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Terasawa M, Imamura H, Allard MA, Pietrasz D, Ciacio O, Pittau G, Salloum C, Sa Cunha A, Cherqui D, Adam R, Azoulay D, Saiura A, Vibert E, Golse N. Intraoperative indocyanine green fluorescence imaging to predict early hepatic arterial complications after liver transplantation. Liver Transpl 2024; 30:805-815. [PMID: 38466885 DOI: 10.1097/lvt.0000000000000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/19/2024] [Indexed: 03/13/2024]
Abstract
The purpose of this study was to propose an innovative intraoperative criterion in a liver transplantation setting that would judge arterial flow abnormality that may lead to early hepatic arterial occlusion, that is, thrombosis or stenosis, when left untreated and to carry out reanastomosis. After liver graft implantation, and after ensuring that there is no abnormality on the Doppler ultrasound (qualitative and quantitative assessment), we intraoperatively injected indocyanine green dye (0.01 mg/Kg), and we quantified the fluorescence signal at the graft pedicle using ImageJ software. From the obtained images of 89 adult patients transplanted in our center between September 2017 and April 2019, we constructed fluorescence intensity curves of the hepatic arterial signal and examined their relationship with the occurrence of early hepatic arterial occlusion (thrombosis or stenosis). Early hepatic arterial occlusion occurred in 7 patients (7.8%), including 3 thrombosis and 4 stenosis. Among various parameters of the flow intensity curve analyzed, the ratio of peak to plateau fluorescence intensity and the jagged wave pattern at the plateau phase were closely associated with this dreaded event. By combining the ratio of peak to plateau at 0.275 and a jagged wave, we best predicted the occurrence of early hepatic arterial occlusion and thrombosis, with sensitivity/specificity of 0.86/0.98 and 1.00/0.94, respectively. Through a simple composite parameter, the indocyanine green fluorescence imaging system is an additional and promising intraoperative modality for identifying recipients of transplant at high risk of developing early hepatic arterial occlusion. This tool could assist the surgeon in the decision to redo the anastomosis despite normal Doppler ultrasonography.
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Affiliation(s)
- Muga Terasawa
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Marc Antoine Allard
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Inserm, Université Paris-Saclay, Physiopathogénèse et traitement des maladies du foie, FHU Hepatinov, Villejuif, France
| | - Daniel Pietrasz
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Inserm, Université Paris-Saclay, Physiopathogénèse et traitement des maladies du foie, FHU Hepatinov, Villejuif, France
| | - Oriana Ciacio
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
| | - Gabriella Pittau
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
| | - Chady Salloum
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
| | - Antonio Sa Cunha
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Inserm, Université Paris-Saclay, Physiopathogénèse et traitement des maladies du foie, FHU Hepatinov, Villejuif, France
| | - Daniel Cherqui
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Inserm, Université Paris-Saclay, Physiopathogénèse et traitement des maladies du foie, FHU Hepatinov, Villejuif, France
| | - René Adam
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
| | - Daniel Azoulay
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Inserm, Université Paris-Saclay, Physiopathogénèse et traitement des maladies du foie, FHU Hepatinov, Villejuif, France
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Eric Vibert
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Inserm, Université Paris-Saclay, Physiopathogénèse et traitement des maladies du foie, FHU Hepatinov, Villejuif, France
| | - Nicolas Golse
- Hôpital Paul Brousse, Centre Hépato-Biliaire, AP-HP, Villejuif, France
- Inserm, Université Paris-Saclay, Physiopathogénèse et traitement des maladies du foie, FHU Hepatinov, Villejuif, France
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2
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Mishra S, Taneja S. Algorithmic Approach to Deranged Liver Functions After Transplantation. J Clin Exp Hepatol 2024; 14:101317. [PMID: 38264576 PMCID: PMC10801315 DOI: 10.1016/j.jceh.2023.101317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
Liver transplant (LT) recipients require close follow-up with regular monitoring of the liver function tests (LFTs). Evaluation of deranged LFT should be individualized depending upon the time since LT, peri-operative events, clinical course, and any complications. These derangements can range from mild and asymptomatic to severe and symptomatic elevations requiring expedited personalized assessment and management. Pattern of LFT derangement (hepatocellular, cholestatic, or mixed), donor-recipient risk factors, timing after LT (post-operative, 1-12 months, and >12 months since LT) along with clinical context and symptomatology are important considerations before proceeding with the initial evaluation. Compliance to immunosuppression and drug interactions should be ascertained along with local epidemiology of infections. Essential initial evaluation must include an ultrasound abdomen with Doppler to rule out any structural causes such as biliary or vascular complications apart from focussed laboratory evaluation. Early allograft dysfunction, ischemia reperfusion injury, small-for-size syndrome, biliary leaks, hepatic artery, and portal vein thrombosis are usual culprits in the early post-operative period whereas viral hepatitis (acute or reactivation), opportunistic infections, and recurrence of the primary disease are more frequent in the later period. Graft rejection, biliary strictures, sepsis, and drug induced liver injury remain possible etiologies at all times points after LT. Initial evaluation algorithm must be customized based on history, clinical examination, risk factors, and pattern and severity of deranged LFT. Allograft rejection is a diagnosis of exclusion and requires liver biopsy to confirm and assess severity. Empirical treatment of rejection sans liver biopsy is discouraged.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector 22, Panchkula, Haryana 134109, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Desai SV, Natarajan B, Khanna V, Brady P. Hepatic artery stenosis following adult liver transplantation: evaluation of different endovascular treatment approaches. CVIR Endovasc 2024; 7:39. [PMID: 38642226 PMCID: PMC11032299 DOI: 10.1186/s42155-024-00439-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/19/2024] [Indexed: 04/22/2024] Open
Abstract
PURPOSE To evaluate the efficacy and safety of hepatic artery interventions (HAI) versus extra-hepatic arterial interventions (EHAI) when managing clinically significant hepatic artery stenosis (HAS) after adult orthotopic liver transplantation. MATERIALS AND METHODS A single-center retrospective cohort analysis was conducted on liver transplant patients who underwent intervention for clinically significant HAS from September 2012 to September 2021. The HAI treatment arm included hepatic artery angioplasty and/or stent placement while the EHAI treatment arm comprised of non-hepatic visceral artery embolization. Primary outcomes included peri-procedural complications and 1-year liver-related deaths. Secondary outcomes included biliary ischemic events, longitudinal trends in liver enzymes and ultrasound parameters pre-and post-intervention. RESULTS The HAI arm included 21 procedures in 18 patients and the EHAI arm included 27 procedures in 22 patients. There were increased 1-year liver-related deaths (10% [2/21] vs 0% [0/27], p = 0.10) and complications (29% [6/21] vs 4% [1/27], p = 0.015) in the HAI group compared to the EHAI group. Both HAI and EHAI groups exhibited similar improvements in transaminitis including changes of ALT (-72 U/L vs -112.5 U/L, p = 0.60) and AST (-58 U/L vs -48 U/L, p = 0.56) at 1-month post-procedure. Both treatment arms demonstrated increases in post-procedural peak systolic velocity of the hepatic artery distal to the stenosis, while the HAI group also showed significant improvement in resistive indices following the intervention. CONCLUSION Direct hepatic artery interventions remain the definitive treatment for clinically significant hepatic artery stenosis; however, non-hepatic visceral artery embolization can be considered a safe alternative intervention in cases of unfavorable hepatic anatomy.
