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Lerut AV, Pirenne J, Sainz-Barriga M, Blondeel J, Maleux G, Monbaliu D. Case report: Immediate revascularization for symptomatic hepatic artery pseudoaneurysm after orthotopic liver transplantation? A case series and literature review. Front Surg 2023; 10:1169556. [PMID: 37440926 PMCID: PMC10333477 DOI: 10.3389/fsurg.2023.1169556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/06/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Hepatic artery pseudoaneurysm (HAPA), a rare vascular complication that can develop after liver transplantation, is associated with a high mortality rate and graft loss. To salvage the liver graft, immediate revascularization, either through surgical or endovascular intervention, is required. However, currently there is no consensus on the optimal strategy. Here, we report three cases of liver transplant recipients diagnosed with HAPA and treated with immediate revascularization. In addition, we present an overview of HAPA cases described in the literature and make recommendations on how to treat this rare complication. Methods All adults transplanted in our center between 2005 and 2021 were retrospectively reviewed. Literature search was done in PubMed for original studies between 1980 and 2021 reporting early hepatic artery (pseudo) aneurysm after liver transplantation requiring either surgical or endovascular intervention. Results From a total of 1,172, 3 liver transplant patients were identified with a symptomatic HAPA and treated with immediate revascularization. HAPA occurred 73, 27, and 8 days after liver transplantation and was treated with immediate revascularization (two surgical and one endovascular intervention). Literature review identified 127 cases of HAPA. HAPA was managed with endovascular therapy in 20 cases and by surgical intervention in 89 cases. Overall reported mortality rate was 39.6%, whereas overall graft survival was 45.2%. Conclusion Immediate surgical or radiological interventional excision and prompt revascularization to salvage liver grafts is feasible but still associated with a high mortality.
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Affiliation(s)
- An Verena Lerut
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Mauricio Sainz-Barriga
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Joris Blondeel
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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2
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Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults (with video). Hepatobiliary Pancreat Dis Int 2022; 21:25-32. [PMID: 34426078 DOI: 10.1016/j.hbpd.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management is unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children. METHODS From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22-66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein. RESULTS Median operative time was 500 min (range 300-730). Median follow-up duration was 22 months (range 2-169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB. CONCLUSIONS Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.
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Radulova-Mauersberger O, Weitz J, Riediger C. Vascular surgery in liver resection. Langenbecks Arch Surg 2021; 406:2217-2248. [PMID: 34519878 PMCID: PMC8578135 DOI: 10.1007/s00423-021-02310-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/18/2021] [Indexed: 01/04/2023]
Abstract
Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.
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Affiliation(s)
- Olga Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
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Reding R, Chardot C, Paul K, Veyckemans F, Obbergh LV, Clety SCD, Detaille T, Clapuyt P, Saint-Martin C, Janssen M, Lerut J, Sokal E, Otte JB. Living-Related Liver Transplantation in Children at Saint-Luc University Clinics : A Seven Year Experience in 77 Recipients. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2001.12098576] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- R. Reding
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Chr. Chardot
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - K. Paul
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - F. Veyckemans
- Pediatric Liver Transplant Program. Departments of Anaesthesiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - L. Van Obbergh
- Pediatric Liver Transplant Program. Departments of Anaesthesiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - S. Clement De Clety
- Pediatric Liver Transplant Program. Departments of Intensive Care, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Th. Detaille
- Pediatric Liver Transplant Program. Departments of Intensive Care, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Ph. Clapuyt
- Pediatric Liver Transplant Program. Departments of Radiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - Chr. Saint-Martin
