Versatility of the inferior epigastric artery as an interpositional vascular graft in living-related liver transplantation

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.

Two-step hepatic artery reconstruction for a hepatic artery lacking in length for the use of a microclamp in living donor liver transplantation

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A graft hepatic artery we experienced too short to rotate a microclamp in living donor liver transplantation.

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We performed two-step hepatic artery reconstruction.

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In the first step, we cut the recipient right hepatic artery and used it as an arterial graft.

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The graft hepatic artery was coapted to the distal stump of the arterial graft without a microclamp.

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In the second step, the proximal stump of the arterial graft was coapted to the recipient right hepatic artery.

Introduction

We describe successful two-step hepatic artery reconstruction in a patient whose graft site hepatic artery was too short for the use of a microclamp in living donor liver transplantation.

Presentation of case

A 57-year-old woman was diagnosed as having hepatitis C and liver cirrhosis. Her 26-year-old son was the living liver donor. The living donor underwent right lobectomy. The dissected graft hepatic artery was too short for the use of a microclamp. The recipient right hepatic artery was cut and used as an arterial graft. The graft right hepatic artery was sutured to the right hepatic artery of the arterial graft and the graft posterior branch of the right hepatic artery was sutured to the middle hepatic artery of the arterial graft. After reconstruction of the portal vein and hepatic vein was completed, anastomosis was performed between the graft right hepatic artery and right hepatic artery. The patency of the vessels was checked using color Doppler ultrasonography for 1 week postoperatively. No postoperative complications involving blood flow of the hepatic artery were observed.

Discussion

In our case, the recipient hepatic artery was cut and used as an arterial graft. Although the number of anastomotic sites of the hepatic artery increased, we could perform hepatic artery reconstruction safely and easily.

Conclusion

Two-step hepatic artery reconstruction is a useful method in cases where the recipient hepatic artery does not have enough length.

Hepatic artery reconstruction following ablative surgery for hepatobiliary and pancreatic malignancies

OBJECTIVE

Hepatic artery (HA) reconstruction is an important part of resective surgery for advanced hepatobiliary and pancreatic malignancies, but few reports have been published. To identify indications for HA reconstruction, we retrospectively analyzed our surgical procedures and outcomes.

METHODS

En-bloc resection of advanced hepatobiliary and pancreatic malignancies followed by HA reconstruction was performed in 35 patients. Patients ranged in age from 27 to 81 years and included 18 men and 17 women. The primary site of cancer included the bile duct in 22 patients, the pancreas in 7, and others in 6. Reconstruction of the HA was necessitated by HA resection due to direct cancer invasion in 29 patients and by accidental arterial injury during surgical procedure in 6 patients.

RESULTS

The HA was reconstructed with end-to-end anastomosis between hepatic arteries in 17 patients. Transposition of an intra-abdominal artery, such as the gastroepiploic artery, was required in 14 patients, and arterial grafting was required in 4 patients. Although the HA patency was achieved in 30 patients, 4 cases of arterial thrombosis and 1 case of arterial rupture developed postoperatively. The overall RFS time was analyzed in all patients, and mean and median RFS times were 18 and 9 months, respectively.

CONCLUSION

Although oncologic outcomes remain poor, HA resection and reconstruction can be performed in selected patients. We believe that the method of first choice for HA reconstruction is end-to-end anastomosis between HAs. A vascular autograft should be used only in selected cases.

Versatility of right gastroepiploic and gastroduodenal arteries for arterial reconstruction in adult living donor liver transplantation

BACKGROUND

In cases where there is severe intimal dissection in the recipient hepatic artery (HA), or if the HA has been used already and additional operations are needed due to graft rejection or arterial occlusion, an alternative is necessary. In the present study, we have reported the feasibility of using the right gastroepiploic artery (RGEA) and gastroduodenal artery (GDA) in various situations where the HA is not a feasible option.

METHODS

Among 463 patients who underwent primary adult-to-adult living donor liver transplantation from January 2002 to July 2010, eight subjects required alternative vessels. Four recipients displayed severe intimal injury associated with previous transarterial chemoembolization (TACE); two, required a salvage operation due to hepatic artery thrombosis (HAT); and two, retransplantations due to chronic rejection. The RGEA was used in five and the GDA in three patients.

RESULTS

Postoperative Doppler ultrasonography and three-dimensional computed tomography showed patent arterial flow in all patients. However, HAT recurred in one patient who underwent a salvage operation with the RGEA; she died 2 months later. Two other patients died due to wound infection and respiratory failure within 3 months despite intact hepatic arterial flow. Four patients had no further complications during follow-up (mean = 33 months).

CONCLUSION

Although there was a discrepancy in the diameter of the HA and the RGEA (or GDA), there was no problem with mobilization and microanastomosis. We therefore believe that these vessels can be good alternatives when the hepatic artery is unavailable.