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Affiliation(s)
- Sagar V Desai
- Department of Interventional Radiology, Jefferson Einstein Hospital, Philadelphia, PA, USA.
| | | | - Vinit Khanna
- Department of Interventional Radiology, Jefferson Einstein Hospital, Philadelphia, PA, USA
| | - Paul Brady
- Department of Interventional Radiology, Jefferson Einstein Hospital, Philadelphia, PA, USA
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Khati I, Jacquier A, Cadour F, Bartoli A, Graber M, Hardwigsen J, Tradi F, Barral PA. Endovascular therapies for hepatic artery stenosis post liver transplantation. CVIR Endovasc 2022; 5:63. [PMID: 36478229 PMCID: PMC9729479 DOI: 10.1186/s42155-022-00338-7] [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: 06/27/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To evaluate primary patency at 12 months after endovascular therapies in hepatic artery stenosis. METHODS A retrospective review of all endovascular interventions for hepatic artery stenosis (HAS) after liver transplantation that occurred between June 2013 and November 2020 was performed at a single institution in France. Follow up occurred from 1 month to 4 years (median 15 months). The treatment consisted of dilation with a balloon or stent. We analyzed short-term (technical success and complications) and long-term outcomes (liver function, arterial patency, graft survival at 12 months (GS), and reintervention). We also compared percutaneous balloon angioplasty (PBA) with stent placement. PBA alone was used if < 30% residual stenosis of the hepatic artery was achieved. Stenting was performed if there was greater than 30% residual stenosis and in the case of complications (dissection or rupture). RESULTS A total of 18 stenoses were suspected on the basis of routine surveillance duplex ultrasound imaging (peak systolic velocity > 200 cm/s, systolic accelerating time > 10 ms and resistive index < 0.5), all of which were confirmed by angio CT, but only 17 were confirmed by angiography. Seventeen patients were included (14 males, mean age 57 years; and three females, mean age 58 years). Interventions were performed in 17 cases (95%) with PBA only (5/17), stent only (5/17) or both (4/17). Immediate technical success was 100%. Major complications occurred in 1 of 17 cases (5.8%), consisting of target vessel dissection. The analysis of the three (groups PBA only, stent only or both) showed the same procedural success (100%), GS (100%) and normal liver function after the procedures but different rates of complications (20% vs. 0% vs. 0%), arterial patency at 12 months (60% vs. 80% vs. 85%) (p = 0.4), early stenosis (40% vs. 80% vs. 0%) or late stenosis (60% vs. 20% vs. 100%) and requirement for reintervention (40% vs. 20% vs. 14%) (p = 0.56). CONCLUSION This study suggests that PBA, stent, or both procedures show the same primary patency at 12 months. It is probably not a definitive answer, but these treatments are safe and effective for extending graft survival in the context of graft shortages.
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Affiliation(s)
- I. Khati
- grid.411266.60000 0001 0404 1115Department of Radiology, CHU Timone 2, Marseille APHM, Marseille, France
| | - A. Jacquier
- grid.411266.60000 0001 0404 1115Department of Radiology, CHU Timone 2, Marseille APHM, Marseille, France
| | - F. Cadour
- grid.411266.60000 0001 0404 1115Department of Radiology, CHU Timone 2, Marseille APHM, Marseille, France
| | - A. Bartoli
- grid.411266.60000 0001 0404 1115Department of Radiology, CHU Timone 2, Marseille APHM, Marseille, France
| | - M. Graber
- grid.411266.60000 0001 0404 1115Department of Radiology, CHU Timone 2, Marseille APHM, Marseille, France
| | - J. Hardwigsen
- grid.411266.60000 0001 0404 1115Department of Surgery, CHU Timone 2, Marseille APHM, Marseille, France
| | - F. Tradi
- grid.411266.60000 0001 0404 1115Department of Radiology, CHU Timone 2, Marseille APHM, Marseille, France
| | - P.-A. Barral
- grid.411266.60000 0001 0404 1115Department of Radiology, CHU Timone 2, Marseille APHM, Marseille, France
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Vairavamurthy JP, Li C, Urban S, Katz M. Percutaneous Transarterial Stent Placement in a Transplant Liver Hepatic Artery Complicated by Angioplasty Balloon Rupture and Fragmentation. Semin Intervent Radiol 2019; 36:133-136. [PMID: 31123386 DOI: 10.1055/s-0039-1688428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The incidence of posttransplant hepatic arterial stenosis (HAS) has been reported in 5 to 10% of orthotopic liver transplants and, left untreated, can lead to hepatic arterial thrombosis. Most vascular complications develop less than 3 months after initial transplant, with thrombosis representing over half of all complications. There has been a trend toward minimally invasive, endovascular techniques for treating HAS with angioplasty and stenting. In one review of endovascular therapies for HAS, primary technical success was achieved in 95% of the interventions. Complication rates following endovascular repair of HAS have been reported to be between 0 and 23% in the literature. The main risk factors for complications include tortuosity of the hepatic artery and history of a second liver transplant. Other associated risk factors include female gender, age greater than 60 years, prior history of transarterial chemoembolization, and multiple arterial graft anastomoses. The case presented here is representative of a complication of balloon rupture and fragmentation in a patient undergoing hepatic arterial stent placement post-liver transplant.