- Pediatric Liver Transplant Program. Departments of Radiology, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - M. Janssen
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - J. Lerut
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - E. Sokal
- Pediatric Liver Transplant Program. Departments of Pediatrics, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
| | - J.-B. Otte
- Pediatric Liver Transplant Program. Departments of Surgery, Saint-Luc University Clinics, Universite catholique de Louvain, Brussels, Belgium
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Living Donor Liver Transplantation in Children: Surgical and Immunological Results in 250 Recipients at Université Catholique de Louvain. Ann Surg 2016; 262:1141-9. [PMID: 25563870 DOI: 10.1097/sla.0000000000001094] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate the outcome of pediatric living donor liver transplantation (LDLT) regarding portal vein (PV) reconstruction, ABO compatibility, and impact of maternal donation on graft acceptance. BACKGROUND LDLT and ABO-mismatched transplantation constitute feasible options to alleviate organ shortage in children. Vascular complications of portal hypoplasia in biliary atresia (BA) and acute rejection (AR) are still major concerns in this field. METHODS Data from 250 pediatric LDLT recipients, performed at Cliniques Universitaires Saint-Luc between July 1993 and June 2012, were collected retrospectively. Results were analyzed according to ABO matching and PV complications. Uni- and multivariate analyses were performed to study the impact of immunosuppression, sex matching, and maternal donation on AR rate. RESULTS Overall, the 10-year patient survival rate was 93.2%. Neither patient or graft loss nor vascular rejection, nor hemolysis, was encountered in the ABO nonidentical patients (n = 58), provided pretransplant levels of relevant isoagglutinins were below 1/16. In BA recipients, the rate of PV complications was lower after portoplasty (4.6%) than after truncal PV anastomosis (9.8%) and to jump graft interposition (26.9%; P = 0.027). In parental donation, maternal grafts were associated with higher 1-year AR-free survival (55.2%) than paternal grafts (39.8%; P = 0.041), but only in BA patients. CONCLUSIONS LDLT, including ABO-mismatched transplantation, constitutes a safe and efficient therapy for liver failure in children. In BA patients with PV hypoplasia, portoplasty seems to constitute the best technique for PV reconstruction. Maternal donation might be a protective factor for AR.
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Heng WL, Madhavan K, Wee P, Seck T, Lim YP, Lim CH. Banking of cryopreserved iliac artery and vein homografts: clinical uses in transplantation. Cell Tissue Bank 2014; 16:235-42. [PMID: 25151404 PMCID: PMC4426133 DOI: 10.1007/s10561-014-9469-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 08/16/2014] [Indexed: 11/27/2022]
Abstract
Iliac artery and vein homografts are critical for revascularization in living-donor liver transplantation. Since 2010, National Cardiovascular Homograft Bank and National University Hospital have collaborated in the pioneer endeavor of banking iliac vessel homografts for such surgeries in Singapore. This article aims to demonstrate that the processing, decontamination and cryopreservation techniques that our bank follow, help preserve iliac vessel homografts for a longer duration as compared to homografts preserved using short-term preservation techniques. This paper reports the first 4 years of post-operative outcome for recipients as a preliminary report for a longer-term outcome study. Criteria for donor assessment, techniques of iliac vessel homograft recovery, processing, decontamination, cryopreservation and storage according to the American Association of Tissue Banks standards are also described. From 2010 until 2013, we discovered of the iliac vessel homografts processed, 17 (94.4 %) were suitable for clinical use. Nine iliac artery grafts (64 %) and one iliac vein graft (14 %) were implanted. Irrespective of vessel type, homografts <90 mm in length were of little use. Of the nine current iliac vessel homograft recipients, eight patients (89 %) had living-donor liver transplantation and one patient (11 %) had reconstruction of the right internal carotid artery after resection of an aneurysm. Our preliminary results supports existing literatures that suggest cryopreserved iliac vessel homografts can be successfully used for revascularization in liver transplantation and reconstruction of carotid artery. Encouraging short-term post-operative patient outcomes have been achieved, with no report of adverse event attributed to implanted homografts. We believe that our processing, decontamination and cryopreservation techniques have helped preserve the homografts for longer duration as compared to homografts preserved using short-term preservation techniques.
