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Pereira R, Pearch BJ, Pavilion G, Rajkomar K. Systematic review of extrahepatic hepatic artery pseudoaneurysm following adult liver transplantation: Risk factors and treatment modalities. J Med Imaging Radiat Oncol 2025; 69:100-111. [PMID: 39428121 DOI: 10.1111/1754-9485.13745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 07/31/2024] [Indexed: 10/22/2024]
Abstract
Hepatic artery pseudoaneurysm (HAP) is a rare vascular complication following liver transplantation (LTx) with treatment choice frequently driven by institutional experience. Approximately, 10% of hepatic grafts are lost from this complication, requiring re-transplantation and placing further demand on the already present organ shortage. Secondly, patients with HAP can present with catastrophic bleeding, with reported mortality of up to 78%. We aim to identify risk factors associated with HAP and assess the survival benefit of different treatment modalities used (endovascular and open surgical techniques). Early detection may facilitate semi-elective management of this condition. A systematic search was performed in PubMed, Medline and Embase up to 1 October 2023. Case series with ≥5 patients focusing on adult patients who developed extrahepatic pseudoaneurysm following LTx were included. A total of 11 studies were pooled, comprising of 118 patients with survival data available in 61 patients. The most common presentation was haemorrhagic shock or luminal haemorrhage (75.5%). Bile leak was documented in 66.7% (28/42), 15.2% (18/118) associated foregut pathologies and 28.6% (14/49) of microbiology cultures grew a fungal organism. Flow preserving strategies (stenting, revascularization) trended towards better survival at 120 months compared to non-flow preserving strategies (embolization, HAL); however, this was not statistically significant following log rank (Mantel-Cox) analysis (P 0.169). Any patient following LTx presenting with haemorrhagic shock or luminal bleeding needs HAP excluded urgently. HAP management is complex, requiring careful consideration of patient specific presentation, anatomic factors and associated pathologies.
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Affiliation(s)
- Ryan Pereira
- Department of Interventional Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Benjamin J Pearch
- Department of Interventional Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Gilbert Pavilion
- Department of Interventional Radiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Kheman Rajkomar
- Department of Surgery, Bankstown Hospital, Sydney, New South Wales, Australia
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Silva MS, Waisberg DR, Caldas TG, Martino RB, Rocha-Santos V, Pinheiro RS, Ducatti L, Arantes RM, Alvarez J, Marin-Castro P, Vieira IF, Almeida JD, Carneiro-D'Albuquerque LA, Andraus W. Life-Threatening Ruptured Hepatic Artery Pseudoaneurysm Post-Liver Transplant: A Case Report. Transplant Proc 2024; 56:1092-1095. [PMID: 38744591 DOI: 10.1016/j.transproceed.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/01/2024] [Accepted: 04/21/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Hepatic artery pseudoaneurysm after liver transplantation is a rare condition that can lead to spontaneous bleeding, depending on its extent and location. Treatment involves endovascular and surgical approaches in addition to liver retransplantation in cases of graft failure. CASE REPORT A 42-year-old female underwent deceased donor liver transplantation due to cryptogenic cirrhosis and schistosomiasis with an uneventful postoperative course. However, 18 days after the operation, she presented to the emergency department with abdominal pain, hypotension, and lipothymia. A computed tomography scan revealed a hepatic artery anastomotic pseudoaneurysm, and due to hemodynamic instability, emergency laparotomy was indicated. During the operation, the pseudoaneurysm was found to be ruptured, and the recipient's hepatic artery was ligated due to life-threatening bleeding. She later developed ischemic cholangiopathy and biliary complications, eventually undergoing retransplantation 7 months after the emergency operation. The patient remains well 11 months after the retransplantation. CONCLUSION We report a rare case of life-threatening rupture of hepatic artery pseudoaneurysm, which required emergency ligation of the recipient's hepatic artery and subsequent liver retransplantation due to biliary complications.
