The incidence, clinical presentation, therapeutic options, and outcome of hepatic artery thrombosis (HAT) were analyzed in a series of 1,192 consecutive adult orthotopic liver transplantations (OLTs). HAT after OLT was observed in 30 cases, resulting in an incidence of 2.5%. The incidence of HAT increased 5.76-fold when the donor hepatic artery was reconstructed with an interposition graft to the supraceliac aorta (P <.05). Early HAT (within the first 30 days after OLT) occurred in 14 of these patients (46.7%), whereas in 16 patients (53.3%), HAT occurred beyond 30 days post-OLT. Clinical presentation of HAT ranged from an increase in serum transaminase levels with or without cholestasis to liver abscess and biliary complications, including cholangitis, bile duct stenosis or necrosis, to liver dysfunction and failure. Impairment of graft function was observed in patients with early HAT, whereas biliary tract destruction was seen more often in patients with late HAT. In only 1 patient was HAT clinically asymptomatic. Therapy consisted of recombinant plasminogen lysis with hepaticojejunostomy, liver abscess drainage, endoscopy or surveillance, and surgical thrombectomy. In 14 of 30 patients (46.7%), the occurrence of HAT required re-OLT. Nine patients with HAT died during follow-up; however, only 4 of these deaths were related to HAT, resulting in a mortality rate of 13.3%. Our results indicate that HAT is a rare but serious complication after OLT, requiring re-OLT in almost 50% of patients. In particular, conservative treatment modalities may significantly prolong graft survival, thus postponing re-OLT.

Arterial steal syndromes (ASSs) after orthotopic liver transplantation (OLT) are characterized by arterial hypoperfusion of the graft caused by shifting of blood flow into the splenic or gastroduodenal artery. Despite their potentially devastating consequences, such as ischemic biliary tract destruction or graft failure, ASSs have received little attention to date. We report the incidence, diagnosis, and treatment of ASS among 1,250 consecutive OLTs. ASS was observed in 69 patients (5.9%). All these patients presented with elevated liver enzyme levels, impaired graft function, or cholestasis. Treatment consisted of splenectomy (n ‫؍‬ 18), coil embolization of the splenic or gastroduodenal artery (n ‫؍‬ 29), or reduction in splenic artery blood flow through administration of an artificial stenosis (banding; n ‫؍‬ 9). Mild symptoms of ASS did not warrant treatment in 13 patients. However, 3 of these patients developed ischemic biliary destruction requiring re-OLT. Serious complications also were observed after splenectomy and coil embolization, requiring re-OLT in 18%. Conversely, no complications were observed after banding the splenic artery. Prophylactic banding of the splenic artery was performed in 97 patients and was associated with a complication rate of 4%. In summary, the incidence of ASS is similar to that of other vascular complications. Untreated ASSs may lead to serious complications in more than 30% of patients. Of a variety of treatment options, banding the splenic artery was associated with the lowest complication rate. Banding also may be performed prophylactically in selected patients to prevent the development of ASS after OLT. (Liver Transpl 2003;9: 596-602.)

Immediate tracheal extubation was safe and well tolerated. The incidence of reintubation was not increased when compared to patients in whom extubation succeeded later. However, special attention should be given to transplant recipients presenting in reduced clinical condition at the time of OLT, undergoing complicated surgery, or receiving liver allografts with severe reperfusion injury because of an increased risk for prolonged mechanical ventilation.