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Affiliation(s)
- Wee Ling Heng
- National Cardiovascular Homograft Bank, National Heart Centre Singapore, Singapore, Singapore,
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Wang CC, Lopez-Valdes S, Lin TL, Yap A, Yong CC, Li WF, Wang SH, Lin CC, Liu YW, Lin TS, Concejero AM, Eng HL, Henry D, Cheng YF, Jawan B, Chen CL. Outcomes of long storage times for cryopreserved vascular grafts in outflow reconstruction in living donor liver transplantation. Liver Transpl 2014; 20:173-81. [PMID: 24382821 DOI: 10.1002/lt.23785] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 10/15/2013] [Indexed: 02/07/2023]
Abstract
The outflow reconstruction of the right anterior sector in a right liver graft (RLG) with cryopreserved vascular grafts (CVGs) is crucial for preventing graft congestion in living donor liver transplantation (LDLT). The impact of the duration of cryopreservation has not been evaluated so far. From 2006 to 2009, 250 LDLT were performed: 47 of these patients (group 1) received CVGs stored for ≦1 year, and 33 patients (group 2) received CVGs stored for >1 year. Single or multiple segment 8 hepatic veins were reconstructed. The number of anastomoses did not affect vascular graft patency (P = 0.21). The length of the cryopreservation time did not affect the histological findings for CVGs. The preoperative and postoperative liver graft volumes were 783.8 ± 129.7 and 1102 ± 194.7 cc, respectively, for group 1 and 753.7 ± 158.5 and 1097.2 ± 178.7 cc, respectively, for group 2. The regeneration indices for liver grafts in the whole patient group, group 1, and group 2 were 48.9%, 47.4%, and 51.05%, respectively. In conclusion, the storage duration has no impact on the patency of CVGs in outflow reconstruction or on the regeneration of RLGs in LDLT. CVGs stored for >1 year can be safely used for the outflow reconstruction of RLGs in LDLT.
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Affiliation(s)
- Chih-Chi Wang
- Liver Transplantation Program, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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8
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Palma AF, Oberkofler CE, Raptis DA, Eshmuminov D, de Rougemont O, Schnyder A, Dimitroulis D, Lesurtel M, Dutkowski P, Clavien PA. Novel rescue procedure for inferior vena cava reconstruction in living-donor liver transplantation using a vascular graft recovered 25 h after donors' circulatory death and systematic review. Transpl Int 2013; 27:204-10. [PMID: 24289717 DOI: 10.1111/tri.12238] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 09/15/2013] [Accepted: 11/01/2013] [Indexed: 12/20/2022]
Abstract
Liver transplantation is a lifesaving treatment for patients suffering from end-stage liver disease. Rarely, acute congestion of the inferior vena cava (IVC) is being encountered because of tumor compression. MELD allocation does not reflect severity of this condition because of lack of organ failure. Herein, a patient is being presented undergoing urgent living-donor liver transplantation (LDLT) with IVC reconstruction for a fast-growing hepatic epithelioid hemangioendothelioma (HEH). IVC reconstruction using a venous graft recovered from a 25-h after circulatory-death prior transplantation became necessary to compensate severe venous congestion. Additionally, a systematic review of the literature searching MEDLINE/PubMed was performed. Protocol and eligibility criteria were specified in advance and registered at the PROSPERO registry (CRD42013004827). Published literature of IVC reconstruction in LDLT was selected. Two reports describing IVC reconstruction with cryopreserved IVC grafts and one IVC reconstruction using a deceased after-circulatory-death-donor IVC graft were included. Follow-up was at 12 and 13 months, respectively. Regarding the graft recovery in the setting of living-related donation, this graft remained patent during the nine-month follow-up period. This is the first report on the use of a venous graft from a circulatory-death-donor, not eligible for whole organ recovery. We demonstrate in this study the feasibility of using a size and blood-group-compatible IVC graft from a cold-stored donor, which can solve the problem of urgent IVC reconstruction in patients undergoing LDLT.
