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Ramalingam V, Shami SMU, Weinstein J, Lee D, Curry M, Eckhoff D, Ahmed M, Sarwar A. Safety and Effectiveness of Early Primary Stent Placement for Hepatic Artery Stenosis in Liver Transplant Recipients. J Vasc Interv Radiol 2025; 36:425-434. [PMID: 39586537 DOI: 10.1016/j.jvir.2024.11.019] [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: 06/11/2024] [Revised: 11/01/2024] [Accepted: 11/16/2024] [Indexed: 11/27/2024] Open
Abstract
PURPOSE To evaluate the outcomes of early primary stent placement (within 30 days of liver transplantation) for hepatic artery stenosis (HAS). MATERIALS AND METHODS Patients who underwent liver transplantation between February 2001 and February 2024 were evaluated for HAS. Patients who underwent primary stent placement were selected and stratified based on the time from anastomosis to intervention. Early intervention was defined as primary stent placement within 30 days of surgical anastomosis. Kaplan-Meier analysis was performed for primary patency. RESULTS HAS occurred in 83 of 779 (11%) patients (median age, 55 years; interquartile range, 48-63 years; 27 [48%] women), with 56 patients meeting inclusion criteria. Stent placement was performed within 0-6 days of the anastomosis in 11 (20%), 7-14 days in 11 (20%), 15-30 days in 7 (12%), 31-70 days in 9 (16%), and >70 days in 18 (32%) patients. Technical success was 100%. Primary patency rates were 89%, 87%, and 87% at 1, 3, and 5 years, respectively. Primary assisted patency rates were 100% at 1, 3, and 5 years. Early interventions at 0-6 days, 7-14 days, and 15-30 days showed primary patency rates of 100%, 90%, and 86%, respectively, at 1 year (P = .58). There was no difference in primary patency between the early (<30 days) and late (>30 days) cohorts (P = .88). There was 1 Grade 4 adverse event. There were no cases of anastomotic rupture, hepatic artery dissection, or graft failure. CONCLUSIONS Hepatic artery stent placement within 30 days of liver transplantation is safe and technically successful with excellent long-term primary patency.
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Affiliation(s)
- Vijay Ramalingam
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts.
| | - Sheikh Muhammad Usman Shami
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Jeffrey Weinstein
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - David Lee
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Michael Curry
- Division of Hepatology, Department of Gastroenterology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Devin Eckhoff
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Muneeb Ahmed
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Ammar Sarwar
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
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Li W, Kotsou T, Hartog H, Scheenstra R, de Meijer VE, Stenekes MW, Verhagen MV, Bokkers RPH, van der Doef HPJ. Hepatic artery stenosis after pediatric liver transplantation: The potential role of conservative management. Dig Liver Dis 2025; 57:502-511. [PMID: 39379231 DOI: 10.1016/j.dld.2024.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 09/17/2024] [Accepted: 09/19/2024] [Indexed: 10/10/2024]
Abstract
AIM This study aimed to investigate the outcomes and effectiveness of various treatment strategies in patients with hepatic artery stenosis (HAS) after pediatric liver transplantation (pLT). METHODS This is a single center observational cohort study between January 1st, 2004 and August 1st, 2023, including pLT recipients aged <18 years. The primary outcome was graft and patient survival. The secondary outcomes included incidence of biliary complications, technical success of surgery or endovascular therapy (EVT), and changes in liver function. The cut-off for early and late HAS was 14 days after pLT. RESULTS Among a total of 327 pLT patients, 4 % (n = 13) developed HAS (n = 3 early; n = 10 late). Treatments included surgical revascularization for one early HAS, conservative management with anticoagulation for one early and four late HAS, and EVT for one early and six late HAS. Over a median follow-up of 28.2 months after the diagnosis of HAS, graft survival was 100 % and 83 % in early and late HAS groups, and patient survival reached 100 % in both groups. One graft loss occurred in the conservative group. Conversely, graft survival in the EVT group was 100 %. CONCLUSION The long-term outcomes of HAS after pLT are excellent. Both EVT and conservative management exhibited high graft survival rates for late HAS, with EVT achieving high technical success.
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Affiliation(s)
- Weihao Li
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Thomai Kotsou
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Faculty of Medical Sciences, University of Groningen, Groningen, the Netherlands
| | - Hermien Hartog
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Rene Scheenstra
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Vincent E de Meijer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Martin W Stenekes
- Department of Plastic and Reconstructive Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Martijn V Verhagen
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hubert P J van der Doef
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Chau SS, Beutler BD, Grant EG, Tchelepi H. Ultrasound innovations in abdominal radiology: multiparametic imaging in liver transplantation. Abdom Radiol (NY) 2025; 50:679-692. [PMID: 39167237 PMCID: PMC11794643 DOI: 10.1007/s00261-024-04518-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/31/2024] [Accepted: 08/05/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE Ultrasound plays a central role in liver transplant evaluation. Acute, subacute, and chronic complications can be readily identified using grayscale and color Doppler ultrasound. Contrast-enhanced ultrasound adds a new dimension to liver transplant evaluation, depicting vascular and parenchymal processes with exquisite detail. In addition, emerging evidence suggests that contrast-enhanced ultrasound may allow for localization of biliary leak in select patients. We aimed to assess the use of multiparametric ultrasound-including grayscale, color and spectral Doppler, and contrast-enhanced ultrasound-in the setting of liver transplantation. METHODS A literature review was performed using the MEDLINE bibliographic database through the National Library of Medicine. The following terms were searched and relevant citations assessed: "abdominal ultrasound," "contrast-enhanced ultrasound," "liver transplant," and "ultrasound." RESULTS Grayscale and color Doppler ultrasound represent the mainstay imaging modalities for postoperative liver transplant evaluation. The addition of contrast enhancement plays a complementary role and can provide valuable information related to the allograft vasculature, parenchyma, and biliary tree. The appropriate implementation of grayscale, color Doppler, and contrast-enhanced ultrasound can optimize sensitivity, specificity, and accuracy for the detection of liver transplantation complications, including hepatic artery stenosis, biliary leakage, and infection. CONCLUSION Multimodal sonographic evaluation is essential to identify postoperative complications in liver transplant recipients. Contrast-enhanced ultrasound may be of value in challenging cases, providing excellent anatomic delineation and reducing the risk of false-positive and false-negative diagnoses. A broad familiarity with appropriate applications of both nonenhanced and contrast-enhanced ultrasound may help radiologists optimize allograft assessment and improve patient outcomes.