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Affiliation(s)
- Jenanan P Vairavamurthy
- Division of Interventional Radiology, Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Charles Li
- Division of Interventional Radiology, Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Seth Urban
- Division of Interventional Radiology, Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Michael Katz
- Division of Interventional Radiology, Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Molvar C, Ogilvie R, Aggarwal D, Borge M. Transplant Hepatic Artery Stenosis: Endovascular Treatment and Complications. Semin Intervent Radiol 2019; 36:84-90. [PMID: 31123377 DOI: 10.1055/s-0039-1688420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Hepatic artery stenosis (HAS) is an infrequent complication of liver transplant; if left untreated, it can lead to hepatic artery thrombosis with high risk of biliary necrosis and graft loss. HAS is diagnosed with screening Doppler ultrasound, together with computed tomography angiography and magnetic resonance angiography. Endovascular treatment with angioplasty ± stent placement is safe and effective with infrequent major complications; however, when complications occur, they can devastate long-term graft survival. Herein, we present two cases of HAS treated with balloon angioplasty with resultant major complications requiring operative intervention.
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Affiliation(s)
- Christopher Molvar
- Section of Vascular and Interventional Radiology, Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Ross Ogilvie
- Section of Vascular and Interventional Radiology, Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Deep Aggarwal
- Section of Vascular and Interventional Radiology, Department of Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Marc Borge
- Section of Vascular and Interventional Radiology, Department of Radiology, Loyola University Medical Center, Maywood, Illinois
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Endovascular Treatment of Arterial Complications After Liver Transplantation: Long-Term Follow-Up Evaluated on Doppler Ultrasound and Magnetic Resonance Cholangiopancreatography. Cardiovasc Intervent Radiol 2018; 42:381-388. [DOI: 10.1007/s00270-018-2108-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023]
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8
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Choi HJ, Kim DG, Kim Y, Kwak BJ, Han JH, Hong TH, You YK. Clinical Course of Hepatic Artery Thrombosis After Living Donor Liver Transplantation Using the Right Lobe. Liver Transpl 2018; 24:1554-1560. [PMID: 29604232 DOI: 10.1002/lt.25065] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
Hepatic artery thrombosis (HAT) can result in biliary tree necrosis and graft loss, necessitating retransplantation. The most effective treatment approach is still controversial. This study was performed to review the outcomes of HAT after living donor liver transplantation (LDLT) and to clarify the feasibility of different strategies. From May 1996 to August 2017, LDLT using the right lobe was performed in 827 adult patients in our center. Our technique of hepatic artery (HA) reconstruction is end-to-end anastomosis under a microscope (10×). Diagnosis of HAT was performed using Doppler sonography and computed tomography (CT) angiography. HAT was initially treated with surgical or endovascular procedure, and retransplantation was considered according to the graft condition. Among the 827 cases of LDLT using the right lobe, HAT occurred in 16 (1.9%) cases within 1 month after transplantation. Within the first week, 7 of these HAT cases (43.8%) occurred (early HAT), while the remaining 9 cases (56.2%) occurred between the first week and 1 month (late HAT). The incidence of graft failure was high in early HAT (42.9%), and the frequency of biliary complications was high in late HAT (77.8%). The success rate of HA recanalization was 62.5% (10/16): 100% (5/5) after reoperation and 45.5% (5/11) after the endovascular procedure. Of the patients in whom treatment failed in late HAT (n = 5), 4 underwent neovascularization during observation. A total of 5 patients underwent graft failure, and 3 of these patients underwent repeat liver transplantation (LT). Mortality occurred in 3 patients, including 1 in the surgical group and 2 in the endovascular group. In conclusion, early diagnosis and aggressive treatment of HAT are necessary to avoid graft failure, and the choice of treatment depends on various factors. Although further studies are required, early HAT requires preparation for graft failure, while late HAT requires treatment for biliary complications.
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Affiliation(s)
- Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yumi Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Bong Jun Kwak
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyun Han
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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9
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Lee DD, Paz-Fumagalli R, Croome KP, Paz D, Wright L, Nguyen JH, Taner CB. Hepatic artery stenosis after liver transplant: Donation after cardiac death donor vs donation after brain death donor grafts. Clin Transplant 2018; 32:e13413. [DOI: 10.1111/ctr.13413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 08/26/2018] [Accepted: 09/15/2018] [Indexed: 12/22/2022]
Affiliation(s)
- David D. Lee
- Department of Transplantation; Mayo Clinic Florida and Mayo Clinic Collaborative in Transplant Research and Outcomes; Jacksonville Florida
| | | | - Kristopher P. Croome
- Department of Transplantation; Mayo Clinic Florida and Mayo Clinic Collaborative in Transplant Research and Outcomes; Jacksonville Florida
| | - Diego Paz
- Clinical Research Internship Study Program (CRISP) Mayo Clinic Florida; Jacksonville Florida
| | - Lauren Wright
- Department of Transplantation; Mayo Clinic Florida and Mayo Clinic Collaborative in Transplant Research and Outcomes; Jacksonville Florida
| | - Justin H. Nguyen
- Department of Transplantation; Mayo Clinic Florida and Mayo Clinic Collaborative in Transplant Research and Outcomes; Jacksonville Florida
| | - C. Burcin Taner
- Department of Transplantation; Mayo Clinic Florida and Mayo Clinic Collaborative in Transplant Research and Outcomes; Jacksonville Florida
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Sarwar A, Chen C, Khwaja K, Malik R, Raven KE, Weinstein JL, Evenson A, Faintuch S, Fisher R, Curry MP, Ahmed M. Primary Stent Placement for Hepatic Artery Stenosis After Liver Transplantation: Improving Primary Patency and Reintervention Rates. Liver Transpl 2018; 24:1377-1383. [PMID: 30359488 DOI: 10.1002/lt.25292] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/22/2018] [Accepted: 06/04/2018] [Indexed: 02/06/2023]
Abstract
Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow-up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow-up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24-68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow-up period (median, 41 months; interquartile range [IQR], 25-86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4-11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow-up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.