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Affiliation(s)
- Adrian F Palma
- Department of Surgery, Swiss HPB and Transplant Center, University Hospital Zürich, Zürich, Switzerland
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Panaro F, Miggino M, Bouyabrine H, Carabalona JP, Berthet JP, Canaud L, Nougaret S, Ramos J, Navarro F. Reversed saphenous bypass for hepatic artery pseudoaneurysm after liver transplantation. Ann Vasc Surg 2013; 27:1088-97. [PMID: 23972638 DOI: 10.1016/j.avsg.2013.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 10/23/2012] [Accepted: 01/12/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic artery pseudoaneurysm (HAP) is found in 1-2% of liver transplantation (LT) patients. The mortality associated with pseudoaneurysm formation after orthotopic LT is reported to be as high as 75%. Because of the rarity of complications, particularly when considered individually, much of the direction for the management of complications is anecdotal. This article discusses the presentation, etiology, types, treatment indications, and vascular procedures used to manage complications with LT. METHODS Between January 2004 and December 2011, 464 LTs were performed at our institution. Of these, 9 (1.9%) consecutive patients underwent surgical treatment of HAP (8 men and 1 woman; median age, 58.4 years [range, 46-67 years]). Four patients underwent transarterial chemoembolization before LT for hepatocellular carcinoma. In all cases, revascularization with a reversed autologous saphenous vein bypass was performed. RESULTS Four patients had ruptured pseudoaneurysms, and the others were diagnosed as having asymptomatic pseudoaneurysms during the follow-up period. The median delay between LT and the diagnosis of HAP was 39.6 days (range, 22-92 days). All were anatomically extrahepatic. The median diameter was 15.3 mm (range, 9-30 mm). Four patients had a T-tube. In 6 cases, biliary leakage was associated with the LT and, in the remaining 3, mycosis was recorded. After surgery, 1 patient underwent retransplantation because of ischemic cholangitis. Five years later, 5 patients had normal arterial anatomy, and the other 3 patients had stenosis that was successfully treated by stents. All of the patients had normal liver function at follow-up. One patient died 16 months later because of a heart attack. CONCLUSIONS HAP with massive intraperitoneal bleeding is a rare but serious life-threatening complication when it occurs after LT. The majority of HAP cases are associated with bile leakage and mycosis; therefore, surgery must be the treatment of choice. Our conclusions support surgical revascularization with reversed saphenous grafts as a feasible and efficient treatment in cases of HAP.
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Affiliation(s)
- Fabrizio Panaro
- Department of General and Liver Transplant Surgery, University of Montpellier, Hôpital Saint Eloi, Montpellier, France.
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Mabrut JY, Abdullah SS, Rode A, Bourgeot JP, Eljaafari A, Baulieux J, Ducerf C. Cryopreserved iliac artery allograft for primary arterial revascularization in adult liver transplantation. Clin Transplant 2011; 26:E12-6. [PMID: 21919967 DOI: 10.1111/j.1399-0012.2011.01518.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Arterial allograft represents a material of choice for primary arterial revascularization in liver transplantation (LT) when interposition of a vascular conduit is required. In case of non-availability of such graft, the use of cryopreserved vessels should be an interesting option. Three patients were grafted using a cryopreserved iliac artery allograft (CIAA) previously harvested and stored at -140°C in a tissue bank. An auxiliary partial LT was performed in one patient for acute liver failure. During follow-up, an efficient regeneration of the native hemi-liver was observed while atrophy of the auxiliary graft occurred, leading to functional portal vein and hepatic artery thrombosis at six and nine months, respectively. Two other patients presented with celiac trunk compression because of arcuate ligament without available arterial allograft in the donor. Late arterial thrombosis occurred at six months in one patient without impairment of graft function. The last patient was alive and symptom free 29 months after LT with a patent cryopreserved arterial conduit. Our preliminary results suggest that CIAA might represent an efficient solution as vessel interposition for primary arterial hepatic revascularization in LT setting when no other suitable graft is available. However, long-term patency of CIAA remains questionable.
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Affiliation(s)
- Jean-Yves Mabrut
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Lyon Cedex, France.