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Affiliation(s)
- Samantha S Chau
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Bryce D Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA.
| | - Edward G Grant
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Hisham Tchelepi
- Department of Radiology, Los Angeles General Medical Center, Los Angeles, CA, USA
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Srivastava S, Garg I. Thrombotic complications post liver transplantation: Etiology and management. World J Crit Care Med 2024; 13:96074. [PMID: 39655303 PMCID: PMC11577539 DOI: 10.5492/wjccm.v13.i4.96074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 10/01/2024] [Accepted: 10/24/2024] [Indexed: 10/31/2024] Open
Abstract
Liver transplantation (LT) is the life saving therapeutic option for patients with acute and chronic end stage liver disease. This is a routine procedure with excellent outcomes in terms of patient survival and quality of life post LT. Orthotopic LT (OLT) patients require a critical care as they are prone to variety of post-operative vascular, cardiovascular, biliary, pulmonary and abdominal complications. Thrombotic complications (both arterial and venous) are not uncommon post liver transplant surgery. Such vascular problems lead to increased morbidity and mortality in both donor and graft recipient. Although thromboprophylaxis is recommended in general surgery patients, no such standards exist for liver transplant patients. Drastic advancements of surgical and anesthetic procedures have improvised survival rates of patients post OLT. Despite these, haemostatic imbalance leading to thrombotic events post OLT cause significant graft loss and morbidity and even lead to patient's death. Thus it is extremely important to understand pathophysiology of thrombosis in LT patients and shorten the timing of its diagnosis to avoid morbidity and mortality in both donor and graft recipient. Present review summarizes the current knowledge of vascular complications associated with LT to highlight their impact on short and long-term morbidity and mortality post LT. Also, present report discusses the lacunae existing in the literature regarding the risk factors leading to arterial and venous thrombosis in LT patients.
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Affiliation(s)
- Swati Srivastava
- Defence Institute of Physiology and Allied Sciences, Defence Research and Development organization, Delhi 110054, India
| | - Iti Garg
- Defence Institute of Physiology and Allied Sciences, Defence Research and Development organization, Delhi 110054, India
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. S2k-Leitlinie Lebertransplantation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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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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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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Sasaki K, Asaoka T, Kobayashi S, Iwagami Y, Yamada D, Tomimaru Y, Noda T, Wada H, Gotoh K, Takahashi H, Maeda N, Kimura Y, Ono Y, Doki Y, Eguchi H. Successful endovascular embolization of the common hepatic artery for pseudoaneurysm associated with pancreatic fistula after liver transplantation: a case report. Surg Case Rep 2023; 9:143. [PMID: 37561260 PMCID: PMC10415245 DOI: 10.1186/s40792-023-01723-7] [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: 05/10/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND After orthotopic liver transplantation (OLT), complications such as hepatic artery stenosis, thrombosis, and bleeding are possible. Hepatic artery pseudoaneurysms (HAP) are prone to rupture, rupture hemorrhage, and increased mortality risk. Endovascular treatment of HAP may result in recurrence, even after successful embolization with thrombin. Formation of a HAP in the common hepatic artery (CHA) is challenging because the CHA is the only artery in the liver graft after OLT. Therefore, CHA embolization in HAP is not an initial option. We report a case of HAP at the CHA after OLT that was treated with endovascular therapy, resulting in the occlusion of the CHA with coil embolization, achieving a radical cure. CASE PRESENTATION A 59-year-old man with decompensated hepatitis C virus cirrhosis underwent deceased donor whole-liver transplantation after graft failure of a living donor liver transplantation. After the second transplantation, the patient developed infectious narrow-necked HAP at the CHA associated with postoperative pancreatic fistula. Repeated transcatheter arterial embolization with thrombin and n-butyl-2-cyanoacrylate was unsuccessful, as confirmed by postprocedure angiography, which revealed recanalization and regrowth of the HAP. Eight months after the first transcatheter arterial embolization, the patient presented with a chief complaint of abdominal pain due to an enlarged HAP. Angiography of the superior mesenteric artery (SMA) revealed a collateral bypass around the bile duct from the SMA to the liver graft. Coil embolization of the HAP in the CHA completely occluded the HAP without complications. More than 2 years after coil embolization, the liver graft function test results remained within normal limits without HAP recurrence. CONCLUSIONS HAP at the CHA after liver transplantation can be fatal if ruptured. Because the liver is a highly angiogenic organ, even if initial treatment is not successful, radical treatment to occlude the CHA with HAP is possible if sufficient collateral vessels are developed.
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Affiliation(s)
- Kazuki Sasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
- Department of Gastroenterological Surgery, Osaka Police Hospital, Osaka, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Noboru Maeda
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasushi Kimura
- Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Ono
- Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 E2 Yamadaoka, Suita, Osaka 565-0871 Japan
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Luo X, Nicoară-Farcău O, Magaz M, Betancourt F, Soy G, Baiges A, Turon F, Hernández-Gea V, García-Pagán JC. Obstruction of the liver circulation. CARDIO-HEPATOLOGY 2023:65-92. [DOI: 10.1016/b978-0-12-817394-7.00004-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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10
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Misra AC, Emamaullee J. CAQ Corner: Surgical evaluation for liver transplantation. Liver Transpl 2022; 28:1936-1943. [PMID: 35575000 PMCID: PMC9666671 DOI: 10.1002/lt.26505] [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: 01/29/2022] [Revised: 04/12/2022] [Accepted: 05/11/2022] [Indexed: 01/07/2023]
Abstract
The evaluation of a liver transplantation candidate is a complex and detailed process that in many cases must be done in an expedited manner because of the critically ill status of some patients with end-stage liver disease. It involves great effort from and the collaboration of multiple disciplines, and during the evaluation several studies and interventions are performed to assess and potentially prepare a patient for liver transplant. Here we review the liver transplantation evaluation from a surgical perspective.