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Affiliation(s)
- Maciana Santos Silva
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Daniel Reis Waisberg
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil.
| | - Tarsila Gomes Caldas
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Rodrigo Bronze Martino
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Vinicius Rocha-Santos
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Rafael Soares Pinheiro
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Liliana Ducatti
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Rubens Macedo Arantes
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Jhosimar Alvarez
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Pedro Marin-Castro
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Igor Ferreira Vieira
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Juliani Dourado Almeida
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
| | - Luiz Augusto Carneiro-D'Albuquerque
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil; Laboratory of Medical Investigation 37 (LIM-37), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
| | - Wellington Andraus
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil; Laboratory of Medical Investigation 37 (LIM-37), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil
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Nejatollahi SMR, Hasanzade A, Ghorbani F. Successful Surgical Management of Ruptured Hepatic Artery Pseudoaneurysm Post-Liver Retransplant: A Case Report. Int J Surg Case Rep 2023; 112:108989. [PMID: 37913669 PMCID: PMC10667863 DOI: 10.1016/j.ijscr.2023.108989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/14/2023] [Accepted: 10/21/2023] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Hepatic Artery Pseudoaneurysm (HAP) is a rare and potentially fatal complication following liver transplantation, with unclear etiology. Various predisposing factors, including local infections, biliary-enteric anastomosis, particularly Roux-en-Y hepaticojejunostomy, vascular interventions, and iatrogenic injuries, have been identified. PRESENTATION OF CASE We report a case of HAP occurring after liver re-transplantation in a twenty-year-old male patient who had initially undergone liver transplantation for cirrhosis resulting from autoimmune hepatitis. Subsequently diagnosed with chronic ischemic liver disease accompanied by diffuse cholangiopathy and a liver abscess, the patient underwent a liver re-transplantation. Within the early days post-re-transplantation, the patient presented symptoms of gastrointestinal bleeding and sudden hypotension. A high clinical suspicion led to prompt laparotomy, ultimately successful preserving both the graft and the recipient's life. DISCUSSION HAP is an uncommon complication following liver transplantation. This condition may remain asymptomatic until the rupture of the HAP, which can result in gastrointestinal bleeding, hypotension, and, eventually, mortality. While there have been emerging non-surgical techniques proposed for HAP treatment, surgical intervention remains the definitive solution for preserving the graft and ensuring the recipient's survival. CONCLUSION HAP, while uncommon, represents a life-threatening complication post-transplantation. In the event of rupture, immediate intervention is imperative for the patient's survival. Hence, it is critical for surgeons to be cautious about this complication, recognize its symptoms, and be aware of associated risk factors.
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Affiliation(s)
- Seyed Mohammad Reza Nejatollahi
- Hepato-Pancreato-Biliary and Transplant Surgery, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Arman Hasanzade
- Hepato-Pancreato-Biliary and Transplant Surgery, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Ghorbani
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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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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Li SX, Fan YH, Tian GY, Lv GY. Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients. World J Gastrointest Surg 2022; 14:976-985. [PMID: 36185558 PMCID: PMC9521469 DOI: 10.4240/wjgs.v14.i9.976] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/22/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In orthotopic liver transplantation (OLT) recipients, median arcuate ligament syndrome (MALS) is considered a risk factor for hepatic arterial thrombosis (HAT), which is dreadful for OLT recipients. Different alternative surgical procedures have been proposed to overcome the impact of MALS on transplantation, but clinical evidence is still scarce.
AIM To evaluate the feasible surgical management of MALS to reduce complications in OLT patients.
METHODS Data for 288 consecutive patients who underwent OLT at The First Hospital of Jilin University between January 2017 and July 2020 were retrospectively reviewed. The surgical management of median arcuate ligament (MAL) and modifications to the arterial anastomosis were recorded. The perioperative and long-term prognosis of MALS recipients were noted. Detailed preoperative and postoperative data of patients were analyzed in a descriptive manner.
RESULTS Eight patients with MALS were included in this study. The first patient with MALS received no intervention during the primary surgery and developed postoperative HAT. Salvage liver transplantation with MAL division was successfully performed. Gastroduodenal artery (GDA) preservation with splenic artery ligation was performed on three patients, only GDA preservation was performed on two patients, and no intervention was performed on two patients. No patient developed HAT after surgery and postoperative recovery was satisfactory.
CONCLUSION The preservation of collateral circulation between the superior mesenteric artery and celiac trunk via the GDA with or without splenic artery ligation is a safe and feasible alternative to MAL division.