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Backes A, Gibelli N, Tannuri A, Santos M, Pinho-Apezzato M, Andrade W, Maksoud-Filho J, Queiróz A, Tannuri U. Hepatic Artery Graft in Pediatric Liver Transplantation: Single-Center Experience With 58 Cases. Transplant Proc 2011; 43:177-80. [DOI: 10.1016/j.transproceed.2010.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chardot C, Darani A, Dubois R, Mure PY, Pracros JP, Lachaux A. Modified technique of meso-Rex shunt in case of insufficient length of the jugular vein graft. J Pediatr Surg 2009; 44:e9-12. [PMID: 19944208 DOI: 10.1016/j.jpedsurg.2009.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 08/03/2009] [Accepted: 08/04/2009] [Indexed: 11/26/2022]
Abstract
UNLABELLED Meso-Rex shunt (MRS) can relieve portal hypertension and restore a physiological portal flow in patients with portal vein thrombosis. We describe a technical variant where the autologous internal jugular vein (IJV) was too short to bridge the superior mesenteric vein (SMV) and the Rex recessus. PATIENT A 15-year-old boy with portal cavernoma had several episodes of gastrointestinal bleeding despite repeated sclerotherapy. Preoperative assessment, including retrograde transjugular portography, showed persistent esophageal and gastric varices, severe hypertensive gastropathy, obstructed portal vein, patent SMV and splenomesenteric confluence, patent intrahepatic portal branches, and normal transhepatic pressure gradient. An MRS was planned. The left IJV was retrieved from its infracranial part to its confluence with subclavian vein. After performing the Rex recessus to IJV graft anastomosis, the IJV graft proved to be too short for classical end-to-side anastomosis onto the SMV. After clamp testing showing good tolerance of the small bowel, the proximal jejunal branches of the SMV were tied, the proximal SMV was mobilized and transsected 4 cm below the pancreas, and an end-to-end anastomosis between SMV and IJV was performed. Portal pressure decreased from 23 to 13 mm Hg, and intraoperative Ultra Sound Doppler (US Doppler) showed good flows in the shunt. Postoperative course was uneventful, and 1 year after surgery, the child is clinically well, off medication, with a patent shunt, and no portal hypertension. CONCLUSION This modified MRS technique may be useful when the autologous IJV graft is too short, avoiding the need for prosthetic conduits and prolonged postoperative anticoagulation.
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Use of the Abdominal Rectus Fascia as a Nonvascularized Allograft for Abdominal Wall Closure After Liver, Intestinal, and Multivisceral Transplantation. Transplantation 2009; 87:1884-8. [DOI: 10.1097/tp.0b013e3181a7697a] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Hwang S, Ha TY, Jung DH, Park JI, Lee SG. Portal vein interposition using homologous iliac vein graft during extensive resection for hilar bile duct cancer. J Gastrointest Surg 2007; 11:888-92. [PMID: 17440791 DOI: 10.1007/s11605-007-0146-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 02/14/2007] [Accepted: 03/06/2007] [Indexed: 01/31/2023]
Abstract
Although autologous vein grafts have been used for portal vein (PV) reconstruction after long-segment portal vein resection during surgery for hilar bile duct cancer, their procurement prolongs operation time and increases morbidity. Less is known regarding the use of homologous vein grafts. The feasibility of homografts for PV reconstruction was preliminarily evaluated in two patients who underwent curative resection for hilar cholangiocarcinoma. Both patients underwent left lobectomy, caudate lobectomy, bile duct resection, and segmental PV resection and interposition vein graft reconstruction. The iliac vein homografts were obtained from deceased organ donors and stored for 1-2 days in cold preservation solution without freezing. Neither immunosuppression nor anticoagulation was attempted. One patient has shown good PV patency for 27 months. The second patient, who had received adjuvant chemoradiotherapy, showed an asymptomatic waisting at the proximal PV anastomosis site after 4 months, which was relieved by percutaneous balloon dilatation, and has been doing well for 12 months. In conclusion, our preliminary experience with these two patients suggests that cold-stored iliac vein homografts can be considered as PV substitutes after long PV segment resection during extensive hepatobiliary surgery.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea.