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Affiliation(s)
- Asish C. Misra
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Juliet Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
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11
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Splenic Artery Embolization for Splenic Artery Steal Syndrome After Living Donor Liver Transplantation: A Case Report. Transplant Proc 2022; 54:2772-2778. [DOI: 10.1016/j.transproceed.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 08/10/2022] [Accepted: 09/13/2022] [Indexed: 11/15/2022]
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12
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Singh JP, Agarwal N, Sahni V, Kumar V, Saruchi, Malhotra R, Pathak D. Detection of blood flow through artery in the presence of steno-occlusive disease post liver transplantation by modeling for theatrical and detrimental environmental changes. J INDIAN CHEM SOC 2022. [DOI: 10.1016/j.jics.2022.100581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Superb Microvascular Imaging (SMI) Compared with Color Doppler Ultrasound for the Assessment of Hepatic Artery in Pediatric Liver Transplants: A Feasibility Study. Diagnostics (Basel) 2022; 12:diagnostics12061476. [PMID: 35741286 PMCID: PMC9221873 DOI: 10.3390/diagnostics12061476] [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] [Received: 04/15/2022] [Revised: 06/05/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Despite progression in surgical techniques and immunological treatments, hepatic artery (HA) thrombosis and stenosis still develop as an early or late liver transplant (LT) complication. We aimed to compare superb microvascular imaging (SMI) with conventional Doppler imaging (CDI) in the assessment of HA in a cohort of pediatric patients undergoing follow-up ultrasound (US) for LT. (2) Methods: This prospective, observational study included 73 pediatric LT recipients (median age, 7 years; IQR, 5.8 years; 35 females) who underwent US during LT follow-up from March to December 2019. For each examination, CDI and SMI were separately assessed in terms of HA visibility and spectral waveform morphology (SWM). The former was scored based on HA discrimination from the blooming signal of the surrounding vessels, as follows: 0, not visible; 1, majority course hardly distinguishable; and 2, majority course clearly distinguishable. The latter was scored on a two-point scale: 0, combined venous and arterial SWM, and 1, pure arterial SWM. The patient’s overall score was finally calculated by adding the two individual scores. (3) Results: Both the absolute scores and frequency of overall scores equal to 3 (maximum global score) were higher using SMI compared with CDI. The median overall score was 3 for SMI and 2 for CDI (p = 0.011; IQR = 1). An overall score equal to 3 was obtained in 74% and 49.3% of the study population using SMI and CDI, respectively (p = 0.002). This was attributable to a better score in HA visibility (p = 0.007). (4) Conclusions: SMI has shown promise for assessing HA in pediatric LT recipients, possibly serving as a complementary non-invasive tool of CDI in everyday practice.
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14
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Brookmeyer CE, Bhatt S, Fishman EK, Sheth S. Multimodality Imaging after Liver Transplant: Top 10 Important Complications. Radiographics 2022; 42:702-721. [PMID: 35245104 DOI: 10.1148/rg.210108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients who have undergone liver transplant are now regularly seen in day-to-day radiology practice. All surgical techniques for liver transplant require arterial, portal venous, hepatic venous and caval, and biliary anastomoses. This review is focused on the 10 "not to be missed" complications of liver transplant that affect the health and life of the graft and graft recipient. Arterial complications are the most common and devastating. Early hepatic artery thrombosis may be catastrophic because the biliary tree is solely dependent on the hepatic artery after transplant and collateral vessels have not yet formed. In contrast, delayed hepatic artery thrombosis may be more insidious as collateral arteries develop. US findings of delayed hepatic artery thrombosis may be similar to those of hepatic artery stenosis and celiac artery stenosis. Splenic artery steal syndrome is an increasingly recognized cause of graft ischemia. Venous complications are much less common. Hepatic venous and caval complications are notable for their increased incidence in living-donor and pediatric transplants. Biliary complications often result from arterial ischemia. Biliary cast syndrome is a notable example in which ischemic biliary mucosa sloughs into and obstructs the duct lumens. Neoplasms also may occur within the hepatic graft and may be due to recurrent malignancy, posttransplant lymphoproliferative disorder, or metastases. US is the initial imaging modality of choice, particularly in the acute postoperative setting. Further evaluation with contrast-enhanced US, CT, or MRI; catheter angiography; endoscopic retrograde cholangiopancreatography; and/or nuclear medicine studies is performed as needed. An invited commentary by Bhargava is available online. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Claire E Brookmeyer
- From the Department of Radiology, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287 (C.E.B., E.K.F.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.); and Department of Radiology, New York University Langone Health, New York, NY (S.S.)
| | - Shweta Bhatt
- From the Department of Radiology, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287 (C.E.B., E.K.F.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.); and Department of Radiology, New York University Langone Health, New York, NY (S.S.)
| | - Elliot K Fishman
- From the Department of Radiology, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287 (C.E.B., E.K.F.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.); and Department of Radiology, New York University Langone Health, New York, NY (S.S.)
| | - Sheila Sheth
- From the Department of Radiology, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287 (C.E.B., E.K.F.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (S.B.); and Department of Radiology, New York University Langone Health, New York, NY (S.S.)