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Affiliation(s)
- Ammar Sarwar
- Divisions of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christine Chen
- Divisions of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Khalid Khwaja
- Divisions of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Raza Malik
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kristin E Raven
- Divisions of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeffrey L Weinstein
- Divisions of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amy Evenson
- Divisions of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Salomao Faintuch
- Divisions of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robert Fisher
- Divisions of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael P Curry
- Divisions of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Muneeb Ahmed
- Divisions of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Marked Decrease in Urgent Listing for Liver Transplantation Over Time: Evolution of Characteristics and Outcomes of Status-1 Liver Transplantation. Transplantation 2018; 102:e18-e25. [PMID: 28968354 DOI: 10.1097/tp.0000000000001967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Approximately 5% of liver transplants annually are performed urgently with "status-1" designation. This study aims to determine if the demand, characteristics, and outcome for status-1 liver transplantation has changed over time. METHODS We used the Scientific Registry of Transplant Patients (2003-2015) to characterize 2352 adult patients who underwent 2408 status-1 liver transplants and compared them between Era1 (2003-6/2009) and Era2 (7/2009-2015). RESULTS Overall, there were fewer liver transplants performed with the status-1 designation in Era2 than Era1 (1099 vs 1309). Although the number of urgent liver transplants was relatively constant with successive years, the proportion transplanted with status-1 designation decreased markedly over time. Era2 patients were older (43.2 years vs 41.7 years, P = 0.01) and less likely be ABO-incompatible (1.1% vs 2.4%, P = 0.01) or retransplant (77 vs 124, P = 0.03). In terms of disease etiology, the largest group was "acute liver failure (ALF), nonspecified" (43.4%). There was no difference in proportion with drug-induced liver injury (DILI), but the subset of herbal/dietary supplements increased in Era2 (1.3% vs 0.46%, P = 0.04). Survival was increased in Era2 in the overall cohort and for patients with autoimmune disease (P < 0.05), despite longer waiting times for this etiology (186 days vs 149 days). DILI or nonspecified ALF had shorter waiting times, and 90% were transplanted within 7 days. CONCLUSIONS Liver transplantation for the most urgent indications (status-1) is decreasing while survival remains excellent. Fewer incidences of ALF are classified as indeterminate, mostly as a result of increasing awareness of autoimmune hepatitis and DILI as causes of the syndrome.
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12
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Complications after endovascular treatment of hepatic artery stenosis after liver transplantation. J Vasc Surg 2017; 66:1488-1496. [PMID: 28697937 DOI: 10.1016/j.jvs.2017.04.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/30/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis (HAT) and a subsequent 30% to 50% risk of graft loss. Although endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment, the potential risks of these interventions are poorly described. METHODS A retrospective review of all endovascular interventions for HAS after liver transplantation between August 2009 and March 2016 was performed at a single institution, which has the largest volume of liver transplants in the United States. Severe HAS was identified by routine surveillance duplex ultrasound imaging (peak systolic velocity >400 cm/s, resistive index <0.5, and presence of tardus parvus waveforms). RESULTS In 1129 liver transplant recipients during the study period, 106 angiograms were performed in 79 patients (6.9%) for severe de novo or recurrent HAS. Interventions were performed in 99 of 106 cases (93.4%) with percutaneous transluminal angioplasty alone (34 of 99) or with stent placement (65 of 99). Immediate technical success was 91%. Major complications occurred in eight of 106 cases (7.5%), consisting of target vessel dissection (5 of 8) and rupture (3 of 8). Successful endovascular treatment was possible in six of the eight patients (75%). Ruptures were treated with the use of a covered coronary balloon-expandable stent graft or balloon tamponade. Dissections were treated with placement of bare-metal or drug-eluting stents. No open surgical intervention was required to manage any of these complications. With a median of follow-up of 22 months, four of eight patients (50%) with a major complication progressed to HAT compared with one of 71 patients (1.4%) undergoing a hepatic intervention without a major complication (P < .001). One patient required retransplantation. Severe vessel tortuosity was present in 75% (6 of 8) of interventions with a major complication compared with 34.6% (34 of 98) in those without (P = .05). In the complication cohort, 37.5% (3 of 8) of the patients had received a second liver transplant before intervention compared with 12.6% (9 of 71) of the patients in the noncomplication cohort (P = .097). CONCLUSIONS Although endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery and prior retransplantation were associated with a twofold to threefold increased risk of a major complication. Acute vessel injury can be managed successfully using endovascular techniques, but these patients have a significant risk of subsequent HAT and need close surveillance.