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Bourdeaux C, Darwish A, Jamart J, Tri TT, Janssen M, Lerut J, Otte JB, Sokal E, de Ville de Goyet J, Reding R. Living-related versus deceased donor pediatric liver transplantation: a multivariate analysis of technical and immunological complications in 235 recipients. Am J Transplant 2007; 7:440-7. [PMID: 17173657 DOI: 10.1111/j.1600-6143.2006.01626.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Timely access to a living donor (LD) reduced pretransplant mortality in pediatric liver transplantation (LT). We hypothesized that this strategy may provide better posttransplant outcome. Between July 1993 and April 2002, 235 children received a primary LT from a LD (n = 100) or a deceased donor (DD) (n = 135). Demographic, surgical and immunological variables were compared, and respective impact on posttransplant complications was studied using a multivariate analysis. Five-year patient survival rates were 92% and 85% for groups LD and DD, respectively (p = 0.181), the corresponding graft survival rates being 89% and 77% (p = 0.033). At multivariate analysis: (1) type of donor (DD) was correlated with higher rate of artery thrombosis (p < 0.012); (2) biliary complication rate at 5 years was 29% and 23% for groups LD and DD, respectively (p = 0.451); (3) lower acute rejection incidence could be correlated with type of donor (DD) (p = 0.001), and immunosuppressive therapy (tacrolimus) (p < 0.001). We conclude that (1) according to the multivariate analysis, LT with LD provided similar patient and graft outcome, when compared to DD; (2) a higher rate of artery thrombosis and a lower rate of rejection were observed in group DD; (3) this study confirms the efficacy of tacrolimus for immunoprophylaxis, whatever the type of organ donor is.
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Affiliation(s)
- C Bourdeaux
- Pediatric Liver Transplant Program, Université Catholique de Louvain, Saint-Luc University Clinics, Brussels, Belgium
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16
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Darwish AA, Bourdeaux C, Kader HA, Janssen M, Sokal E, Lerut J, Ciccarelli O, Veyckemans F, Otte JB, de Goyet JDV, Reding R. Pediatric liver transplantation using left hepatic segments from living related donors: surgical experience in 100 recipients at Saint-Luc University Clinics. Pediatr Transplant 2006; 10:345-53. [PMID: 16677359 DOI: 10.1111/j.1399-3046.2005.00477.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Living-related liver transplantation was developed in the context of deceased donor organ shortage, which is particularly acute for pediatric recipients. This retrospective study analyzes the surgical technique and complications in the first 100 pediatric liver transplantation using left segmental liver grafts from living donors, performed at Saint-Luc University Clinics between July 1993 and April 2002. Pre-operative evaluation in donors and recipients, analysis of the surgical technique, and postoperative complications were reviewed. After a median follow-up period of 2526 days, no donor mortality was encountered, with a minimal morbidity and no long-term sequelae. At one and five yr post-transplantation, the actuarial patient survival rates were 94% and 92%, the corresponding figures being 92% and 89% for graft survival. The incidences of portal vein and hepatic artery thromboses, and of biliary complications were 14%, 1%, and 27%, respectively. Living-related liver transplantation in children constitutes an efficient therapy for liver failure to face the increased demand for liver grafts. Donor morbidity was kept to acceptable incidence, and surgical technique in the recipient needs to be tailored to minimize postoperative complications.
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Affiliation(s)
- Ahmed A Darwish
- Pediatric Liver Transplantation Program, Saint-Luc University Clinics, Université catholique de Louvain, Brussels, Belgium
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17
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Muralidharan V, Imber C, Leelaudomlipi S, Gunson BK, Buckels JAC, Mirza DF, Mayer AD, Bramhall SR. Arterial conduits for hepatic artery revascularisation in adult liver transplantation. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00423.