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15
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de Jong IEM, Overi D, Carpino G, Gouw ASH, van den Heuvel MC, van Kempen LC, Mancone C, Onori P, Cardinale V, Casadei L, Alvaro D, Porte RJ, Gaudio E. Persistent biliary hypoxia and lack of regeneration are key mechanisms in the pathogenesis of posttransplant nonanastomotic strictures. Hepatology 2022; 75:814-830. [PMID: 34543480 PMCID: PMC9300015 DOI: 10.1002/hep.32166] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 08/30/2021] [Accepted: 09/16/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Nonanastomotic biliary strictures (NAS) are a major cause of morbidity after orthotopic liver transplantation (OLT). Although ischemic injury of peribiliary glands (PBGs) and peribiliary vascular plexus during OLT has been associated with the later development of NAS, the exact underlying mechanisms remain unclear. We hypothesized that bile ducts of patients with NAS suffer from ongoing biliary hypoxia and lack of regeneration from PBG stem/progenitor cells. APPROACH AND RESULTS Forty-two patients, requiring retransplantation for either NAS (n = 18), hepatic artery thrombosis (HAT; n = 13), or nonbiliary graft failure (controls; n = 11), were included in this study. Histomorphological analysis of perihilar bile ducts was performed to assess differences in markers of cell proliferation and differentiation in PBGs, microvascular density (MVD), and hypoxia. In addition, isolated human biliary tree stem cells (hBTSCs) were used to examine exo-metabolomics during in vitro differentiation toward mature cholangiocytes. Bile ducts of patients with NAS or HAT had significantly reduced indices of PBG mass, cellular proliferation and differentiation (mucus production, secretin receptor expression, and primary cilia), reduced MVD, and increased PBG apoptosis and hypoxia marker expression, compared to controls. Metabolomics of hBTSCs during in vitro differentiation toward cholangiocytes revealed a switch from a glycolytic to oxidative metabolism, indicating the need for oxygen. CONCLUSIONS NAS are characterized by a microscopic phenotype of chronic biliary hypoxia attributed to loss of microvasculature, resulting in reduced proliferation and differentiation of PBG stem/progenitor cells into mature cholangiocytes. These findings suggest that persistent biliary hypoxia is a key mechanism underlying the development of NAS after OLT.
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Affiliation(s)
- Iris E M de Jong
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands.,Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Diletta Overi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic SciencesSapienza University of RomeRomeItaly
| | - Guido Carpino
- Division of Health SciencesDepartment of Movement, Human and Health SciencesUniversity of Rome "Foro Italico"RomeItaly
| | - Annette S H Gouw
- Department of PathologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Marius C van den Heuvel
- Department of PathologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Léon C van Kempen
- Department of PathologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Carmine Mancone
- Department of Molecular MedicineSapienza University of RomeRomeItaly
| | - Paolo Onori
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic SciencesSapienza University of RomeRomeItaly
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and BiotechnologiesPolo Pontino, Sapienza University of RomeRomeItaly
| | - Luca Casadei
- Department of ChemistrySapienza University of RomeRomeItaly
| | - Domenico Alvaro
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic SciencesSapienza University of RomeRomeItaly
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16
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Dumortier J, Besch C, Moga L, Coilly A, Conti F, Corpechot C, Del Bello A, Faitot F, Francoz C, Hilleret MN, Houssel-Debry P, Jezequel C, Lavayssière L, Neau-Cransac M, Erard-Poinsot D, de Lédinghen V, Bourlière M, Bureau C, Ganne-Carrié N. Non-invasive diagnosis and follow-up in liver transplantation. Clin Res Hepatol Gastroenterol 2022; 46:101774. [PMID: 34332131 DOI: 10.1016/j.clinre.2021.101774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
The field of liver transplantation directly or indirectly embodies all liver diseases, in addition to specific ones related to organ rejection (cellular and humoral). The recommended non-invasive methods for determining the indication for liver transplantation are the Model for End-stage Liver Disease score, and the alpha-foetoprotein score in case of hepatocellular carcinoma. Radiological methods are the cornerstones for the diagnosis of vascular and biliary complications after liver transplantation. The possible diseases of the liver graft after transplantation are multiple and often intertwined. Non-invasive diagnostic methods have been poorly evaluated in this context, apart from the recurrence of hepatitis C. Liver biopsy remains the gold standard for evaluating graft lesions in the majority of cases, especially graft rejection.
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Affiliation(s)
- Jérôme Dumortier
- Service d'hépato-gastroentérologie, Unité de transplantation hépatique, Hôpital Edouard Herriot - HCL, CHU Lyon, Lyon.