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Feasibility and Midterm Results of Endovascular Treatment of Hepatic Artery Occlusion within 24 Hours after Living-Donor Liver Transplantation. J Vasc Interv Radiol 2017; 28:269-275. [DOI: 10.1016/j.jvir.2016.06.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/23/2016] [Accepted: 06/25/2016] [Indexed: 02/06/2023] Open
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Rajakannu M, Awad S, Ciacio O, Pittau G, Adam R, Cunha AS, Castaing D, Samuel D, Lewin M, Cherqui D, Vibert E. Intention-to-treat analysis of percutaneous endovascular treatment of hepatic artery stenosis after orthotopic liver transplantation. Liver Transpl 2016; 22:923-33. [PMID: 27097277 DOI: 10.1002/lt.24468] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/16/2016] [Indexed: 02/06/2023]
Abstract
Hepatic artery stenosis (HAS) is a rare complication of orthotopic liver transplantation (LT). HAS could evolve into complete thrombosis and lead to graft loss, incurring significant morbidity and mortality. Even though endovascular management by percutaneous transluminal angioplasty ± stenting (PTA) is the primary treatment of HAS, its longterm impact on hepatic artery (HA) patency and graft survival remains unclear. This study aimed to evaluate longterm outcomes of PTA and to define the risk factors of treatment failure. From 2006 to 2012, 30 patients with critical HAS (>50% stenosis of HA) and treated by PTA were identified from 870 adult patients undergoing LT. Seventeen patients were diagnosed by post-LT screening, and 13 patients were symptomatic due to HAS. PTA was completed successfully in 27 (90%) patients with angioplasty plus stenting in 23 and angioplasty alone in 4. The immediate technical success rate was 90%. A major complication that was observed was arterial dissection (1 patient) which eventually necessitated retransplantation. Restenosis was observed in 10 (33%) patients. One-year, 3-year, and 5-year HA patency rates were 68%, 62.8%, and 62.8%, respectively. Overall patient survival was 93.3% at 3 years and 85.3% at 5 years. The 3-year and 5-year liver graft survival rates were 84.7% and 64.5%, respectively. No significant difference was observed in patient and graft survivals between asymptomatic and symptomatic patients after PTA. Similarly, no difference was observed between angioplasty alone and angioplasty plus stenting. In conclusion, endovascular therapy ensures a good 5-year graft survival (64.5%) and patient survival (85.3%) in patients with critical HAS by maintaining HA patency with a low risk of serious morbidity (3.3%). Liver Transplantation 22 923-933 2016 AASLD.
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Affiliation(s)
- Muthukumarassamy Rajakannu
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Unités Mixtes de Recherche en Santé 1193, INSERM, Villejuif, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Sameh Awad
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - Oriana Ciacio
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - Gabriella Pittau
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Unités Mixtes de Recherche en Santé 776, INSERM, Villejuif, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Antonio Sa Cunha
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Denis Castaing
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Unités Mixtes de Recherche en Santé 1193, INSERM, Villejuif, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Didier Samuel
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Unités Mixtes de Recherche en Santé 1193, INSERM, Villejuif, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Maïté Lewin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Unités Mixtes de Recherche en Santé 1193, INSERM, Villejuif, France
| | - Daniel Cherqui
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France.,Unités Mixtes de Recherche en Santé 1193, INSERM, Villejuif, France.,Université Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France
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Piardi T, Lhuaire M, Bruno O, Memeo R, Pessaux P, Kianmanesh R, Sommacale D. Vascular complications following liver transplantation: A literature review of advances in 2015. World J Hepatol 2016; 8:36-57. [PMID: 26783420 PMCID: PMC4705452 DOI: 10.4254/wjh.v8.i1.36] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 12/02/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Although vascular complications (VCs) following orthotopic liver transplantation (OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the blood flow of the transplant (either inflow or outflow). Diagnosis and therapeutic management of VCs constitute a major challenge in terms of increasing the success rate of liver transplantation. While surgical treatment used to be considered the first choice for management, advances in endovascular intervention have increased to make this a viable therapeutic option. Considering VC as a rare but a major and dreadful issue in OLT history, and in view of the continuing and rapid progress in recent years, an update on these uncommon conditions seemed necessary. In this sense, this review comprehensively discusses the important features (epidemiological, clinical, paraclinical, prognostic and therapeutic) of VCs following OLT.
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Affiliation(s)
- Tullio Piardi
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Martin Lhuaire
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Onorina Bruno
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Riccardo Memeo
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Patrick Pessaux
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Reza Kianmanesh
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
| | - Daniele Sommacale
- Tullio Piardi, Martin Lhuaire, Reza Kianmanesh, Daniele Sommacale, Department of General, Digestive and Endocrine Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, 51100 Reims, France
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Kogut MJ, Shin DS, Padia SA, Johnson GE, Hippe DS, Valji K. Intra-Arterial Thrombolysis for Hepatic Artery Thrombosis following Liver Transplantation. J Vasc Interv Radiol 2015; 26:1317-22. [PMID: 26190188 DOI: 10.1016/j.jvir.2015.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Hepatic artery thrombosis (HAT) is a major cause of morbidity and death following liver transplantation. The purpose of this study was to evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) in liver transplant recipients with HAT. MATERIALS AND METHODS Adult liver transplant recipients who underwent attempted IAT for HAT were identified. This included patients with early and late HAT (occurring less than or greater than 30 d after transplantation). Records were reviewed to determine the rates of technical success, complications, surgical revascularization, repeat liver transplantation, and ischemic cholangiopathy. RESULTS Twenty-six patients underwent attempted thrombolysis, 13 of whom had early HAT. IAT was successfully initiated in 23 patients (88%), with a median IAT duration of 28 hours (range, 12-90 h). Recanalization was achieved in 12 patients (46%). Major complications were observed in 11 patients (42%). The early HAT group showed a trend toward increased major bleeding compared with the late HAT group (50% vs 9%; P = .07). Among 12 patients who had technically successful thrombolysis, five (42%) required surgical revascularization or repeat transplantation within 2 months. At 6 months after thrombolysis, 45% with unsuccessful recanalization avoided surgery or development of ischemic cholangiopathy, similar to the proportion in those who had successful recanalization (42%; P = .88). CONCLUSIONS Posttransplantation hepatic artery thrombolysis yields suboptimal results with a high complication rate, especially in early HAT. Even with successful restoration of flow, clinical outcomes are poor. Although thrombolysis may still be considered in view of the limited treatment options for HAT, awareness of potential complications and suboptimal success rate is essential.
