Hepatic artery reconstruction in living donor liver transplantation: strategy of the extension of graft or recipient artery

Techniques of hepatic arterial reconstruction in liver transplantation

BACKGROUND

Hepatic artery reconstruction is an essential part of liver transplantation. This difficult stage of the operation is even more demanding in living donor liver transplantation than in deceased donor liver transplantation. One of the most important advances in hepatic artery reconstruction for living liver grafts was the introduction of microsurgical techniques involving an operative microscope or surgical loupe. Many surgical reconstruction techniques have been used in this field.

PURPOSE

In this article, first, we will talk about the hepatic artery reconstruction techniques that are frequently used in deceased donor liver transplantation, and afterward, we will talk about the hepatic artery reconstruction techniques used in living donor liver transplantation, which include the hepatic artery reconstruction technique we use and call "one stay corner suture technique".

CONCLUSIONS

We think high-volume transplant centers should tend to develop a standardized technique for doing hepatic artery reconstruction with their teams. We think the "one stay corner suture technique" can be easily applied in centers that perform LDLT.

Use of the Descending Branch of the Lateral Circumflex Femoral Artery as an Arterial Graft in Living Donor Liver Transplant

BACKGROUND

Reconstructing the hepatic artery in living donor liver transplantation presents the challenges of a short and small donor vessel stump, which is compounded by poor surgical access for microsurgical anastomosis. Arterial interpositional grafts (eg, the radial artery) have been used to overcome these problems. The purpose of this presentation is to describe the use of the descending branch of the lateral circumflex femoral artery (DLCFA) as an alternative when the patient has had an abnormal Allen's test precluding the use of the radial artery or if a Y-graft is needed.

METHODS

The DLCFA resides in the septum between the rectus femoris and vastus lateralis muscles. A linear incision made over the proximal third of this septum exposed the avascular plane in which the vessel resides. A graft exceeding 10 cm could be harvested with diameters ranging between ≤2 and 7 mm. There were several muscular branches emanating from the profunda femoris artery system that could be dissected to the required length for a Y-shaped graft. Three cases of living donor liver transplantation using the DLCFA (straight and Y grafts) are described.

RESULTS

After DLCFA interpositional grafting, all patients had normal resistive indices on duplex ultrasonography of the intrahepatic arterial system. Follow-up of the 3 patients was between 2 and 6 months. There was no donor site morbidity.

CONCLUSIONS

The DLCFA graft was a useful arterial graft for hepatic artery reconstruction. It was easily harvested with minimal donor site morbidity.

Hepatic Artery Reconstruction in Living Donor Liver Transplantation With the Radial Artery Interpositional Graft

INTRODUCTION

Reconstitution of hepatic artery inflow is essential for a successful liver transplantation. Living donor transplantation presents additional challenges in the form of a short and small donor vessel stump, exacerbating the poor surgical access for microsurgery. Few reports have described the use of the radial artery as an interposition graft in liver transplantation; we present a series of 6 cases and discuss the technical merits of this procedure.

METHODS

Retrospective review of consecutive patients undergoing living donor liver transplantation from December 2015 to December 2019 was performed. Demographics, operative details, and postoperative outcomes were reviewed.

RESULTS

Twenty-two patients underwent living donor liver transplantation. Radial artery interposition grafting was used in 6 cases, including 1 salvage case for hepatic artery thrombosis. One patient developed hepatic artery stenosis (2 weeks postoperatively) that was conservatively managed. After radial artery grafting, all patients had normal resistive indices on duplex ultrasonography at up to 20 months postoperatively. The mean follow-up was 15.2 months.

CONCLUSION

When faced with a significantly short vessel stump or caliber mismatch, radial artery interpositional grafting is a safe and useful technique for reducing tension and overcoming vessel size mismatch in hepatic artery reconstruction.

Use of the Gastroduodenal Artery in Hepatic Artery Reconstruction for Iatrogenic Hepatic Artery Injury During Laparoscopic Total Gastrectomy: Case Report and Review of the Literature

Iatrogenic injury of the hepatic artery is a potential hazard of hepatopancreatobiliary and gastric surgery. Prompt recognition and specialist management is paramount to limit morbidity for the patient. Several reconstruction options have been reported in the literature, but the optimum approach should be tailored to the individual patient bearing in mind variations in anatomy, clinical conditions, and other concurrent operative interventions. We report the case of a successful hepatic artery reconstruction using the gastroduodenal artery as a transposition graft for inadvertent transection of the common hepatic artery during laparoscopic total gastrectomy. In expert hands, the use of the gastroduodenal artery for extra-anatomic reconstruction of the hepatic artery is a safe, feasible, and effective option.