| | - Camille Besch
- Service de chirurgie hépato-bilio-pancréatique et transplantation hépatique, Hôpital Hautepierre, CHRU Strasbourg, Strasbourg
| | - Lucile Moga
- Service d'Hépatologie et Transplantation Hépatique, Hôpital Beaujon, APHP, Clichy
| | - Audrey Coilly
- Centre Hépato-Biliaire, Hôpital Paul Brousse, APHP, Villejuif
| | - Filomena Conti
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, APHP, Paris
| | | | - Arnaud Del Bello
- Département de néphrologie et transplantation d'organes, Hôpital Rangueil, CHU Toulouse, Toulouse
| | - François Faitot
- Service de chirurgie hépato-bilio-pancréatique et transplantation hépatique, Hôpital Hautepierre, CHRU Strasbourg, Strasbourg
| | - Claire Francoz
- Service d'Hépatologie et Transplantation Hépatique, Hôpital Beaujon, APHP, Clichy
| | | | | | | | - Laurence Lavayssière
- Département de néphrologie et transplantation d'organes, Hôpital Rangueil, CHU Toulouse, Toulouse
| | | | - Domitille Erard-Poinsot
- Service d'hépato-gastroentérologie, Unité de transplantation hépatique, Hôpital Edouard Herriot - HCL, CHU Lyon, Lyon
| | - Victor de Lédinghen
- Unité Transplantation Hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Bordeaux
| | - Marc Bourlière
- Service d'hépato-gastroentérologie, Hôpital Saint Joseph & INSERM UMR 1252 IRD SESSTIM Aix Marseille Université, Marseille
| | | | - Nathalie Ganne-Carrié
- Service d'hépatologie, Hôpital Avicenne, APHP, Université Sorbonne Paris Nord, Bobigny & INSERM UMR 1138, Centre de Recherche des Cordeliers, Université de Paris
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17
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Avolio AW, Contegiacomo A, Spoletini G, Moschetta G, Bianco G, Agnes S, Melcher ML, Burra P. Toward a novel evidence-based definition of early allograft failure in the perspective of liver retransplant. Transpl Int 2021; 34:2905-2907. [PMID: 34784075 DOI: 10.1111/tri.14162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alfonso W Avolio
- Divisione di Chirurgia Generale e del Trapianto di Fegato, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Dipartimento di Medicina e Chirurgia Translazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Contegiacomo
- Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Gabriele Spoletini
- Divisione di Chirurgia Generale e del Trapianto di Fegato, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Giovanni Moschetta
- Divisione di Chirurgia Generale e del Trapianto di Fegato, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Giuseppe Bianco
- Divisione di Chirurgia Generale e del Trapianto di Fegato, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Salvatore Agnes
- Divisione di Chirurgia Generale e del Trapianto di Fegato, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Dipartimento di Medicina e Chirurgia Translazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marc L Melcher
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Patrizia Burra
- Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Azienda ospedaliera universitaria, Padua, Italy
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18
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Vu J, Beltran-Perez J, Bordlee B. Gastroduodenal artery steal syndrome treated with coil embolization after orthotopic liver transplantation. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii200052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- James Vu
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Jesus Beltran-Perez
- Department of Radiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Bruce Bordlee
- Department of Radiology, Tulane University School of Medicine, New Orleans, LA, USA
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19
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Stephenson K, Kalkwarf K, Giorgakis E. Application of resuscitative endovascular balloon occlusion in post-transplant mycotic hepatic artery pseudoaneurysm rupture in the setting of Aspergillus Constellatus bacteremia. Ann Hepatobiliary Pancreat Surg 2021; 25:126-131. [PMID: 33649265 PMCID: PMC7952665 DOI: 10.14701/ahbps.2021.25.1.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 11/17/2022] Open
Abstract
Hepatic artery pseudoaneurysm (HAP) is a rare, highly morbid and frequently fatal complication of liver transplantation. Most are a mycotic mediated weakness of the arterial wall, with associated bacterial or fungal infection of ascitic fluid. As it is usually asymptomatic prior to rupture, the majority present in acute hemorrhagic shock and dire extremis. Resuscitative endovascular balloon occlusion (REBOA) was initially developed for the management of noncompressible hemorrhagic shock in trauma; however, remains underutilized and understudied in the non-trauma setting. We present the case of a mycotic hepatic artery pseudoaneurysm rupture due to Streptococcus constellatus and Klebsiella pneumoniae post directed donor orthoptic liver transplant, in which REBOA was employed in the setting of impending exsanguination as a bridge to definitive surgical intervention. Although this patient passed away of multiorgan system failure prior to re-transplant, this case demonstrates the importance of a heightened suspicion of this devastating complication, especially in the setting of bilioenteric reconstruction and perihepatic fluid collection, as well as the benefit of utilizing resuscitative techniques such as REBOA prior to definitive surgical or endovascular therapy to mitigate the high morbidity and mortality of this condition.
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Affiliation(s)
- Krista Stephenson
- Division of Solid Organ Transplantation, Department of Surgery, UAMS Medical Center, AR, USA
| | - Kyle Kalkwarf
- Division of Trauma and Critical Care Surgery, Department of Surgery, UAMS Medical Center, Little Rock, AR, USA
| | - Emmanouil Giorgakis
- Division of Solid Organ Transplantation, Department of Surgery, UAMS Medical Center, AR, USA
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20
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Gaspari R, Teofili L, Mignani V, Franco A, Valentini CG, Cutuli SL, Cina A, Agnes S, Avolio AW, Antonelli M. Duplex Doppler evidence of high hepatic artery resistive index after liver transplantation: Role of portal hypertension and clinical impact. Dig Liver Dis 2020; 52:301-307. [PMID: 31806469 DOI: 10.1016/j.dld.2019.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early increase of hepatic artery resistive index (HARI) is frequently observed after liver transplant (LTx). AIM We aimed to investigate contributing factors and prognostic relevance of high HARI after LTx from deceased donor. METHODS We conducted a retrospective analysis of prospectively collected data from January 2017 and February 2019. According to the Duplex Doppler HARI values (3d post-operative day), patients were grouped in normal (0.55-0.80) and high (>0.80-1) HARI groups. RESULTS Among 81 LTx, 36 had a high HARI and 45 a normal HARI. Patients developing high HARI were older, exhibited lower platelet, hemoglobin, platelet count/spleen diameter ratio, higher serum creatinine, and a more pronounced spleen enlargement (median values 170 versus 120 mm). At multivariate analysis, PLT/spleen diameter ratio (OR 0.994, p < 0.001) creatinine levels (OR 2.418, p = 0.029), and recipient age (OR 1.157, p = 0.004) significantly predicted the occurrence of high HARI. Patients with high or normal HARI had similar vascular complications, rejection rate and 90-day mortality. In most cases, HARI recovered to normal without any clinical effect. CONCLUSIONS HARI rises in presence of several surrogate markers of portal hypertension. The increase is mostly transitory, and it may result from the hepatic artery spasm due to the high portal blood flow.