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Affiliation(s)
- Matthew J Kogut
- Interventional Radiology Section, University of Washington, 1959 NE Pacific St., Seattle, WA 98195; Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195.
| | - David S Shin
- Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195
| | - Siddharth A Padia
- Interventional Radiology Section, University of Washington, 1959 NE Pacific St., Seattle, WA 98195; Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195
| | - Guy E Johnson
- Interventional Radiology Section, University of Washington, 1959 NE Pacific St., Seattle, WA 98195; Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195
| | - Daniel S Hippe
- Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195
| | - Karim Valji
- Interventional Radiology Section, University of Washington, 1959 NE Pacific St., Seattle, WA 98195; Department of Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA 98195
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17
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Le L, Terral W, Zea N, Bazan HA, Smith TA, Loss GE, Bluth E, Sternbergh WC. Primary stent placement for hepatic artery stenosis after liver transplantation. J Vasc Surg 2015; 62:704-9. [PMID: 26054583 DOI: 10.1016/j.jvs.2015.04.400] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/19/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Significant hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT) can lead to thrombosis, with subsequent liver failure in 30% of patients. Although operative intervention or retransplantation has been the traditional solution, endovascular therapy has emerged as a less invasive treatment strategy. Prior smaller studies have been conflicting in the relative efficacy of percutaneous transluminal angioplasty (PTA) vs primary stent placement for HAS. METHODS This was a single-center retrospective review of all endovascular interventions for HAS after OLT during a 54-month period (August 2009-December 2013). Patients with ultrasound imaging with evidence of severe HAS (peak systolic velocity >400-450 cm/s, resistive index <0.5) underwent endovascular treatment with primary stent placement or PTA. Outcomes calculated were technical success, primary and primary assisted patency rates, reinterventions, and complications. RESULTS Sixty-two interventions for HAS were performed in 42 patients with a mean follow-up of 19.1 ± 15.2 months. During the study period, 654 OLTs were performed. Of 61 patients diagnosed with HAS, 42 underwent an endovascular intervention. The rate of endovascularly treated HAS was 6.4% (42 of 654). Primary technical success was achieved in 95% (59 of 62) of the interventions. Initial treatment was with PTA alone in 17 or primary stent in 25. Primary patency rates after initial stent placement were 87%, 76.5%, 78%, and 78% at 1, 6, 12, and 24 months, respectively, compared with initial PTA rates of 64.7%, 53.3%, 40%, and 0% (P = .19). There were 20 reinterventions in 14 patients (eight stents, six PTAs). The time to the initial reintervention was 51 days in patients with PTA alone vs 105.8 days for those with an initial stent (P = .16). Overall primary assisted patency was 93% at 24 months. Major complications were one arterial rupture and two hepatic artery dissections. The long-term risk of hepatic artery thrombosis in the entire patient cohort was 3.2%. CONCLUSIONS HAS after OLT can be treated endovascularly with high technical success and excellent primary assisted patency. This series represents the largest reported cohort of endovascular interventions for HAS to date. Initial use of a stent showed a strong trend toward decreasing the need for reintervention. Avoidance of hepatic artery thrombosis is possible in >95% of patients with endovascular treatment and close follow-up.
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Affiliation(s)
- Linda Le
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La
| | - William Terral
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La
| | - Nicolas Zea
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La
| | - Hernan A Bazan
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La
| | - Taylor A Smith
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La
| | - George E Loss
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La
| | - Edward Bluth
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La
| | - W Charles Sternbergh
- Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La.
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18
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Gu L, Fang H, Li F, Zhang S, Shen C, Han L. Impact of hepatic arterial hemodynamics in predicting early hepatic arterial thrombosis in pediatric recipients younger than three yr after living donor liver transplantation. Pediatr Transplant 2015; 19:273-8. [PMID: 25693722 DOI: 10.1111/petr.12444] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 12/11/2022]
Abstract
We used Doppler US to evaluate the changes in hepatic arterial hemodynamics that occur following LDLT in pediatric recipients, with a view to assessing the utility of these parameters in predicting early HAT. A retrospective review of 144 pediatric recipients (73 males, 71 females) who underwent routine Doppler US in the first week after LDLT was undertaken, and changes in hepatic arterial hemodynamics were assessed. The HARI and HAPSV were compared in patients with early HAT (defined as occurring in the first postoperative week) and a control group, and the utility of these parameters in predicting early HAT after LDLT was determined. A total of 11 pediatric recipients experienced early HAT, being diagnosed on average four and a half days after LDLT. HARI and HAPSV values were significantly different between the early HAT group and controls. HARI values <0.6 on the day before the onset of early HAT were able to predict HAT development with a sensitivity of 81.8% and specificity of 95.2%. This provides evidence for routine Doppler US examination in these patients and supports consideration of more intensive anticoagulation in these high-risk patients.
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Affiliation(s)
- Lihong Gu
- Department of Ultrasound, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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19
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Pulitano C, Joseph D, Sandroussi C, Verran D, Strasser SI, Shackel NA, McCaughan GW, Crawford M. Hepatic artery stenosis after liver transplantation: is endovascular treatment always necessary? Liver Transpl 2015; 21:162-8. [PMID: 25378262 DOI: 10.1002/lt.24043] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 09/15/2014] [Accepted: 10/12/2014] [Indexed: 12/12/2022]
Abstract
Hepatic artery stenosis (HAS) is thought to predispose patients to biliary complications secondary to ischemic injury. Despite this, the clinical significance of HAS remains poorly defined. The aims of this study were to determine the prevalence and outcomes of HAS and to define which patients might benefit from endovascular treatment. From a prospective database of 662 adult patients undergoing liver transplantation between 2000 and 2011, we identified 54 patients who developed HAS. HAS was defined as any stenosis > 70% that was seen during multidetector computed tomographic angiography (MDCTA) or digital subtraction angiography. The benefit of endovascular therapy was evaluated with propensity score matching. New biliary complications occurred in 17 patients (31.4%), and 23 of the 54 study patients with HAS received endovascular treatment. Among the propensity score-matched patients, the biliary stricture-free survival time was significantly longer for those who received endovascular therapy (P = 0.03). An incidental diagnosis (P = 0.07) and a time from transplantation > 6 months (P = 0.021) were associated with a reduced risk of developing biliary stricture. Patients with symptomatic HAS who received treatment had better biliary stricture-free survival than patients who were treated conservatively, although no significant difference was recorded (P = 0.11). No patient with asymptomatic HAS and normal liver function tests developed biliary strictures. In conclusion, HAS intervention was associated with improved biliary stricture-free survival. In patients with late-onset HAS (≥6 months) and asymptomatic patients, endovascular treatment is not warranted.
