONCLUSIONS

The sonographic evaluation of hepatic artery stenosis remains critical during the first 2 years after stent placement. While the vast majority of patients do not restenose, resistive index and peak systolic velocity differed significantly between the 2 groups and may be prognostic surveillance markers for the development of restenosis.

Catheter Thrombolysis of Thrombosed Hepatic Arteries in Liver Transplant Recipients: Predictors of Success and Role of Thrombolysis

Hepatic artery thrombosis is an uncommon complication of liver transplantation. However, it is a major indication for re-transplantation. The use of transcatheter thrombolysis and subsequent surgical revascularization as a graft salvage procedure is discussed. Four of 5 cases (80%) were successful in re-establishing flow and uncovering underlying arterial anatomic defects. None were treated definitively by endoluminal measures due to an inability to resolve the underlying anatomic defects. However, 2 of 5 cases (40%) went on to a successful surgical revascularization and represent successful long-term outcome of transcatheter thrombolysis followed by definitive surgical revascularization. We conclude that, definitive endoluminal success cannot be achieved without resolving associated, and possibly instigating, underlying arterial anatomical defects. However, reestablishing flow to the graft can unmask underlying lesions as well as asses surrounding vasculature thus providing anatomical information for a more elective, better planned and definitive surgical revision.

Percutaneous Transluminal Angioplasty and Stenting for Hepatic Vessel Stenosis after Orthotopic Liver Transplantation

BACKGROUND

This study aimed to evaluate the efficacy of vascular intervention in percutaneous transluminal angioplasty (PTA) for the treatment of hepatic artery and hepatic vein stenosis after liver transplantation (LT), including thrombotic total occluded lesions.

METHODS

Percutaneous transluminal angioplasty after orthotopic liver transplantation was performed to re-open hepatic vessel lesions. We daily used routine Doppler ultrasound during admission for early detection of graft hepatic vessel lesions, including hepatic artery and vein lesions. In outpatients, Doppler ultrasound was performed every month. Urokinase was delivered with a dose of 150,000-300,000 IU by catheter before PTA for thrombotic total occlusion of the graft for hepatic artery patients. Laboratory data were collected to evaluate the effects of the PTA procedure.

RESULTS

The study involved a total of seven patients, six of whom were successfully treated by a first PTA procedure. Thrombolysis use of urokinase in totally occluded donor hepatic arteries post-LT following stenting was successful in three patients. One complication occurred, an arterial dissection and perforation, finalizing the success rate at ~86% and the complication rate at ~14%. Therefore, our study has a primary patency rate of 100% at 1 and 3 months. Also, the graft survival rate was 100 % and 86 % in the first and third months, respectively.

CONCLUSIONS

PTA with stenting is an effective treatment for hepatic vessel stenosis, including hepatic arteries and hepatic veins, after a liver transplantation without an increase in the complication rate. In addition, thrombolysis using urokinase intra-artery infusion in graft thrombotic total occluded patients is a good treatment strategy as well.

KEY WORDS

Angioplasty; Complication; Liver transplantation.

Percutaneous Endovascular Treatment for Hepatic Artery Stenosis after Liver Transplantation: The Role of Percutaneous Endovascular Treatment

BACKGROUND

To retrospectively analyze the outcomes of interventional radiology treatment of patients with hepatic artery stenosis (HAS) after liver transplantation at our Institution.

MATERIAL/METHODS

Hepatic artery stenosis was diagnosed and treated by endovascular technique in 8 (2.8%) patients, who underwent liver transplantation between July 2007 and July 2011. Patients entered the follow-up period, during which we analyzed hepatic artery patency with Doppler ultrasound at 1, 3, 6, and 12 months after percutaneous endovascular treatment (PTA), and every six months thereafter.

RESULTS

During the 12-month follow-up period, 6 out of 8 patients (75%) were asymptomatic with patent hepatic artery, which was confirmed by multislice computed tomography (MSCT) angiography, or color Doppler (CD) ultrasound. One patient had a fatal outcome of unknown cause, and one patient underwent orthotopic liver retransplantation (re-OLT) procedure due to graft failure.

CONCLUSIONS

Our results suggest that HAS angioplasty and stenting are minimally invasive and safe endovascular procedures that represent a good alternative to open surgery, with good 12-month follow-up patency results comparable to surgery.