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Vivarelli M, Cavallari A, Buzzi M, Conte R. Successful arterial revascularization in liver transplantation using a cryopreserved arterial allograft. Transplantation 2004; 77:792. [PMID: 15021853 DOI: 10.1097/01.tp.0000114592.04652.8b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Otte JB, Pritchard J, Aronson DC, Brown J, Czauderna P, Maibach R, Perilongo G, Shafford E, Plaschkes J. Liver transplantation for hepatoblastoma: results from the International Society of Pediatric Oncology (SIOP) study SIOPEL-1 and review of the world experience. Pediatr Blood Cancer 2004; 42:74-83. [PMID: 14752798 DOI: 10.1002/pbc.10376] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND For hepatoblastoma (HB) that remains unresectable by partial hepatectomy after chemotherapy, total hepatectomy with orthotopic liver transplantation (LTX) has been advocated as the best treatment option. The role of LTX in the overall management of HB is still, however, unclear. PROCEDURE The results of LTX from the first study of HB by the International Society of Pediatric Oncology, SIOPEL-1, were analyzed. In addition, the world experience of LTX for HB was extensively reviewed. Twelve patients in the SIOPEL-1 study underwent a LTX. Median (range) follow-up at Dec. 31, 2001 was 117 months (52-125) since LTX. RESULTS Overall survival at 10 years post-LTX was 85% for the seven children who received a "primary LTX" and 40% for the 5 children who underwent a "rescue LTX" after previous partial hepatectomy. In the world experience (147 cases), the overall survival rate at 6 year post-LTX was 82% for 106 patients who received a "primary LTX" and 30% for 41 patients who underwent a "rescue LTX." Multivariate analysis of patients undergoing primary LTX showed that only macroscopic venous invasion had a significant impact (P-value: 0.045 with a hazard ratio of 2.96) on overall survival. CONCLUSIONS Orthotopic LTX has added a new dimension to the treatment of HB unresectable by partial hepatectomy. Because of the rarity of the disease and to optimize results, children with extensive HB should be treated in centers with surgical expertise in pediatric major liver resection and LTX, in close collaboration with pediatric oncologists, radiologists, and histopathologists.
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Affiliation(s)
- J B Otte
- Department of Pediatric Surgery and Liver Transplantation, Université Catholique de Louvain, Cliniques Saint-Luc, Brussels, Belgium.
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20
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Shames BD, Odorico JS, D'Alessandro AM, Pirsch JD, Sollinger HW. Surgical repair of transplant renal artery stenosis with preserved cadaveric iliac artery grafts. Ann Surg 2003; 237:116-22. [PMID: 12496538 PMCID: PMC1513976 DOI: 10.1097/00000658-200301000-00016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the authors' experience with ABO-matched, preserved, cadaveric, iliac artery grafts for treatment of transplant renal artery stenosis (TRAS). SUMMARY BACKGROUND DATA TRAS is an important and treatable cause of hypertension and graft dysfunction in renal allograft recipients. Surgical treatment is reserved for lesions that are not amenable to percutaneous transluminal angioplasty (PTA) or for recurrence after PTA. Various surgical options for reconstruction of the transplant renal artery exist, although no single technique has been demonstrated to be superior. The authors have used preserved, blood type-matched, iliac artery grafts procured from cadaver organ donors to reconstruct transplant renal arteries in patients with specific lesions and following unsuccessful PTAs. METHODS Between 1991 and 2001, 21 patients underwent reconstruction of allograft renal arteries using cadaveric iliac artery as conduit. Charts, operative notes, and imaging studies of all patients were reviewed. A successful intervention for TRAS was defined as technical success as well as a decrease in serum creatinine and/or blood pressure 6 weeks after the procedure. Development of a hemodynamically significant lesion following renal artery reconstruction was considered a recurrence. RESULTS In patients treated with surgical reconstruction, hemodynamically significant TRAS occurred at or within 1 to 2 mm of the anastomosis in 13 patients, in the middle of the renal artery in 4, and secondary to a kink in 2 patients. Surgical treatment was undertaken in seven patients following unsuccessful PTA. Two patients had aneurysms of the iliac artery. Reconstruction using cadaveric iliac artery was successful in 19 of 21 (90%) patients, and only 1 these patients (4.8%) failed due to recurrence, with a median follow-up of 42 months. Graft loss secondary to TRAS occurred in two patients. The authors have not seen any long-term complications related to cadaveric iliac artery grafts, and the majority of the allografts continue to function well. CONCLUSIONS Surgical reconstruction of the transplant renal artery with blood type-matched iliac artery grafts should be considered a viable option for patients with specific anatomic lesions, those who have had an unsuccessful PTA, and those with recurrence following PTA.
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Affiliation(s)
- Brian D Shames
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, 53792, USA.