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.

Experimental results and clinical impact of using autologous rectus fascia sheath for vascular replacement

Vascular complications are major causes of graft failure in liver transplantation. The use of different vascular grafts is common but the results are controversial. The aim of this study was to create an 'ideal' arterial interponate for vascular replacements in the clinical field. An autologous, tubular graft prepared from the posterior rectus fascia sheath was used for iliac artery replacement in dogs for 1, 3, 6 and 12 months. Forty-one grafts were implanted and immunosuppression was used in separate groups. The patency rate was followed by Doppler ultrasound. Thirty-seven grafts remained patent, 2 cases with thrombosis and 2 cases with stenosis occurred. There was no evidence of necrosis or aneurysmatic formation. The histological analysis included conventional light microscopic and immunohistochemical examinations for CD34 and factor VIII. The explanted grafts showed signs of arterialisation, appearance of elastin fibres, and smooth muscle cells after 6 months. Electron microscopy showed intact mitochondrial structures without signs of hypoxia. In conclusion, the autologous graft presents acceptable long-term patency rate. It is easy to handle and the concept of beneficial presence of the anti-clot mesothelium until endothelialisation seems to work. The first clinical use was already reported by our group with more than 2 years survival.

Intimal dissection of the hepatic artery after thrombectomy as a cause of graft loss in pediatric living-related liver transplantation

HAT is the main cause of graft loss in pediatric living-related LTx. Revascularization of the graft by thrombectomy and re-anastomosis has been reported to be effective for graft salvage in cases of HAT and should be attempted when potential donors are not available for emergency re-transplantation. Immediate complications secondary to revascularization attempts in cases of HAT are not described. Late complications are mainly related to biliary tree ischemia. We report a case of child who experienced intimal hepatic artery dissection, which extended into intra-hepatic branches of the artery after a thrombectomy with a Fogarty balloon catheter in an attempt to restore arterial flow after HAT. This complication led to acute deterioration of the graft and the need for emergency re-transplantation.

Interventional radiology in liver transplantation

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation.

Using a radial artery as an interpositional vascular graft in a living-donor liver transplantation for hepatocellular carcinoma

With increasing numbers of living-donor liver transplantations (LDLTs) for hepatocellular carcinoma (HCC), cases with some arterial troubles are encountered; because most HCC cases waiting for LDLT have undergone interventional treatments. In these patients, the reconstruction of the graft artery needs to be planned preoperatively. We report a 52-year-old male, with hepatitis C-related liver cirrhosis and advanced HCC, who for 4 years repeatedly underwent continuous intraarterial chemotherapy through an implanted reservoir port. A suitable artery was not available for arterial reconstruction and the patient underwent LDLT using an autologous radial artery conduit based on the infrarenal aorta. Postoperatively, the patient is well with normal liver function and efficient arterial flow. Autologous radial artery can be safely and successfully used as an aortic-based arterial conduit when HCC patients waiting for LDLT have undergone long-term repeated intraarterial chemotherapy.

Use of a branch patch with the cystic artery in living-related liver transplantation

Technical aspects in living-related liver transplantation are still under debate: the main pitfall is the arterial reconstruction due to the small diameter and the discrepancy between stumps, with a subsequent increased risk of arterial thrombosis. The gold standard is the microsurgical technique, that reports the lowest risk of thrombosis, but it is a time consuming procedure requiring a long training. Our method of choice reconstructing hepatic artery in right lobe is the use of the cystic artery as a branch patch with the recipient hepatic artery by loop magnification, saving time and with a low incidence of hepatic artery thrombosis.

Experimental vascular graft for liver transplantation

Hepatic artery thrombosis is a major cause of graft failure in liver transplantation. Use of donor interponates are common, but results are controversial because of necrosis or thrombosis after rejection. Reperfusion injury, hypoxia and free radical production determinate the survival. The aim of the study was to create an 'ideal' arterial interponate. Autologous, tubular graft lined with mesothelial cells, prepared from the posterior rectus fascia sheath, was used for iliac artery replacement in eight mongrel dogs for six months under immunosuppression. Patency rate was followed by Doppler ultrasound. Eight grafts remained patent and another two are patent after one year. The patency rate was good (median Doppler flow: 370 cm/sec) and there was no necrosis, thrombosis or aneurysmatic formation. The grafts showed viable morphology with neoangiogenesis, appearance of elastin, smooth muscle and endothelial cells. Electron microscopy showed intact mitochondrial structures without signs of hypoxia. Tissue oxygenation was good in all cases with normal (< 30 ng/ml) myeloperoxidase production. In conclusion, this autologous graft presents good long-term patency rate. Viability, arterialisation and low thrombogenicity are prognostic factors indicating usability of the graft in the clinical practice without the risk of rejection. Further investigations such as cell cultures and standardisation are necessary.