Ultrasound findings after endovascular stent deployment in transplant liver hepatic artery stenosis

OBJECTIVE

Endovascular stenting is a safe, effective treatment of hepatic artery stenosis after liver transplant, but no detailed evaluation has been completed of changes in ultrasound monitoring parameters after stenting. This study aims to improve poststenting surveillance by delineating the expected postoperative findings.

MATERIALS AND METHODS

Thirty-one stent procedures were performed at our institution for hepatic artery stenosis after liver transplant between October 2010 and October 2012. Of these, 28 (90%) were technically successful, of which 23 met the minimum follow-up time (76 days, defined by the earliest diagnosed restenosis). These patients were followed with serial ultrasound, per the following schedule: within 1 week of stenting, 3 months after stenting, 6 months after stenting, and every 6 months thereafter; additional, unscheduled examinations were frequently performed when indicated on the basis of deterioration of clinical and laboratory status. Follow-up examinations (mean, 268 days total follow-up) were compared with prestenting examinations to evaluate changes in peak systolic velocity (PSV), resistive index (RI), and tardus-parvus waveforms. Data were analyzed to determine a normal range for postprocedure values and time course of change in values.

RESULTS

Of the 23 patients, six experienced restenosis. In all patients, mean PSV decreased by 124 cm/s, and mean RI increased by 0.13 within 48 hours after stenting. PSV differed between patency and restenosis groups only at more than 90 days after stenting (mean PSV, 234 and 400 cm/s, respectively), with PSV above 300 cm/s serving as a high-sensitivity threshold for the determination of restenosis. Prestenting RI of below 0.40 had a strong correlation with restenosis. Poststenting RI differed between patency and restenosis groups only at more than 48 hours after stenting, with RI of below 0.55 having a strong correlation with restenosis. Tardus-parvus waveform resolution was often delayed well beyond 48 hours after stenting, and time to tardus-parvus waveform resolution had no correlation with patency or restenosis.

CONCLUSION

Ultrasound is convenient and useful to follow stents in hepatic artery stenosis after liver transplant. Prestenting hemodynamics can have value in predicting restenosis. Diagnosis of restenosis can be made with RI and PSV, whereas resolution time of tardus-parvus waveform is of less concern. These parameters can guide which patients require closer monitoring and aggressive treatment.

Stent placement versus angioplasty for hepatic artery stenosis after liver transplant: a meta-analysis of case series

BACKGROUND

Hepatic artery stenosis (HAS) is a serious complication of liver transplantation but data on the most effective endovascular management are lacking. We aimed to compare percutaneous balloon angioplasty (PBA) with stent placement.

METHODS

We searched MEDLINE, Cochrane, Web of Science, EMBASE, SCOPUS, and Biosis Previews between 1970 and December 2011 and performed meta-analysis of short-term (procedural success, complications) and long-term outcomes (liver function, arterial patency, survival, re-intervention, re-transplantation). Random effects models were used for the analysis and meta-regression performed for the year of study.

RESULTS

A total of 263 liver transplants in 257 patients [age 43 (±8) years] underwent 147 PBAs and 116 stents. Transplanted livers were from deceased donors in 240 (91 %). Follow-up was 1 month to 4.5 years (median 17 months). PBA and stent had similar procedural success (89 % vs. 98 %), complications (16 % vs. 19 %), normal liver function tests (80 % vs. 68 %), arterial patency (76 % vs. 68 %), survival (80 % vs. 82 %), and requirement for re-intervention (22 % vs. 25 %) or re-transplantation (20 % vs. 24 %) (P non-significant). In the most recent studies re-transplantation was reported less compared to older series (P = 0.04).

CONCLUSION

Both PBA and stent offer comparable results for HAS. These techniques have contributed to a recent decline in re-transplantation.

KEY POINTS

• Interventional radiological procedures are often used to treat post-transplant hepatic artery stenosis. • Meta-analysis shows that percutaneous balloon angioplasty and stent placement are both efficacious. • Percutaneous balloon angioplasty and stent placement appear to have similar complication rates. • Re-transplantation rates have declined, partly due to interventional management for arterial stenosis.