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Affiliation(s)
- Rita Gaspari
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per immagini, radioterapia, oncologia ed ematologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vittorio Mignani
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Franco
- Dipartimento di Scienze gastroenterologiche, endocrino-metaboliche e nefro-urologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Caterina G Valentini
- Dipartimento di Diagnostica per immagini, radioterapia, oncologia ed ematologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Salvatore L Cutuli
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Alessandro Cina
- Dipartimento di Diagnostica per immagini, radioterapia, oncologia ed ematologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Salvatore Agnes
- Dipartimento di Scienze gastroenterologiche, endocrino-metaboliche e nefro-urologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfonso W Avolio
- Dipartimento di Scienze gastroenterologiche, endocrino-metaboliche e nefro-urologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Massimo Antonelli
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
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21
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Hepatic Artery Pseudoaneurysm in the Liver Transplant Recipient: A Case Series. Case Rep Transplant 2019; 2019:9108903. [PMID: 31976118 PMCID: PMC6959152 DOI: 10.1155/2019/9108903] [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: 08/16/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Hepatic artery pseudoaneurysm is a rare and potentially fatal complication of liver transplantation with a reported incidence of 0.3–2.6% and associated mortality approaching 75%. Clinical presentation typically includes sudden hypotension, gastrointestinal bleed or abnormal liver function tests within two months of transplantation. We report a series of four cases of hepatic artery pseudoaneurysm in adult liver transplant recipients with the goal of identifying factors that may aid in early diagnosis, prior to the development of life threatening complications. Methods A retrospective chart review at a high volume transplant center revealed 4 cases of hepatic artery pseudoaneurysm among 553 liver transplants (Incidence 0.72%) between March 2013 and March 2017. Results Two of the four patients died immediately after intervention, one patient survived an additional 151 days prior to death from an unrelated condition and one patient survived at two years follow up. All cases utilized multiple imaging modalities that failed to identify the pseudoaneurysm prior to diagnosis with computed tomography angiography (CTA). Two cases had culture proven preoperative intrabdominal infections, while the remaining two cases manifested a perioperative course highly suspicious for infection (retransplant for hepatic necrosis after hepatic artery thrombosis and infected appearing vessel at reoperation, respectively). Three of the four cases either had a delayed biliary anastomosis or development of a bile leak, leading to contamination of the abdomen with bile. Additionally, three of the four cases demonstrated at least one episode of hypotension with acute anemia at least 5 days prior to diagnosis of the hepatic artery pseudoaneurysm. Conclusions Recognition of several clinical features may increase the early identification of hepatic artery pseudoaneurysm in liver transplant recipients. These include culture proven intrabdominal infection or high clinical suspicion for infection, complicated surgical course resulting either in delayed performance of biliary anastomosis or a biliary leak, and an episode of hypotension with acute anemia. In combination, the presence of these characteristics can lead the clinician to investigate with appropriate imaging prior to the onset of life threatening complications requiring emergent intervention. This may lead to increased survival in patients with this life threatening complication.
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22
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Magand N, Coronado JL, Drevon H, Manichon A, Mabrut J, Mohkam K, Ducerf C, Boussel L, Rode A. Primary angioplasty or stenting for hepatic artery stenosis treatment after liver transplantation. Clin Transplant 2019; 33:e13729. [DOI: 10.1111/ctr.13729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 08/27/2019] [Accepted: 09/14/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Nicolas Magand
- Diagnostic and interventional radiology department Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - José Luis Coronado
- Diagnostic and interventional radiology department Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - Harir Drevon
- Diagnostic and interventional radiology department Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - Anne‐Frédérique Manichon
- Diagnostic and interventional radiology department Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - Jean‐Yves Mabrut
- Visceral surgery and liver transplantation Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - Kayvan Mohkam
- Visceral surgery and liver transplantation Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - Christian Ducerf
- Visceral surgery and liver transplantation Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - Loïc Boussel
- Diagnostic and interventional radiology department Croix Rousse Hospital Hospices Civils de Lyon Lyon France
| | - Agnès Rode
- Diagnostic and interventional radiology department Croix Rousse Hospital Hospices Civils de Lyon Lyon France
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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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Miranda LE, Leitão L, Jucá N, Lacerda CM. Dissection of the Hepatic Artery: A Rare Cause of Late Ischemia After Liver Transplant. EXP CLIN TRANSPLANT 2019; 18:641-644. [PMID: 31250739 DOI: 10.6002/ect.2019.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hepatic artery dissection is an infrequent vascular complication that can arise after orthotopic liver transplant. Most patients with this complication are diagnosed during the intraoperative period or the first days after liver transplant, with an association shown with living-donor liver transplant. In this study, we discuss a rare case of an extrahepatic artery dissection that was successfully managed through surgical excision and arterial revascularization that was diagnosed 4 years after orthotopic liver transplant. Furthermore, we hypothesize on the potential causes of its occurrence.
