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

Single vs Multiple Arterial Reconstructions in Living Donor Liver Transplant

BACKGROUND

It is true that multiple arterial reconstructions are sometimes required in living donor liver transplant (LDLT). However, the best procedure is still controversial regarding arterial reconstruction in liver grafts with multiple arteries.

METHODS

A total of 93 patients, 55 right lobe grafts and 38 left lobe grafts, who underwent LDLT at our university from 2003 to 2017 were enrolled for this study. Regarding arterial reconstruction in grafts with multiple hepatic arteries, the dominant artery was reconstructed first. Subsequently, when both the pulsating arterial flow from the remaining artery stumps and the intra-graft arterial flow by Doppler ultrasonography were confirmed, the remaining arteries were not reconstructed. The patients were divided into the following 3 groups: (1) single artery/single reconstruction (n = 81), (2) selective arterial reconstruction of multiple arterial grafts (n = 7), and (3) multiple arterial reconstructions (n = 5).

RESULTS

A total of 12.9% (12/93; right lobe: 2/55; left lobe 10/38) of grafts had multiple arteries. The incidence of multiple arteries was significantly higher in the left lobe grafts (P = .0029). The arterial diameters (SD) of multiple arterial grafts were narrower (2.43 [0.84] mm) than single arterial grafts (3.70 [1.30] mm) (P = .0135). Extra-anatomic arterial reconstruction were frequently required in multiple arterial reconstructions (group 1 and 2 vs 3) (P = .0007). The strategy of selective arterial reconstruction with the above criteria did not negatively affect the rates of biliary complications or the overall patient survival (P = .52).

CONCLUSIONS

It can be argued that selective arterial reconstructions demonstrated acceptable outcomes in LDLT, provided that the above criteria were satisfied.

The technique and outcomes of branch-patch arterial reconstruction in living donor liver transplantation

BACKGROUND

Although living donor liver transplantation (LDLT) is now an established therapeutic modality for end-stage liver disease, technical dilemmas exist. The pretransplant imaging findings may not clearly define the surgical anatomy of the hepatic artery (HA), especially its diameter. A tiny artery (<2 mm) has always been found during the hilar dissection. Its size is discrepant to the diameter to the recipient arterial stump. The aim of this paper was to report a hepatic arterial reconstruction technique for small diameter (<2 mm) vessels in a partial liver graft.

METHODS

Since January 2002 to May 2007, we performed 9 LDLT with small hepatic arteries (<2 mm), which were analyzed retrospectively for this report. In this technique, we transect the donor hepatic artery proximally and distally to the tiny graft artery, take off and create a patch for arterial anastomosis. Computed tomographic angiography is used to evaluate the vascular anatomy and to measure the diameter of the graft HAs.

RESULTS

All donors were discharged without any vascular complications. One donor experienced a bile leakage from the dissections plane of the liver, which was treated by draining the abdominal cavity. Eight of the 9 patients survived without evidence of hepatic artery thrombosis during 32 months (range, 14-72); one subject died due to cytomegalovirus infection.

CONCLUSION

The arterial reconstruction technique enabled use of tiny arteries, eliminating the problems of diameter discrepancy without increasing donor complications.

Branch patch reconstruction in living donor liver transplantation: arterialization of grafts with replaced type arteries

We developed a hepatic arterialization technique in living donor liver transplantation. The technique was indicated in patients with a left graft from donors with a right hepatic artery originated from superior mesenteric artery or a right graft from donors with a left hepatic artery from left gastric artery. The donor common hepatic and gastroduodenal arteries were split. On the recipient side, left and right hepatic arteries or branches of the right hepatic artery were split, received patch plasty, and anastomosed with the graft arteries under loupe observation. Livers from 25 donors were procured (16 right livers and 9 left livers) using this technique. There were no vascular complications in the donors. Three recipients died due to infectious disease with arterial patency. The remaining 22 recipients survived without hepatic arterial thrombosis. In limited situations, this technique can be adapted for living donor liver transplantation without increasing donor complications.

Outcome in right living related liver transplantation with branch-patch arterial reconstruction

cRight lobe living liver transplantation is being performed worldwide with increased frequency. Difficult arterial reconstructions are often encountered because of small diameter or discrepancy between arterial stumps. The risk of arterial thrombosis is reported as high as 26%: microsurgical techniques have reduced this rate below 2%, increasing warm ischemia time. We have developed a new branch patch technique in living related liver transplantation using the donor cystic artery to create an enlarged patch anastomosis that enables increase in the vessel's diameter and therefore greater inflow to the liver. We have followed 8 patients treated with this technique. After more than 1 year (mean follow-up: 636 days) we did not observe any arterial thrombosis by Doppler ultrasound performed every 3 months. The mean resistance index was 0.68 (0.57-0.83-). Three patients died with functional graft without signs of thrombosis. We believe that the cystic artery branch patch technique is feasible in all cases. It is fast (mean time: 6.2 min), it allows a shorter warm ischemia time, and there is no increased risk of thrombosis.