Repeat endovascular treatment of recurring hepatic artery stenoses in orthotopic liver transplantation

Hepatic artery stenosis (HAS) is a complication that impacts the results of orthotopic liver transplantation (OLT). Interventional radiological techniques are important therapeutic options for HAS. The aim of this retrospective study was to evaluate the outcome of repeated radiological treatments in recurring HAS after OLT. Of the 941 patients who underwent OLT at our center from January 1998 to September 2010, 48 (5%) were diagnosed with HAS, 37 (77%) of whom underwent transluminal interventional therapy with the placement of an endovascular stent. Success rate, complications, hepatic artery patency and follow-up were reviewed. After stent placement, artery patency was achieved in all patients. Three patients developed complications, including arterial dissection and hematoma. HAS recurrence was observed in 9 patients (24%), and hepatic artery thrombosis (HAT) occurred in 4 (11%). Radiological interventions were repeated 10 times in 8 patients without complications. At a median follow-up of 66 months (range 10-158), hepatic artery patency was observed in 35 cases (94.6%). The 5-year rates for graft and patient survival were 82.3% and 87.7%, respectively. Restenosis may occur in one-third of patients after endovascular treatment for thrombosis and HAS, but the long-term outcomes of iterative radiological treatment for HAS indicate a high rate of success.

Endovascular treatment of hepatic artery stenosis after liver transplantation

BACKGROUND

Hepatic artery stenosis (HAS) after orthotopic liver transplantation is a significant risk factor for subsequent hepatic artery thrombosis (HAT). HAT is associated with a 30%-50% risk of liver failure culminating in retransplantation or death. Traditional treatment of hepatic artery complications has been surgical, with hepatic artery revision or retransplantation. Endovascular therapy of HAS, described primarily in the interventional radiology literature, may provide a less-invasive treatment option.

METHODS

This was a retrospective review of all endovascular interventions performed for HAS after orthotopic liver transplantation over a 31-month period (August 2009 to January 2012). Patients with duplex ultrasound imaging evidence of severe main HAS (peak systolic velocity of >400 cm/s, resistive index of <.5) underwent endovascular treatment with either primary stent placement or percutaneous transluminal angioplasty (PTA) alone. Patients were followed with serial ultrasound imaging to assess for treatment success and late restenosis. Reintervention was performed if significant restenosis occurred.

RESULTS

Thirty-five hepatic artery interventions were performed in 23 patients. Over the 31-month study period, 318 orthotopic liver transplantations were performed, yielding a 7.4% (23/318) rate of hepatic artery intervention. Primary technical success was achieved in 97% (34/35) of cases. Initial treatment was with PTA alone (n = 10) or primary stent placement (n = 13). The initial postintervention ultrasound images revealed improvements in hepatic artery peak systolic velocity (267 ± 118 [posttreatment] vs 489.9 ± 155 cm/s [pretreatment]; P < .0001) and main hepatic artery resistive index (0.61 ± 0.08 [posttreatment] vs 0.41 ± 0.07 [pretreatment]; P < .0001). At a mean follow-up of 8.2 ± 1.8 months (range, 0-29), there were 12 reinterventions in 10 patients for recurrent HAS. Thirty-one percent (n = 4/13) of patients undergoing initial stent placement required reintervention (at 236 ± 124 days of follow-up) compared with 60% (n = 6/10) of patients undergoing initial PTA (at 62.5 ± 44 days of follow-up). Primary patency rates (Kaplan-Meier) after primary stent placement were 92%, 85%, and 69% at 1, 3, and 6 months, respectively, compared with 70%, 60%, and 50% after PTA (P = .17). Primary-assisted patency for the entire cohort was 97% at 6 and 12 months. Major complications were one arterial rupture managed endovascularly and one artery dissection that precipitated HAT and required retransplantation. The overall rate of HAT in the entire cohort was 4.3% (1/23).

CONCLUSIONS

Endovascular treatment of HAS can be performed with high technical success, excellent primary-assisted patency, and acceptable morbidity. Initial use of a stent may improve primary patency when compared with PTA. The need for reintervention is common, placing particular importance on aggressive surveillance. Longer follow-up and a larger cohort are needed to confirm these encouraging early results.

Hepatic artery stenosis in liver transplantation: imaging and interventional treatment

INTRODUCTION

Main purpose of our study is to demonstrate the spectral and color Doppler ultrasonography (DUS) findings that would indicate hepatic artery stenosis (HAS) after liver transplantation and to report our single center results. Moreover we want to establish role and limits of the different imaging techniques in detecting HAS, proposing a non invasive diagnostic approach and to depict indications and feasibility of endovascular treatment in the single patient.