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Affiliation(s)
- Shu-Xuan Li
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Ye-Hui Fan
- Department of The First Operation Room, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guang-Yao Tian
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Yue Lv
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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Llado L, Iborra E, Ramos E, Sabé N, Cachero A, Fabregat J. Extra-anatomic aortic bypass for the treatment of a mycotic pseudoaneurysm after liver transplantation for hilar cholangiocarcinoma. Hepatobiliary Pancreat Dis Int 2021; 20:285-287. [PMID: 32893144 DOI: 10.1016/j.hbpd.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/18/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Laura Llado
- Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain.
| | - Elena Iborra
- Vascular Surgery Department, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Emilio Ramos
- Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Nuria Sabé
- Infectious Disease Department, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Alba Cachero
- Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Joan Fabregat
- Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
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Yen LH, Sabatino JC. Imaging complications of liver transplantation: a multimodality pictorial review. Abdom Radiol (NY) 2021; 46:2444-2457. [PMID: 31679057 DOI: 10.1007/s00261-019-02270-2] [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: 10/25/2022]
Abstract
Liver transplantation is one of the most commonly performed surgical procedures for the treatment of end-stage liver disease and hepatocellular carcinoma. Post-transplantation complications include vascular, nonvascular, and biliary. Common imaging techniques used to evaluate the hepatic graft are ultrasonography (US), CT, MR imaging, cholangiography, angiography, and scintigraphy. The purposes of this pictorial review are to review imaging findings of complications of liver transplantation and provide a framework for early detection of post-surgical complications.
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Goussous N, St Michel DP, Mcdade H, Gaines S, Borth A, Dawany N, Al-Qaoud T, Bromberg JS, Barth RN, Scalea JR. Is Prophylactic Drainage After Pancreas Transplant Associated With Reduced Reoperation Rate? EXP CLIN TRANSPLANT 2020; 19:64-71. [PMID: 33272163 DOI: 10.6002/ect.2020.0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Advances in surgery and perioperative care have contributed to improved outcomes after pancreas transplant. However, the development of peripancreatic infections carries a poor prognosis. It is not clear whether abdominal drainage is helpful in collection prevention. MATERIALS AND METHODS A retrospective review of adult consecutive pancreas transplants at a single institution between January 2017 and December 2018 was undertaken. Postoperative outcomes were compared between patients in whom prophylactic intraoperative drains were placed and patients with no drains. RESULTS We identified 83 patients who underwent pancreas transplant with a median age of 45 years; 54.2% were males, and median body mass index was 25.8. Thirty patients had 1 or 2 drains placed (36.1%). There was no difference in the readmission rate (70.0% vs 60.4%; P = .48), reoperation (20.0% vs 30.2%; P = .44), or percutaneous drainage of peripancreatic infections (20.0% vs 15.1%; P = .56) between patients with drains and no drains, respectively. However, prophylactic drainage was associated with a lower rate of reoperation for peripancreatic infections compared with those who were not drained (0.0% vs 13.2%; P < .05). No graft loss occurred in the drain group. CONCLUSIONS Prophylactic drainage after pancreas transplant may be helpful for reduction in the infection rate after reoperation. The risks of drain placement should be weighed against those of drain avoidance.
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Affiliation(s)
- Naeem Goussous
- From the Division of Transplantation, Department of Surgery, University of Maryland School of Medicine Baltimore, Maryland, USA
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Cui L, Kong L, Bai YH, Li XH, Wang XQ, Hao JJ, Duan F. Covered stent placement for hepatic artery pseudoaneurysm. Abdom Radiol (NY) 2020; 45:3337-3341. [PMID: 32095858 DOI: 10.1007/s00261-020-02452-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of covered stent placement for the treatment of hepatic artery pseudoaneurysm (HAP). METHODS Between March 2006 and March 2019, 17 consecutive patients underwent emergency covered stent placement for treatment of HAP. There were 12 men and 5 women aged 24-71 years, with an average age of 49.4 years. Eleven patients had undergone Whipple procedure, 3 had hepatic abscess following hepatectomy, 2 had undergone hepatectomy under extracorporeal circulation, and 1 had received surgical exploration after a car accident. The average interval from surgical intervention to massive bleeding was 15.3 days (range: 6-35 days). After HAP was confirmed by angiography, 1-3 covered stent grafts (3-8 mm in diameter and 13 mm-5 cm in length) were implanted. Adequate drainage, anti-infection treatment, and symptomatic treatment were offered after stent placement, and no anticoagulation or antiplatelet drug was used. RESULTS The interventions were successful in all 17 patients. Angiography revealed pseudoaneurysms in common hepatic artery in 16 patients (in gastroduodenal artery stumps in 4 patients) and hemorrhage from a ruptured right hepatic artery in 1 patient. All patients were successfully implanted with 1-3 covered stent grafts. Bleeding was completely controlled in 12 patients (stent diameter: 4.5-8 mm). Four patients (stent diameter: 3-4.5 mm) experienced bleeding recurrence 1 h to 3 days after stent implantation, and type 1 endoleaks were identified during second angiography. Finally, these 4 patients died of multiple organ failure 2-10 days after embolization/blockage. The remaining patient suffered from abdominal hemorrhage again 2 weeks after stent implantation, and second angiography showed hemorrhage from a branch of the superior mesenteric artery; no bleeding occurred after embolization. Thirteen patients survived at discharge, and the average length of hospital stay was 26.53 days (range: 11-58 days). The average follow-up time was 23 months (range: 16-37 months), during which 6 patients died of tumor progression. No bleeding recurred during the follow-up period, and routine color Doppler ultrasound revealed that the common hepatic artery was patent and the blood flow was smooth at the stent implantation site. CONCLUSION Covered stent placement is a safe and effective alternative for treating HAP patients with high risk of severe complications after hepatic artery embolization. Larger stent grafts (> 4 mm in diameter) may achieve better prognosis.