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21
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Chardot C, Saint Martin C, Gilles A, Brichard B, Janssen M, Sokal E, Clapuyt P, Lerut J, Reding R, Otte JB. Living-related liver transplantation and vena cava reconstruction after total hepatectomy including the vena cava for hepatoblastoma. Transplantation 2002; 73:90-2. [PMID: 11792985 DOI: 10.1097/00007890-200201150-00017] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND In most cases of total hepatectomy (TH) required for hepatoblastoma (HB), the retrohepatic inferior vena cava (IVC) has to be removed with the native liver for complete tumor excision. Because the liver graft procured by living donation has no IVC, a reconstruction of the recipient IVC is needed. We report our experience with living-related liver transplantation (LRLT) and IVC replacement in such cases. METHODS Between May 1998 and December 1999, four children underwent TH, including IVC and LRLT with IVC replacement for otherwise irresectable HB after chemotherapy (SIOPEL 2 and 3 protocols). IVC reconstruction used an allogenic iliac vein procured from a cadaveric donor (bank graft) in two cases and an internal jugular vein procured from the donor parent in two cases. Median age and weight at surgery were 17 months (range 10-60) and 9.6 kg (range 8.3-17.9). RESULTS In the living donors, there were two complications of the procurement: one intra-abdominal biliary collection and one subcutaneous abscess. In all four children, complete excision of the tumor could be achieved without any intra-operative complication. One patient died 5 months after LRLT due to lung metastases. Three patients were alive and well with no evidence of tumor recurrence 13-24 months after surgery. Reconstructed IVC was patent in two patients, and asymptomatic thrombosis occurred 2 years after operation in one patient. CONCLUSION Total hepatectomy including the retrohepatic IVC is not a technical obstacle to LRLT. Therefore, scheduled surgery, at the best time after chemotherapy, can be considered in all patients with otherwise irresectable HBs.
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Affiliation(s)
- Christophe Chardot
- Centre Hospitalier Universitaire de Bicêtre, 78 rue du Général Leclerc, F-94275 Le Kremlin Bicetre, France.
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22
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Rogers J, Chavin KD, Kratz JM, Mohamed HK, Lin A, Baillie GM, Shafizadeh SF, Baliga PK. Use of autologous radial artery for revascularization of hepatic artery thrombosis after orthotopic liver transplantation: case report and review of indications and options for urgent hepatic artery reconstruction. Liver Transpl 2001; 7:913-7. [PMID: 11679992 DOI: 10.1053/jlts.2001.26926] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatic artery thrombosis (HAT) is the most common vascular complication after orthotopic liver transplantation (OLT) and has traditionally been managed with re-OLT. However, several reports have shown that urgent revascularization is frequently an effective means of graft salvage. This most often involves hepatic artery (HA) thrombectomy and thrombolysis, with reestablishment of arterial inflow through a donor iliac artery conduit based on the supraceliac or infrarenal aorta. We report a 46-year-old man who developed HAT 13 days after OLT after angiographic splenic artery embolization to reduce splenic artery steal. A suitable donor iliac artery was not available for arterial reconstruction and could not be obtained from neighboring transplant centers. The patient underwent urgent HA thrombectomy, intrahepatic arterial thrombolysis, and revascularization using an autologous radial artery (RA) conduit based on the supraceliac aorta. The patient is alive more than 1 year after revascularization, with normal liver function and documented flow in the arterial conduit by Doppler ultrasound and arteriography. He has not developed late biliary complications or adverse sequelae of RA harvest. Autologous RA can be safely and successfully used as an aortic-based arterial conduit in urgent revascularization of HAT after OLT. RA should be considered for use in HA revascularization if an adequate donor iliac artery is not available and other potential conduits are not usable or desirable. The availability of autologous RA expands the armamentarium of vascular conduits that can be used in HA revascularization and may help minimize re-OLT for otherwise potentially salvageable liver allografts.
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Affiliation(s)
- J Rogers
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, USA.
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Muiesan P, Rela M, Heaton ND. Use of cadaveric superior mesenteric artery as interpositional vascular graft in orthotopic liver transplantation. Br J Surg 2001; 88:70-2. [PMID: 11136313 DOI: 10.1046/j.1365-2168.2001.01623.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- P Muiesan
- Liver Transplant Surgical Service, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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