MATERIALS AND METHODS

Our study consisted of 222 patients who underwent liver transplantation between January 1999 and December 2009. DUS findings were correlated with multidetector computed tomography angiography (MDCTA) and angiographic results.

RESULTS

HAS occurred in 21 cases (9.5%). In all cases diagnosis was performed by DUS. MDCTA quantified stenosis and showed an overall picture of splanchnic vascularization. Based on DUS and MDCTA data integration, in 9 cases we adopted the "wait and see" strategy. Moreover in 12 cases treatment was considered necessary. For hepatic artery stenosis, use of DUS criteria resulted in a sensitivity of 100% (20/20), a specificity of 99.5% (201/202), a positive predictive value (PPV) of 95% (20/21), and negative predictive value (NPV) of 100% (201/201), and an overall accuracy of 99.5% (221/222).

CONCLUSION

Our study underline the role of DUS in early diagnosis of HAS: repeated evaluation of both direct and indirect signs increases NPV and sensitivity of DUS.

Angioplastia subintimal após trombose tardia de stent implantado em artéria hepática de fígado transplantado

Os autores relatam um caso de estenose de artéria hepática transplantada tratada com angioplastia e stent, que evoluiu para trombose completa após 30 dias do procedimento. Realizada trombólise intra-arterial e angioplastia subintimal com sucesso. Controle angiotomográfico após 90 dias demonstra perviedade da artéria hepática.

Vascular complications following liver transplantation

Vascular complications (stenosis or thrombosis of the hepatic artery, portal vein or hepatic vein) are a relatively common occurrence following liver transplantation. Routine screening with ultrasound is critical to early detection of these complications. Careful application of standard interventional techniques (diagnostic catheter angiography, balloon angioplasty with selective stenting) may be used to confirm the ultrasound findings, treat the underlying lesions, and contribute to long-term graft survival.

Treatment of early hepatic artery complications after adult liver transplantation: A single center experience

Introduction

Hepatic artery complication represents recognized sequel of liver transplantation that carries significant morbidity and mortality. Besides retransplantation, hepatic artery recanalization is provided surgically, or by percutaneous angioplasty and stent placement. This study provides an analysis of a single center experience comparing surgical and interventional treatments in cases of early hepatic artery complications.

Methods

In this retrospective single center study, 25 of 365 liver transplant recipients were enrolled who developed early hepatic artery complication after transplantation. Percutaneous intervention was performed in 10 cases, while surgical therapy in 15 cases. Mean follow-up time was not different between the groups (505±377 vs. 706±940 days, respectively).

Results

6 patients in the Intervention Group and 10 patients in the Surgery Group are alive. The retransplantation rate (1 and 3) was lower after interventional procedures, while the development of biliary complications was higher. The mortality rate was higher after operative treatment (2 and 5).

Conclusion

Interventional therapy is a feasible and safe technique for treatment of early hepatic artery complication after transplantation. Being less invasive it is an invaluable alternative treatment having results comparable to surgical methods.

Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver transplantation

Hepatic artery thrombosis (HAT) after pediatric orthotopic liver transplantation (OLT) is a serious complication resulting in bile duct necrosis and often requiring retransplantation. Immediate surgical thrombectomy/thrombolysis has been reported to be a potentially successful treatment for restoring blood flow and avoiding urgent retransplantation. The long-term results of this strategy remain to be determined. In 232 pediatric liver transplants, we analyzed long-term outcomes after urgent revascularization for early HAT. HAT developed in 32 patients (13.7%). In 16 children (50%), immediate surgical thrombectomy was performed in an attempt to salvage the graft. Fourteen patients (44%) underwent urgent retransplantation, and 2 (6%) died before further intervention. Immediate thrombectomy resulted in long-term restoration of the hepatic artery flow in 6 of 16 patients (38%) and in 1- and 5-year graft and patient survival rates of 83% and 67%, respectively. In 10 patients, revascularization was unsuccessful, and retransplantation was inevitable. The 1- and 5-year patient survival rates in this group decreased to 50% and 40%, respectively. After immediate retransplantation, the 5-year patient survival rate was 71%. In conclusion, immediate surgical thrombectomy for HAT after pediatric OLT results in long-term graft salvage in about one-third of patients. However, when thrombectomy is unsuccessful, long-term patient survival is lower than the survival of patients who underwent immediate retransplantation.