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Affiliation(s)
- Carlo Pulitano
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia; Centenary Research Institute, University of Sydney, Sydney, Australia
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Tirumani SH, Shanbhogue AKP, Vikram R, Prasad SR, Menias CO. Imaging of the porta hepatis: spectrum of disease. Radiographics 2015; 34:73-92. [PMID: 24428283 DOI: 10.1148/rg.341125190] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A wide array of pathologic conditions can arise within the porta hepatis, which encompasses the portal triad (the main portal vein, common hepatic artery, and common bile ducts), lymphatics, nerves, and connective tissue. Major vascular diseases of the portal triad include thrombosis, stenosis, and aneurysm. Portal vein thrombosis can complicate liver cirrhosis and hepatocellular carcinoma and has important therapeutic implications. Hepatic artery thrombosis and stenosis require immediate attention to reduce graft loss in liver transplant recipients. Congenital (eg, choledochal cyst) and acquired (benign and malignant) diseases of the biliary system can manifest as mass lesions in the porta hepatis. Lymphadenopathy can arise from neoplastic and nonneoplastic entities. Uncommon causes of mass lesions arise from nerves (eg, neurofibroma, neurofibrosarcoma) and connective tissue (sarcomas) and are rare. The hepatoduodenal ligament is a peritoneal reflection at the porta hepatis and is an important route for the spread of pancreatic and gastrointestinal cancers. Imaging plays a major role in diagnosis and enables appropriate management. Ultrasonography accurately demonstrates anatomic variations and pathologic conditions and is the initial modality of choice for detection of vascular and biliary lesions. Multidetector computed tomography and magnetic resonance imaging allow characterization and differentiation of various masses in the porta hepatis. Imaging-guided interventions, including embolization and stent placement, also play a key role in disease management.
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Affiliation(s)
- Sree Harsha Tirumani
- From the Department of Imaging, Dana Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.H.T.); Department of Radiology, University of Texas Health Sciences Center at San Antonio, San Antonio, Tex (A.K.P.S.); Department of Radiology, University of Texas M.D. Anderson Cancer Center, Houston, Tex (R.V., S.R.P.); and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.O.M.)
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Abstract
Improvements in the design of endovascular devices and technical skills of interventionalists have opened new possibilities for patients with a wide range of peripheral vascular diseases. In lower extremity peripheral artery disease, percutaneous treatments have become the predominant revascularization strategy for simple and complex lesions. Newer generations of stents and drug-coated balloons have demonstrated strong potential in the treatment of femoropopliteal and infrainguinal diseases. One of the most dramatic advances in the recent past has been endovascular repair of thoracic and abdominal aortic aneurysms, which has become the preferred approach in lieu of open surgical repair. Contemporary trials have established the safety and effectiveness of carotid stenting in selected patients with severe stenosis. Endovascular treatments for venous occlusive disease have long been underutilized, but their effectiveness is being increasingly recognized. This review covers new endovascular procedures performed by interventional cardiologists for peripheral vascular diseases.
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Sanada Y, Wakiya T, Hishikawa S, Hirata Y, Yamada N, Okada N, Ihara Y, Urahashi T, Mizuta K, Kobayashi E. Risk factors and treatments for hepatic arterial complications in pediatric living donor liver transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:463-72. [PMID: 24142418 DOI: 10.1002/jhbp.49] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hepatic artery complications (HAC) are a serious complication in pediatric liver transplant recipients because its incidence is high and it can occasionally lead to graft liver failure. We herein present a retrospective analysis of our 10-year experience with pediatric living donor liver transplantation (LDLT) focusing on the risk factors and treatments for HAC. METHODS Between May 2001 and November 2011, 209 LDLTs were performed for 203 pediatric recipients. We performed the multivariate analyses to identify the factors associated with HAC and showed the therapeutic strategy and outcome for HAC. RESULTS The overall incidence of HAC was 7.2%, and the graft survival of recipients with HAC was 73.3%. The multivariate analysis showed that the pediatric end-stage liver disease score (≥20), post-transplant laparotomy except for HAC treatment and extra-anatomical hepatic artery reconstruction were independent risk factors for HAC (P = 0.020, P = 0.015 and P = 0.002, respectively). Eleven surgical interventions and 13 endovascular interventions were performed for 15 recipients with HAC. The serum aspartate aminotransferase levels pre- and post-treatment for HAC were significantly higher in the surgical group than in the endovascular group (P = 0.016 and P = 0.022, respectively). CONCLUSIONS It is important for recipients with risk factors to maintain strict post-transplant management to help prevent HAC and detect it in earlier stages. Endovascular intervention can be a less invasive method for treating HAC than surgical intervention, and can be performed as an early treatment.
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Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
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Rostambeigi N, Hunter D, Duval S, Chinnakotla S, Golzarian J. Stent placement versus angioplasty for hepatic artery stenosis after liver transplant: a meta-analysis of case series. Eur Radiol 2013; 23:1323-34. [PMID: 23239061 DOI: 10.1007/s00330-012-2730-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 10/23/2012] [Accepted: 11/07/2012] [Indexed: 12/12/2022]
Abstract
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.