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Affiliation(s)
- Li Cui
- Department of Interventional Radiology, The General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Lu Kong
- The General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Yan-Hua Bai
- Department of Interventional Radiology, The General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Xiao-Hui Li
- Department of Interventional Radiology, The General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | - Xiu-Qi Wang
- Department of Interventional Radiology, The General Hospital of Chinese People's Liberation Army, Beijing, 100853, China
| | | | - Feng Duan
- Department of Interventional Radiology, The General Hospital of Chinese People's Liberation Army, Beijing, 100853, China.
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Recurrent Hepatocellular Carcinoma in an Adult With Alagille Syndrome Treated With Liver Resection Followed by Liver Transplantation: A Rare Case Report. Transplant Direct 2020; 6:e606. [PMID: 33134486 PMCID: PMC7591122 DOI: 10.1097/txd.0000000000001055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 07/06/2020] [Accepted: 07/27/2020] [Indexed: 12/28/2022] Open
Abstract
Alagille syndrome (AGS) is a disorder that affects the liver, heart, kidneys, and skeleton. Development of hepatocellular carcinoma (HCC) is rare in AGS. A 41-y-old male with AGS presented with a 6 × 8-cm HCC and underwent transarterial chemoembolization (TACE) followed by right hepatic lobectomy. One year later, he developed HCC recurrence within Milan's criteria and received a deceased donor liver transplant. An interposition donor iliac artery graft from the supraceliac aorta to the donor hepatic artery was needed due to celiac axis occlusion noted on TACE. He subsequently underwent a Roux-en-Y hepaticojejunostomy for a bile leak. Surveillance imaging for HCC revealed a 3-cm pseudoaneurysm of his aortoiliac vascular anastomosis, 3 mo posttransplant. An infrarenal aortic jump graft to the donor hepatic artery and ligation of supraceliac aortic conduit was performed, followed by aortic stent-graft placement to occlude the pseudoaneurysm. He received a deceased donor kidney transplant 13 mo after the liver transplant. He remains HCC free with excellent liver and renal allograft function. Adults with AGS undergoing liver transplantation for HCC need special consideration due to related vascular, cardiac, and renal anomalies.
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The devil is in the detail: current management of perioperative surgical complications after liver transplantation. Curr Opin Organ Transplant 2020; 24:138-147. [PMID: 30694994 DOI: 10.1097/mot.0000000000000616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Despite advances in the field, perioperative morbidity is common after liver transplantation. This review examines the current literature to provide up-to-date management of common surgical complications associated with liver transplantation. RECENT FINDINGS Research focuses on problems with anastomoses of the vena cava, portal vein, hepatic artery, and bile ducts. Interventional endoscopic and radiological techniques are used more frequently to avoid reoperation. SUMMARY Advances in the management of perioperative surgical complications have focused on minimally invasive measures that successfully treat technical problems with implantation of liver allografts from both living and deceased donors.