Clinical approach to graft hepatic artery thrombosis following living related liver transplantation

Hepatic artery thrombosis (HAT) has an occurrence rate of 1.7-26% following living donor liver transplantation (LDLT) and is one of the most common reasons for graft loss and mortality in this population. There is a higher incidence of HAT in pediatric recipients. The aim of this case report is to discuss clinical approaches for the treatment of HAT occurring in the early post-operative period after LDLT. An 11-month-old, 7.8-kg female with cirrhosis secondary to biliary atresia underwent LDLT at Gazi University Hospital in Ankara. The graft was a left lateral segment from her father with a left hepatic artery (HA) of 2 mm diameter and a graft weight/recipient body weight ratio of 2.0%. After an uneventful early post-operative period, HAT was diagnosed by Doppler ultrasonography (USG) on the fifth post-operative day. Following angiographic evaluation, immediate exploration and reanastomosis was performed using an operation microscope. Post-operatively, the HA was patented by Doppler USG and graft function returned to normal. Now, 42 months later, the patient continues to do well with normal graft function, using a regimen of tacrolimus monotherapy for immunosuppression. In countries which have very limited resources for urgent re-transplantation, given their serious donor shortage, graft salvage may be the only option for patient survival when HAT occurs. In these circumstances, early diagnosis and immediate revascularization may be the only method for graft salvage. A daily routine of Doppler USG examination in the early post-operative period may provide a method for the early diagnosis of HAT, before liver enzymes are elevated and hepatic necrosis has begun.

Hepatic artery reconstruction in living-donor liver transplantation: a review of its techniques and complications

BACKGROUND

Hepatic arterial reconstruction is one of the most difficult procedures in living-donor liver transplantation (LDLT) because the artery used is generally small in diameter and has a short stalk. If hepatic artery thrombosis (HAT) occurs, the recipient clinical course will be unstable. The introduction of microvascular hepatic arterial reconstruction has significantly decreased the incidence of HAT.

METHODS

Fifty-two cases of LDLT were performed from October 1995 to May 2001 in our institution. Hepatic arterial reconstruction was performed under microscopic guidance.

RESULTS

HATs were recognized in 2 cases (3.8%), both of which needed reoperation.

CONCLUSIONS

Surgeons who perform hepatic arterial reconstruction in LDLT should be highly trained in microvascular techniques to decrease the incidence of HAT. This commentary reviews the surgical techniques of hepatic arterial reconstruction and possible complications that may arise in a reconstructed hepatic artery.

Use of cadaveric superior mesenteric artery as interpositional vascular graft in orthotopic liver transplantation

BACKGROUND

Hepatic artery thrombosis remains the most common technical complication that causes graft failure following orthotopic liver transplantation. The development of split liver and living related liver transplantation has led to the use of shorter and smaller arteries for arterial reconstruction to the graft. The present aim was to assess the effectiveness of the superior mesenteric artery as an interpositional graft in arterial reconstruction during liver transplantation.

METHODS

Cadaveric superior mesenteric artery was used to reconstruct small and short or multiple hepatic arteries in 35 liver transplants including 29 split, three living related, two whole liver transplants and one emergency revascularization post-transplantation.

RESULTS AND CONCLUSION

A low incidence of hepatic artery thrombosis (one of 35 patients) was achieved utilizing cadaveric superior mesenteric artery as an interpositional vascular graft in liver transplantation.

Domino liver transplantation from a living related donor

BACKGROUND

Although domino liver transplantations (OLT) from cadaveric donors have been performed in about 50 cases since 1995, only one case in the Japanese literature has been reported on a domino OLT from a living related donor. The difficulties of the later surgery lie in the small size of the graft volume and the short length of the vascular cuffs in the graft.

METHODS

The left lobe graft was procured from a 43-year-old younger brother of a familial amyloidotic polyneuropathy (FAP) patient. Next, the left lobe graft (510 g, 44% of the estimated standard liver volume of the FAP patient) was implanted into the 48-year-old female FAP patient. At surgery for the FAP patient, a sufficient length of the vascular cuffs was secured by an extended left lobe resection, although the right lobe graft was able to maintain sufficient vascular cuffs. The right lobe graft (720 g, 54% of the recipient's estimated standard liver volume) was then implanted in the 43-year-old male patient with liver cirrhosis and hepatocellular carcinoma (stage IV-A).

RESULTS

The two recipients were discharged from the hospital 1 month after OLT. At 7 months after OLT, they are both doing well and the domino recipient is free of any tumor recurrence.

CONCLUSION

A domino OLT from the living related donor can therefore be done safely when careful attention is paid to the graft volume and the length of the vascular cuffs for anastomosis.