Prevalence, treatment, and outcomes of the hepatic artery stenosis after liver transplantation

INTRODUCTION

Hepatic artery stenosis (HAS) after liver transplantation can lead to altered hepatic function and/or thrombosis, there by increasing morbidity and mortality. The prevalence of HAS in the literatures varies from 4% to 11%.

OBJECTIVE

We sought to describe the prevalence and treatment of hepatic artery stenosis.

METHODS

We performed a descriptive retrospective analysis of 253 liver transplantations from March 1998 to May 2007, including patients with suspected HAS owing to increased hepatic enzymes, altered Doppler ultrasound (us) and hepatic biopsy. The confirmation of HAS was achieved through areriography.

RESULTS

Nine patients were identified to have HAS, a 3.5% prevalence. Among the HAS patients, seven were male and two female. Their average age was 35.5 years (range, 65 to 53). The average time between the diagnosis and transplantation was 14.2 months (range, 9 to 68). The increase in hepatic enzymes among this group averaged: aspartate aminotransferase 131 U/L (range, 26 to 412) and alanine aminotransferase 192 U/L (range, 35 to 511). Doppler US showed alteration in the resistance level index. All patients underwent areriography; only one could not be treated owing to severe hepatic artery spasm, which also occurred during another attempt weeks after the first one. Among the eight patients, six were treated with stents and two with angioplastis. All treated patients displayed improvements in parameters. Four patients treated with stents required retreatment: two underwent angioplasty and two, a thrombolytic. One graft rethrombosed but evolved in compensated fashion with recanalization by collaterals. There has been no graft loss or mortality in this population. The average time of posttreatment follow-up was 31.28 (range, 9 to 68) months.

CONCLUSION

The prevalence of HAS in our unit was within that reported in the literature. Treatment with a stent or angioplasty proved to be efficient to control this complication, considering that hepatic function recovered and that there was neither graft nor patient loss.

Interventional treatment of hepatic artery stenosis after orthotopic liver transplantation with balloon-expandable coronary stent

OBJECTIVE

The aim of this study was to evaluate the efficacy of hepatic artery stenting with a balloon-expandable coronary stent for the treatment of hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT).

PATIENTS AND METHODS

We performed retrospective review of all 11 patients who underwent hepatic artery stenting after a diagnosis of HAS.

RESULTS

A total of 13 balloon-expandable coronary stents were placed into 11 patients. The technical and immediate success rate was 100%; all stents remained patent during follow-up. One patient required 2 stents due to the length of the stenotic artery. Another underwent a second stenting after developing restenosis proximal to the original stenotic site. No procedure-related complications occurred, and no surgical revascularization or retransplantation was required during follow-up.

CONCLUSIONS

A balloon-expandable coronary stent can play a role in the management of HAS. It can be used with great safety, with immediate as well as longer-term success.

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

Hepatic artery stenosis (HAS) and thrombosis (HAT) after orthotopic liver transplantation remain significant causes of graft loss. Postoperative HAT follows approximately 5% to 19% of orthotopic liver transplantation. It is seen more frequently in pediatric patients. In the past, repeat transplantation was considered the first choice for therapy. Recently, interventional radiological techniques, such as thrombolysis, percutaneous transluminal angioplasty, or stent placement in the hepatic artery, have been suggested, but little data exist related to stent placement in the thrombosed hepatic artery during the early postoperative period in pediatric patients. Between March 2000 and March 2005, percutaneous endoluminal stent placement was performed in seven pediatric liver transplant patients. HAT or HAS initially diagnosed in all cases by Doppler ultrasound then confirmed angiographically. We intervened in four cases of hepatic artery stenosis and three cases of hepatic artery occlusion. Stents were placed in all patients. Three ruptures were seen during percutaneous transluminal angioplasty of the hepatic artery using a covered coronary stents on the first, fifth day, or 17th postoperative day. In one patient, dissection of the origin of the common hepatic artery developed owing to a guiding sheath, and a second stent was placed to cover the dissected segment. The other two hepatic artery stents remained patent. In one stent became occluded at 3 months after the intervention with no clinical problems. Follow-up ranged from 9 to 40 months. In conclusion, early and late postoperative stent placement in the graft hepatic artery was technically feasible.

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.