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Affiliation(s)
- Luiz Eduardo Miranda
- From the Division of General Surgery and Liver Transplantation, Hospital Oswaldo Cruz, Pernambuco University, Recife, Pernambuco, Brazil
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25
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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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26
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Capelli R, Allard M, Ciacio O, Pittau G, Golse N, Vibert E, Sa Cunha A, Castaing D, Cherqui D, Adam R. Late hepaticartery thrombosis after liver transplantation: which strategy? A single‐center retrospective study. Transpl Int 2019; 32:473-480. [DOI: 10.1111/tri.13394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/22/2018] [Accepted: 12/12/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Rafaela Capelli
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
| | - Marc‐Antoine Allard
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
- Unités Mixtes de Recherche en Santé 1193 Villejuif France
- Faculté de Médecine Université Paris‐Sud Le Kremlin‐Bicêtre France
| | - Oriana Ciacio
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
| | - Gabriella Pittau
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
| | - Nicolas Golse
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
- Unités Mixtes de Recherche en Santé 1193 Villejuif France
| | - Eric Vibert
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
- Unités Mixtes de Recherche en Santé 1193 Villejuif France
- Faculté de Médecine Université Paris‐Sud Le Kremlin‐Bicêtre France
| | - Antonio Sa Cunha
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
- Faculté de Médecine Université Paris‐Sud Le Kremlin‐Bicêtre France
| | - Denis Castaing
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
- Unités Mixtes de Recherche en Santé 1193 Villejuif France
- Faculté de Médecine Université Paris‐Sud Le Kremlin‐Bicêtre France
| | - Daniel Cherqui
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
- Faculté de Médecine Université Paris‐Sud Le Kremlin‐Bicêtre France
| | - René Adam
- Centre Hépato‐Biliaire AP‐HP Hôpital Paul Brousse Villejuif France
- Faculté de Médecine Université Paris‐Sud Le Kremlin‐Bicêtre France
- Unités Mixtes de Recherche en Santé 985 INSERM Villejuif France
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27
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Esposito A, Vit A, Adani G, Baccarani U, Cherchi V, Risaliti A, Sponza M. Indigo Thrombectomy System for Hepatic Artery Thrombosis After Liver Transplantation: A Case Report. Transplant Proc 2018; 50:4000-4003. [DOI: 10.1016/j.transproceed.2018.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/03/2018] [Accepted: 07/18/2018] [Indexed: 12/18/2022]
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28
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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: 0.4] [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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Endovascular Treatment for Very Early Hepatic Artery Stenosis Following Living-Donor Liver Transplantation: Report of Two Cases. Transplant Proc 2018; 50:1457-1460. [DOI: 10.1016/j.transproceed.2018.02.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/17/2018] [Accepted: 02/06/2018] [Indexed: 12/11/2022]
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Use of a mechanical thrombectomy device to treat early hepatic artery thrombosis after orthotopic liver transplant. Radiol Case Rep 2017; 13:522-526. [PMID: 29904504 PMCID: PMC6000183 DOI: 10.1016/j.radcr.2017.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 12/11/2017] [Indexed: 12/14/2022] Open
Abstract
Hepatic artery thrombosis (HAT) is a major cause of morbidity and mortality after orthotopic liver transplantation, occurring in 5% of cases (Piardi et al, 2016). HAT is the second main cause of graft loss after primary nonfunction, the leading cause of graft failure in the immediate postoperative period (<1 month), and is associated with a mortality rate of up to 60% without intervention (Piardi et al, 2016; Pareja et al., 2010; Crossin et al., 2003). Although retransplantation is the preferred therapy, the limited availability of donor organs can necessitate urgent, alternative treatment. These patients present physicians with an often-severe clinical picture, which requires consideration of endovascular approaches as opposed to the more traditional, invasive surgical interventions. The following case study presents a novel mechanical therapy that uses an endovascular approach for revascularization—a stent retriever device.
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Cesaretti M, Dioguardi Burgio M, Zarzavadjian Le Bian A. Abdominal emergencies after liver transplantation: Presentation and surgical management. Clin Transplant 2017; 31. [PMID: 28871618 DOI: 10.1111/ctr.13102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Manuela Cesaretti
- HPB surgery and Liver Transplantation department; Hôpital Beaujon; Clichy; Assistance Publique - Hôpitaux de Paris; Paris Diderot University; Paris France
- Istituto Italiano di Tecnologia; Genova Italy
| | - Marco Dioguardi Burgio
- Diagnostic and Interventional Radiology; Hôpital Beaujon; Clichy; Assistance Publique - Hôpitaux de Paris; Paris Diderot University; Paris France
| | - Alban Zarzavadjian Le Bian
- Service de Chirurgie Digestive; Centre Hospitalier Simone Veil; Eaubonne France
- Laboratoire d'Ethique Médicale et de Médecine Légale; Université Paris Descartes; Paris France
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Pretransplant Intra-arterial Liver-Directed Therapy Does Not Increase the Risk of Hepatic Arterial Complications in Liver Transplantation: A Single-Center 10-Year Experience. Cardiovasc Intervent Radiol 2017; 41:231-238. [PMID: 28900709 DOI: 10.1007/s00270-017-1793-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/05/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE To investigate the association between pretransplant intra-arterial liver-directed therapy (IAT) for hepatocellular carcinoma (HCC) and hepatic arterial complications (HAC) in orthotopic liver transplantation (OLT) [namely hepatic artery thrombosis (HAT) and/or the need for hepatic arterial conduit]. METHODS A total of 175 HCC patients (mean age: 60 years) underwent IAT with either transarterial chemoembolization or yttrium-90 (90Y) transarterial radioembolization prior to OLT between 2003 and 2013. A matched control cohort of 159 HCC patients who underwent OLT without prior IAT was selected. Incidence of HAC in both cohorts was investigated. The categorical differences between both cohorts were calculated by chi-square test. RESULTS Among the 175 patients (chemoembolization, n = 82; radioembolization, n = 93), 8 (5%) required conduits due to HA disease (chemoembolization, n = 6; radioembolization, n = 2), 3 (2%) developed HAT (chemoembolization, n = 2; radioembolization, n = 1). Eleven of 175 patients (6.7%) had HAC. Of the 159 control patients, 6 (4%) needed conduits for HA disease and 3 (2%) developed HAT. Nine of 159 patients (5.7%) had HAC. Chi-square analysis between the IAT cohort and the control group yielded a p value of 0.810. When comparing chemoembolization to radioembolization, p = 0.076 (not significant at p < 0.05). CONCLUSION Although aggressive pretransplant radioembolization and chemoembolization are both utilized in most liver transplant centers, neither appears to increase the risk of peri-transplant hepatic arterial complications in HCC patients.