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Novotny R, Janousek L, Lipar K, Chlupac J, Fronek J. Large Hepatic Artery Pseudoaneurysm Resection After Orthotopic Liver Transplantation. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1592-1595. [PMID: 31662581 PMCID: PMC6839540 DOI: 10.12659/ajcr.917728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patient: Female, 41 Final Diagnosis: Hepatiic artery aneurysm Symptoms: None Medication: — Clinical Procedure: — Specialty: Surgery
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Affiliation(s)
- Robert Novotny
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Libor Janousek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Kvetoslav Lipar
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jaroslav Chlupac
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,First Faculty of Medicine, Charles University, Prague, Czech Republic.,Second Faculty of Medicine, Charles University, Prague, Czech Republic
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Duodenal Perforation With Transplant Hepatic Artery Pseudoaneurysm. ACG Case Rep J 2019; 6:e00117. [PMID: 31616777 PMCID: PMC6722332 DOI: 10.14309/crj.0000000000000117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/27/2019] [Indexed: 11/17/2022] Open
Abstract
A transplant hepatic artery pseudoaneurysm is a rare postorthotopic liver transplant complication. Bleeding is a common complication of posterior duodenal ulcer secondary to erosion into the gastroduodenal artery. We report the case of a post-transplant patient who presented with massive upper gastrointestinal hemorrhage in the setting of nonsteroidal anti-inflammatory drug use. Endoscopy demonstrated a duodenal ulcer with high-risk stigmata not amenable to hemostasis. Subsequently, an arteriogram revealed a hepatic artery pseudoaneurysm. Transplant professionals should be aware of the possibility of an ulcer eroding into the liver vasculature and in the differential diagnosis for bleeding and pseudoaneurysms in post-transplant patients.
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14
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Zhang J, Khalifeh A, Santini-Dominguez R, Barth RN, Bruno D, Desikan S, Gupta A, Toursavadkohi S. Endovascular Reconstruction of the Hepatic Arterial System for the Management of Mycotic Pseudoaneurysm in a Liver Transplant Patient. Ann Vasc Surg 2019; 61:473.e7-473.e11. [PMID: 31394235 DOI: 10.1016/j.avsg.2019.05.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/19/2019] [Accepted: 05/29/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hepatic artery pseudoaneurysm is a rare but very morbid complication after liver transplant. Treatment options include ligation or endovascular embolization, followed by revascularization. We describe a new endovascular approach by stent exclusion in a high-risk patient. RESULTS A 62-year-old male who received a second liver transplant after failed allograft presented with hemobilia and was diagnosed with a hepatic artery pseudoaneurysm in the setting of infection. Given his hostile abdomen, an endovascular approach was sought. We excluded the mycotic pseudoaneurysm with multiple covered stent grafts extending from the common hepatic artery to the right and left hepatic arteries. He was discharged with long-term antibiotics. On his 6-month follow-up visit, his stent was patent and hepatic function was stable. CONCLUSIONS Endovascular stent-graft placement for management of hepatic artery pseudoaneurysm after liver transplant should be considered as a lower morbidity alternative to surgical repair, even in the setting of infection.
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Affiliation(s)
- Jackie Zhang
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Ali Khalifeh
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD.
| | - Rafael Santini-Dominguez
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Rolf N Barth
- Division of Organ Transplant, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - David Bruno
- Division of Organ Transplant, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Sarasijhaa Desikan
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Anuj Gupta
- Department of Cardiology, University of Maryland Medical Center, Baltimore, MD
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
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Czigany Z, Boecker J, Morales Santana DA, Bednarsch J, Meister FA, Amygdalos I, Isfort P, Liebl M, Neumann UP, Lurje G. Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study. J Clin Med 2019; 8:jcm8040550. [PMID: 31018577 PMCID: PMC6518097 DOI: 10.3390/jcm8040550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/15/2019] [Accepted: 04/22/2019] [Indexed: 12/17/2022] Open
Abstract
Median arcuate ligament compression (MALC) potentially causes arterial complications in orthotopic liver transplantation (OLT). Here we aimed to investigate the incidence of MALC and its impact on clinical outcome after OLT. In addition, we performed an international survey among 52 European liver transplant centers to explore local protocols on the management of these patients. Data of 286 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-07/2017). Preoperative computed-tomography images were evaluated. Celiac axis stenosis due to MALC was found in 34 patients (12%). Intrinsic stenosis was present in 16 (6%) patients. Twenty-six patients (77%) with MALC underwent standard arterial revascularization with median arcuate ligament (MAL)-division. Patients treated for MALC had comparable baseline data and no difference was found in early- and long-term outcome compared to the rest of our cohort. Our survey found heterogeneous strategies regarding diagnosis and treatment of MALC. Only 29% of the centers reported the division of MAL in these patients as routine procedure. Even though there is no consensus on diagnosis and management of MALC among European centers, a surgical division of MAL is feasible and safe and should be considered in OLT recipients with MALC.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Joerg Boecker
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | | | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | | | - Iakovos Amygdalos
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Peter Isfort
- Institute of Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Martin Liebl
- Institute of Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
- Department of Surgery, Maastricht University Medical Centers (MUMC), 6202 AZ Maastricht, The Netherlands.
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
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