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Sommacale D, Aoyagi T, Dondero F, Sibert A, Bruno O, Fteriche S, Francoz C, Durand F, Belghiti J. Repeat endovascular treatment of recurring hepatic artery stenoses in orthotopic liver transplantation. Transpl Int 2013; 26:608-15. [PMID: 23551134 DOI: 10.1111/tri.12089] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 09/08/2012] [Accepted: 02/13/2013] [Indexed: 02/06/2023]
Abstract
Hepatic artery stenosis (HAS) is a complication that impacts the results of orthotopic liver transplantation (OLT). Interventional radiological techniques are important therapeutic options for HAS. The aim of this retrospective study was to evaluate the outcome of repeated radiological treatments in recurring HAS after OLT. Of the 941 patients who underwent OLT at our center from January 1998 to September 2010, 48 (5%) were diagnosed with HAS, 37 (77%) of whom underwent transluminal interventional therapy with the placement of an endovascular stent. Success rate, complications, hepatic artery patency and follow-up were reviewed. After stent placement, artery patency was achieved in all patients. Three patients developed complications, including arterial dissection and hematoma. HAS recurrence was observed in 9 patients (24%), and hepatic artery thrombosis (HAT) occurred in 4 (11%). Radiological interventions were repeated 10 times in 8 patients without complications. At a median follow-up of 66 months (range 10-158), hepatic artery patency was observed in 35 cases (94.6%). The 5-year rates for graft and patient survival were 82.3% and 87.7%, respectively. Restenosis may occur in one-third of patients after endovascular treatment for thrombosis and HAS, but the long-term outcomes of iterative radiological treatment for HAS indicate a high rate of success.
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Affiliation(s)
- Daniele Sommacale
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hospital Beaujon, Clichy, France.
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Hamby BA, Ramirez DE, Loss GE, Bazan HA, Smith TA, Bluth E, Sternbergh WC. Endovascular treatment of hepatic artery stenosis after liver transplantation. J Vasc Surg 2013; 57:1067-72. [PMID: 23332988 DOI: 10.1016/j.jvs.2012.10.086] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 10/12/2012] [Accepted: 10/12/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic artery stenosis (HAS) after orthotopic liver transplantation is a significant risk factor for subsequent hepatic artery thrombosis (HAT). HAT is associated with a 30%-50% risk of liver failure culminating in retransplantation or death. Traditional treatment of hepatic artery complications has been surgical, with hepatic artery revision or retransplantation. Endovascular therapy of HAS, described primarily in the interventional radiology literature, may provide a less-invasive treatment option. METHODS This was a retrospective review of all endovascular interventions performed for HAS after orthotopic liver transplantation over a 31-month period (August 2009 to January 2012). Patients with duplex ultrasound imaging evidence of severe main HAS (peak systolic velocity of >400 cm/s, resistive index of <.5) underwent endovascular treatment with either primary stent placement or percutaneous transluminal angioplasty (PTA) alone. Patients were followed with serial ultrasound imaging to assess for treatment success and late restenosis. Reintervention was performed if significant restenosis occurred. RESULTS Thirty-five hepatic artery interventions were performed in 23 patients. Over the 31-month study period, 318 orthotopic liver transplantations were performed, yielding a 7.4% (23/318) rate of hepatic artery intervention. Primary technical success was achieved in 97% (34/35) of cases. Initial treatment was with PTA alone (n = 10) or primary stent placement (n = 13). The initial postintervention ultrasound images revealed improvements in hepatic artery peak systolic velocity (267 ± 118 [posttreatment] vs 489.9 ± 155 cm/s [pretreatment]; P < .0001) and main hepatic artery resistive index (0.61 ± 0.08 [posttreatment] vs 0.41 ± 0.07 [pretreatment]; P < .0001). At a mean follow-up of 8.2 ± 1.8 months (range, 0-29), there were 12 reinterventions in 10 patients for recurrent HAS. Thirty-one percent (n = 4/13) of patients undergoing initial stent placement required reintervention (at 236 ± 124 days of follow-up) compared with 60% (n = 6/10) of patients undergoing initial PTA (at 62.5 ± 44 days of follow-up). Primary patency rates (Kaplan-Meier) after primary stent placement were 92%, 85%, and 69% at 1, 3, and 6 months, respectively, compared with 70%, 60%, and 50% after PTA (P = .17). Primary-assisted patency for the entire cohort was 97% at 6 and 12 months. Major complications were one arterial rupture managed endovascularly and one artery dissection that precipitated HAT and required retransplantation. The overall rate of HAT in the entire cohort was 4.3% (1/23). CONCLUSIONS Endovascular treatment of HAS can be performed with high technical success, excellent primary-assisted patency, and acceptable morbidity. Initial use of a stent may improve primary patency when compared with PTA. The need for reintervention is common, placing particular importance on aggressive surveillance. Longer follow-up and a larger cohort are needed to confirm these encouraging early results.
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Affiliation(s)
- Blake A Hamby
- Section of Vascular and Endovascular Surgery, Ochsner Clinic Foundation, New Orleans, LA 70121, USA
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Koganemaru M, Abe T, Anai H, Tanaka N, Nonoshita M, Iwamoto R, Kusumoto M, Kuhara A, Kugiyama T, Hayabuchi N. A newly developed double lumen microballoon catheter with a side hole: initial experience of intraarterial infusion chemotherapy and/or embolization. Jpn J Radiol 2012; 30:870-4. [DOI: 10.1007/s11604-012-0128-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 08/23/2012] [Indexed: 12/28/2022]
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Emre S, Umman V, Cimsit B, Rosencrantz R. Current concepts in pediatric liver transplantation. ACTA ACUST UNITED AC 2012; 79:199-213. [PMID: 22499491 DOI: 10.1002/msj.21305] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation is the definitive treatment for end-stage liver disease in both children and adults. Advances over the last 2 decades have resulted in excellent patient and graft survival rates in what were previously cases of fatal disorders. These developments have been due to innovations in surgical technique, increased surgical experience, refinements in immunosuppressive regimens, quality improvements in intraoperative anesthetic management, better understanding of the pathophysiology of the liver diseases, and better preoperative and postoperative care. Remarkably, the use of split-liver and living-related liver transplantation surgical techniques has helped mitigate the well-recognized national organ shortage. This review will discuss the major aspects of pediatric liver transplantation as it pertains to indication for transplantation, recipient selection and listing for orthotopic liver transplantation, pre-orthotopic liver transplantation care of children, optimal timing of orthotopic liver transplantation, surgical technical considerations, postoperative care and complications, and patient and graft survival outcomes.
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Affiliation(s)
- Sukru Emre
- Yale University School of Medicine, New Haven, CT, USA.
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