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33
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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: 2.3] [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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34
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Elsayes KM, Shaaban AM, Rothan SM, Javadi S, Madrazo BL, Castillo RP, Casillas VJ, Menias CO. A Comprehensive Approach to Hepatic Vascular Disease. Radiographics 2017; 37:813-836. [DOI: 10.1148/rg.2017160161] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Khaled M. Elsayes
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
| | - Akram M. Shaaban
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
| | - Sarah M. Rothan
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
| | - Sanaz Javadi
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
| | - Beatrice L. Madrazo
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
| | - Rosa P. Castillo
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
| | - Victor J. Casillas
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
| | - Christine O. Menias
- From the Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030 (K.M.E., S.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (A.M.S.); Department of Diagnostic and Interventional Imaging, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Tex (S.M.R.); Department of Diagnostic Radiology, University of Miami Health System, Miami, Fla (B.L.M., R.P.C., V.J.C.)
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Siskind EJ, Vandermeer F, Siskind TR, Bruno DA, Sultan S, Alvarez-Casas J, Stafford A, Lane B, Lamattina JC, Barth RN, Hanish SI. Postoperative Elevated Resistive Indices Do Not Predict Hepatic Artery Thrombosis in Extended Criteria Donor Livers. Int J Angiol 2017; 26:238-240. [PMID: 29142490 DOI: 10.1055/s-0037-1598623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Postoperative transplant liver ultrasounds were analyzed in standard criteria donor (SCD), extended criteria donor (ECD), and donation after cardiac death (DCD) liver allografts to determine if elevated resistive indices (RIs) are consistently present and if they are pathological. Postoperative transplant liver ultrasounds were reviewed from 115 consecutive patients. Hepatic arterial RIs were stratified based on the type of donor: DCD, macrosteatosis (>30%), or standard criteria. In all patients with elevated RI, subsequent ultrasounds were reviewed to demonstrate RI normalization. The mean RI for all 115 patients was 0.64, DCD was 0.67, macrosteatosis was 0.81, and SCD was 0.61 ( p = 0.033). The RI on subsequent liver ultrasounds for DCD and macrosteatosis normalized without any intervention. There were no incidences of early hepatic artery thrombosis (HAT) observed in the cohort. Hepatic arterial RI in ECDs and DCDs are elevated in the immediate postoperative period but are not predictive of HAT. It represents interparenchymal graft stiffness and overall graft edema rather than an impending technical complication. The results of our study do not support the routine use of anticoagulation or routine investigation with computed tomography angiography for elevated RIs as these findings are self-limiting and normalize over a short period of time. We hope that this information helps guide the clinical management of liver transplant patients from expanded criteria donors.
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Affiliation(s)
- Eric J Siskind
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Fauzia Vandermeer
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Tamar R Siskind
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - David A Bruno
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Samuel Sultan
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Josue Alvarez-Casas
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Arielle Stafford
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Barton Lane
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - John C Lamattina
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Rolf N Barth
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
| | - Steven I Hanish
- Division of Transplantation, University of Maryland Medical Center, Baltimore, Maryland
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36
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Role of MDCT in the detection of early abdominal complications after orthotopic liver transplantation. Clin Imaging 2016; 40:1200-1206. [DOI: 10.1016/j.clinimag.2016.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 08/04/2016] [Accepted: 08/22/2016] [Indexed: 12/19/2022]
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37
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Ren X, Luo Y, Gao N, Niu H, Tang J. Common ultrasound and contrast-enhanced ultrasonography in the diagnosis of hepatic artery pseudoaneurysm after liver transplantation. Exp Ther Med 2016; 12:1029-1033. [PMID: 27446316 PMCID: PMC4950670 DOI: 10.3892/etm.2016.3343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/17/2016] [Indexed: 12/19/2022] Open
Abstract
The diagnostic value of common ultrasound and contrast-enhanced ultrasonography (CEUS) in hepatic artery pseudoaneurysm (HAP) after liver transplantation was investigated. From January 2005 to November 2015, information was collected on 2,085 cases of orthotopic liver transplantation. The cases included 1,617 men and 468 women. Common ultrasound and CEUS were used to monitor arterial blood flow following surgery, and the complications were assessed. Instruments used included Acuson Sequoia 512 and Mylab Twice, and the contrast agent was SonoVue. The standard of common ultrasound in the diagnosis of HAP was follicular structure, which had arterial blood flow signal present beside the hepatic artery. The diagnostic criteria of HAP using CEUS were abnormal and round contrast enhancement zone and perfusion of the contrast agent in the zone near the hepatic artery. The diagnostic standard of HAP was computed tomographic angiography (CTA) and emergency operation. Eight cases of HAP were diagnosed in 2,085 patients after liver transplantation (0.38%). Three cases of HAP were diagnosed successfully by common ultrasound while 5 cases were missed. Sensitivity, specificity and diagnostic accuracy for common ultrasound was 37.5, 100 and 99.76%, respectively. Six cases of HAP were diagnosed by CEUS and 2 cases were missed. Sensitivity, specificity and diagnostic accuracy for CEUS was 75, 100 and 99.9%, respectively. Collectively, CEUS is a convenient and effective diagnostic method for HAP following liver transplantation, the diagnostic sensitivity was obviously higher than that of the common ultrasound, and it was more convenient than CTA. Nevertheless, the diagnosis of pseudoaneurysm with deep location, and unsatisfactory grayscale images were easily missed.
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Affiliation(s)
- Xiuyun Ren
- Department of Ultrasound, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China; Department of Ultrasound, The General Hospital of Chinese People's Armed Police Forces, Beijing 100039, P.R. China
| | - Yukun Luo
- Department of Ultrasound, The General Hospital of Chinese People's Armed Police Forces, Beijing 100039, P.R. China
| | - Nong Gao
- Department of Ultrasound, The General Hospital of Chinese People's Armed Police Forces, Beijing 100039, P.R. China
| | - Hong Niu
- Department of Ultrasound, The General Hospital of Chinese People's Armed Police Forces, Beijing 100039, P.R. China
| | - Jie Tang
- Department of Ultrasound, The General Hospital of Chinese People's Liberation Army, Beijing 100853, P.R. China
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