Hepatic artery complications after orthotopic liver transplantation: interventional treatment or retransplantation?:

Neuroform EZ Stents for Hepatic Artery Stenosis After Liver Transplantation: A Single-Center Preliminary Report

PURPOSE

This preliminary study evaluated the safety and effectiveness for off-label use of Neuroform EZ (NEZ) stents in the revascularization of hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Nine of 489 (5%) OLTs with HAS were managed with NEZ stents between September 2016 and July 2021. Stenting outcomes were evaluated based on the technical success rate, procedure-related complications, and primary patency.

RESULTS

A total of 10 NEZ stents (4.5 mm × 3 cm, n = 6; 4 mm × 3 cm, n = 4) were successfully deployed in 9 torturous hepatic arteries and in 1 relatively straight artery without any procedure-related complications. Combined thrombolysis (n = 3) and balloon angioplasty (n = 6) was performed. The median duration of follow-up was 438 days (range, 120-1126 days). Asymptomatic re-stenoses were detected in 2 stents on days 60 and 433 after stenting. A Kaplan-Meier curve predicted cumulative primary stent patencies at 1, 2, and 3 years of 90%, 75%, and 75%, respectively.

CONCLUSION

NEZ stents can be safely used to treat HAS after OLT with high technical success and favorable primary patency.

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.

Hepatic artery kinking during liver transplantation: survey and prospective intraoperative flow measurement

BACKGROUND

Hepatic artery thrombosis (HAT) represents the most common vascular complication occurring after liver transplantation (LT). Herein, we report the results of a prospective study of hepatic artery flow (HAF) measurement during abdominal wall closure after LT along with the results of an international survey of procedures adopted, in order to avoid the arterial kinking (AK) in case of long artery.

METHODS

Sixty-four surgeons were asked regarding the different procedures used to avoid AK in the presence of long artery. We prospectively assessed the HAF during three phases of LT in 26 consecutive LT performed in patients with a long HA: after completion of the biliary anastomosis (M0), and partial abdominal wall closure with (M1w) or without (M1w/o) hepatic artery anti-kinking method (HAAK).

RESULTS

Sixty (93.7 %) surgeons replied to the survey: 44 (73.3 %) surgeons cut the artery as short as possible, of whom 38 (86.3 %) interposed an oxidized polymer or the omentum, and six (13.7 %) used other systems. Fourteen (23.3 %) surgeons did not use any interposition methods. The remaining two (3.3 %) surgeons left a long artery without HAAK. In our cohort we obtained the following HAF measures: M0 152 mL/min (89-205), M1 without HAAK 114 (66-168) and M1 with HAAK procedure 158 (91-219) (p = 0.002).

CONCLUSIONS

Our survey confirms that no consensus is currently available regarding the most effective method for avoiding AK. Kinking occurs most probably when the liver is released in its final position. The utilization of an interposition method could ensure the maintenance of a correct HAF.

Liver transplantation and spontaneous neovascularization after arterial thrombosis: "the neovascularized liver"

The only arterial pathway available after liver transplantation is the hepatic artery. Therefore, hepatic artery thrombosis can result in graft loss necessitating re-transplantation. Herein, we present evidence of neovascularization at long-term follow-up in a series of transplant patients with hepatic artery thrombosis. We termed this phenomenon "neovascularized liver". Hepatic artery thrombosis was noted in 30/407 cases (7.37%), and occurred early in 13 patients (43.3%) and late (>30 days) in 17 (56.7%) patients. At the time of this study, 11 (36.7%) patients had a neovascularized liver. Those patients with neovascularized liver and normal liver function were closely followed. Of these patients, 10 (91%) showed evidence of neovascularized liver by imaging, and an echo-Doppler arterial signal was recorded in all patients. The mean interval between the diagnosis of hepatic artery thrombosis and neovascularized liver was 4.1 months (range of 3-5.5 months). Liver histology showed an arterial structure in 4 (36.4%) patients. Four factors were associated with development of neovascularized liver: late hepatic artery thrombosis, early hepatic artery stenosis, site of thrombosis, and Roux-en-Y anastomosis. The overall survival rate at 54 months was 90.9%. In conclusion, a late hepatic artery thrombosis may be quite uneventful and should not automatically lead to re-transplantation.

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.

Continuous Intraarterial Thrombolysis for Early Hepatic Artery Thrombosis Following Liver Transplantation: Case Report

Hepatic Artery thrombosis remains one of the major causes of graft failure and mortality in liver transplant recipients. Urgent re-transplantation has been considered as mainstay therapy; however, even with re-transplantation mortality of more than 50% has been reported by many series. Early detection on Doppler ultrasonography and subsequent revascularization in asymptomatic patients can avoid graft loss. Endovascular therapy including intra-arterial thrombolysis, percutaneous transluminal angioplasty, and stent placement have shown encouraging results in recent years; nevertheless, their use remains controversial due to potential risk of bleeding. We present a case of early hepatic artery thrombosis following liver transplantation treated successfully with continuous transcatheter intra-arterial thrombolysis using tissue plasminogen activator (t-PA).