The preservation of a graft's aberrant left hepatic artery (LHA) during liver transplantation (LT) ensures optimal vascularization of the left liver but can also be considered a risk factor for hepatic artery thrombosis (HAT). In contrast, ligation of an aberrant LHA may lead to hepatic ischemia with the potential risk of graft dysfunction and biliary complications. The aim of this study was to prospectively analyze the impact on the surgical strategy for LT of 5 tests performed to establish whether an aberrant LHA was an accessory or a replaced artery, thus leading to the design of a decisional algorithm. From August 2005 to December 2016, 395 whole LTs were performed in 376 patients. Five parameters were evaluated to determine whether an aberrant LHA was an accessory or a replaced artery. On the basis of our decision algorithm, an aberrant LHA was ligated during surgery when assessed as accessory and preserved when assessed as replaced. A total of 138 anatomical variants of hepatic arterial vascularization occurred in 120/395 (30.4%) grafts. Overall, the incidence of an aberrant LHA was 63/395 (15.9%). The LHA was ligated in 33 (52.4%) patients and preserved in 30 (47.6%) patients. After a mean follow-up period of 50.9 ± 39.7 months, the incidence of HAT, primary nonfunction, early allograft dysfunction, biliary stricture or leaks, and overall survival was similar in the 2 groups. In conclusion, once shown to be an accessory, an LHA can be safely ligated without clinical consequences on the outcome of LT. Liver Transplantation 24 204-213 2018 AASLD.

a b s t r a c tContext: Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients. Aims: To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS). Methods and material: Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: 50 years, 51e70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months. Statistical analysis used: One-way ANOVA test for continuous variables, Pearson chi-square (X 2 ) test for categorical variables and multivariate logistic regression analysis for predictors were performed. Results: Among 7930 consecutive ACS patients; 2755 (35%) were 50 years, 4110 (52%) were 51e70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients 50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03e1.60), heart failure (OR 2.8; 95% CI 2.17e3.52) and major bleeding (OR 4.02; 95% CI 1.37 e11.77) and in-hospital mortality (age 51e70: OR 2.67; 95% CI 1.86e3.85, and age >70: OR 4.71; 95% CI 3.11e7.14). Conclusion: Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.

AimTo report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature.MethodsSince January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central.ResultsUntil July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two procedures was 96±47% (range: 24–160%, p<0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8±2.9 days. The average hospital stay was 24.1±13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1±8.5 months, the overall survival was 89% at 3–6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review.ConclusionThe ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.

BackgroundCoronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar.MethodsData were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991–2010) and were analyzed according to gender.ResultsAmong 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27–1.79).ConclusionsWomen presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.