Clinical outcomes from hepatic artery stenting in liver transplantation

Hepatic artery stenosis after liver transplantation may affect liver function and result in hepatic artery thrombosis. Surgical reconstruction has been the first choice for treatment. Interventional radiologic technique can be used, but there is no report on long-term outcome. The aim of this paper is to assess current outcome and complications of hepatic artery stenting. Twenty-six adult patients were stented for hepatic artery stenosis between 1998 and 2003. Nine patients had previous surgical reconstruction for hepatic artery stenosis. Seventeen patients suffered newly developed hepatic artery stenosis. Three patients were retransplanted. After stenting, the patients were followed by Doppler ultrasound at day 1, 1 month, and 6 months. Angiography was scheduled in 6 months. Four patients died within 2 months. The other 22 patients were followed for mean 31 +/- 14 months (8-71 months). One of 22 patients died from renal failure 2 years later. Twelve patients' hepatic arteries looked normal after stenting. Restenosis was seen in 8 patients (36%). Other complications were artery thrombosis (n = 1) and long segment stricture (n = 1). In 2 patients (25%) restenosis resulted in thrombosis. Six of the 8 patients who developed recurrent stenosis were successfully treated interventionally: restent (n = 5) and balloon dilation (n = 3). However, 3 patients (38%) restenosed. Kaplan-Meier complication-free survival was 54% at 1 year after stenting. In conclusion, hepatic artery stenting is a viable treatment for hepatic artery stenosis with reasonable results. Stenting is useful as adjuvant treatment after surgical revision.

Percutaneous transluminal angioplasty for hepatic artery stenosis after living donor liver transplantation

The purpose of this study was to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) for treatment of hepatic artery stenosis after living donor liver transplantation. Eighteen patients with hepatic artery stenosis after living donor liver transplantation were included in this study. The success rate and complications of PTA and recurrent stenosis of the hepatic artery were evaluated. Seventeen of 18 patients (94.4%) were successfully treated without complication by a first PTA procedure. Recurrence of hepatic artery stenosis occurred in 6 patients (33.3%). Repeated PTA was performed 12 times for the 6 patients. Two complications occurred as arterial dissection and perforation. As a consequence, the complication rate was 6.7%, involving 2 of 30 procedures in total. In conclusion, PTA is effective for treatment of hepatic artery stenosis after living donor liver transplantation without an increase in the complication rate.

Hepatic artery stenosis in liver transplant recipients: primary treatment with percutaneous transluminal angioplasty

PURPOSE

To evaluate the efficacy of hepatic artery percutaneous transluminal angioplasty (PTA) in the treatment of hepatic artery stenosis (HAS).

MATERIALS AND METHODS

A retrospective analysis was performed of all cases of HAS documented by angiography from January 1995 to June 2003 at the authors' institution. Management was evaluated and long-term patency was documented by Doppler ultrasonography. The patency, restenosis, and hepatic artery thrombosis (HAT) rates were determined by the Kaplan-Meier method. The technical success of hepatic artery PTA was stratified according to the location of the stenoses relative to the anastomosis, as well as by the presence of associated hepatic arterial kinks.

RESULTS

Thrombosis was seen in 65% +/- 13% of untreated HAS cases within 6 months. Stenotic lesions without associated arterial kinks had an improved technical success rate and a reduced complication rate of 94% and 10%, respectively, compared with lesions with associated hepatic arterial kinks treated with hepatic artery PTA (14% and 29%, respectively). The 1-year primary and primary assisted patency rates of hepatic artery PTA for all lesions were 44% +/- 12% and 60% +/- 11%, respectively, and were 65% +/- 10% and 80% +/- 8%, respectively, for lesions not associated with hepatic arterial kinks. The 1-year HAT rate and restenosis rate after hepatic artery PTA were 19% +/- 10% and 32% +/- 11%, respectively. The 1-year primary assisted patency rate for hepatic artery PTA with repeat PTA performed for restenosed lesions and surgical revascularization performed for failed PTA was 74% +/- 10%.

CONCLUSIONS

Untreated HAS carries a high morbidity rate. Hepatic artery PTA can play a large role in the management of HAS by reducing the HAT rate more than threefold. With appropriate lesion selection, hepatic artery PTA will have better patency rates than those associated with hepatic artery stent placement.

Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

Role of interventional radiology in the management of vascular complications after liver transplantation

The purpose of this study is to review the role of the percutaneous interventional procedures in the treatment of vascular complications after orthotopic liver transplantations (OLT). Vascular complications, such as arterial stenosis and venous thrombosis, which occur in approximately 1% to 10% of liver transplant patients, are associated with a higher risk of graft dysfunction. Percutaneous interventional procedures, including angioplasty, local thrombolysis, and embolization, are useful to manage these complications. A reduced blood loss and a low incidence of procedural complications allow for rapid recovery. Hepatic arterial and portal vein anastomotic stenosis can be treated effectively by means of balloon dilation; stenting has also been proposed, particularly for venous complications. Infusional local thrombolysis may be useful in venous thrombosis. Arteriovenous fistulas, occurring at the level of the anastomosis or after liver biopsy, require intraarterial embolization using microcoils or gelfoam. Timing of the intervention for the treatment of ischemic complications is of outmost importance to guarantee liver functional recovery and avoid irreversible parenchymal injuries. Other interventional procedures may be extremely useful to manage portal hypertension after OLT; for example, by creation of transjugular portosystemic shunts, or, in the case of associated hypersplenism, transarterial embolization of the splenic artery. Finally, in patients with recurrent hepatitis, the transjugular approach has been shown to be safe and effective for liver biopsy, whereas transarterial chemoembolization may be extremely useful to treat recurrent hepatocarcinoma.

Diagnosis and treatment of hepatic artery stenosis after orthotopic liver transplantation

PURPOSE

The purpose of this study was to evaluate the accuracy of Multidetector Computed Tomographic Angiography (MDCTA) to detect hepatic artery (HA) stenosis after orthotopic liver transplantation (OLT) and the efficacy of treatment using percutaneous transluminal angioplasty (PTA).

MATERIALS AND METHODS

Twenty-two consecutive patients with OLT underwent MDCTA for evaluation of HA, followed by digital subtraction angiography (DSA) (gold standard). Source images (Ax) were processed, obtaining multiplanar reformations (MPRs), maximum intensity projections (MIPs), and volume renderings (VRs). Images were evaluated to identify the following: (1) arterial depiction (celiac axis, anastomosis, and left [LHA] and right [RHA] HA), (2) detection of stenoses, and (3) grading of stenoses. Indications for PTA were set at MDCTA and DSA, and PTA was performed when appropriate.

RESULTS

MDCTA depicted the celiac axis and anastomoses in all patients; LHA and RHA were visualized in 21 of 22 patients with Ax, MPRs, and MIPs, and in 17 of 22 with VRs. All reconstruction modalities enabled correct diagnosis of celiac (n = 3) and anastomotic stenoses (n = 14). Of 6 LHA and RHA stenoses, 4 (66.7%) were visualized with Ax, MPRs, and VRs, and 5 (83.3%) were visualized with MIPs. Stenosis was overestimated in 9 (39.1%) cases with VRs and in 3 (13%) with the other modalities. PTA was performed in 8 cases, with 1 case of arterial dissection requiring re-OLT. At a median follow-up of 28 months, the primary and secondary patency rates were 71.4% (5 of 7) and 85.7% (6 of 7), respectively.

CONCLUSIONS

MDCTA and accurate postprocessing enable confident depiction of the arterial anatomy and detection of stenosis after OLT. PTA is safe and allows allograft saving, at least until another suitable donor becomes available.

Endovascular treatment of a recipient celiac trunk stenosis after orthotopic liver transplantation

PURPOSE

To present the successful endovascular treatment of a severe recipient celiac trunk stenosis that led to allograft ischemia following liver transplantation.

CASE REPORT

A 56-year-old woman underwent orthotopic liver transplantation because of hepatitis C-induced cirrhosis. After the operation, routine hepatic Doppler ultrasonography showed a tardus parvus flow pattern in the hepatic artery, suggesting an impending hepatic artery thrombosis. Digital subtraction angiography (DSA), however, showed severe stenosis of the recipient celiac trunk and moderate splenic artery steal. The stenosis was dilated and stented in the same session. The postprocedural DSA showed good dilation of the lesion with immediate improvement of hepatic opacification. Follow-up Doppler ultrasound scans showed normal flow patterns in the hepatic artery at 3 and 6 months.

CONCLUSIONS

In the presence of a tardus parvus flow pattern on Doppler ultrasound after liver transplantation, the possibility of an undetected recipient celiac stenosis should be considered in the differential diagnosis. Such lesions can successfully be treated with angioplasty and stenting.