Arterial conduits for hepatic artery revascularisation in adult liver transplantation

Abstract

Arterial complications after orthotopic liver transplantation (OLT), including hepatic artery thrombosis (HAT), are important causes of early graft failure. The use of an arterial conduit is an accepted alternative to the utilisation of native recipient hepatic artery for specific indications. This study aims to determine the efficacy of arterial conduits and the outcome in OLT. We retrospectively reviewed 1,575 cadaveric adult OLTs and identified those in which an arterial conduit was used for hepatic revascularisation. Data on the primary disease, indication for using arterial conduit, type of vascular graft, operative technique and outcome were obtained. Thirtysix (2.3%) patients underwent OLT in which arterial conduits were used for hepatic artery (HA) revascularisation. Six of these were performed on the primary transplant, while the rest (n = 30) were performed in patients undergoing re-transplantation, including six who had developed hepatic artery aneurysms. The incidence of arterial conduits was 0.4% (6/ 1,426 cases) in all primary OLTs and 20.1% (30/149 cases) in all re-transplants. Twenty-nine procedures utilised iliac artery grafts from the same donor as the liver, six used iliac artery grafts from a different donor, and a single patient underwent a polytetrafluoroethylene (PTFE) graft. Two techniques were used: infra-renal aorto-hepatic artery conduit and interposition between the donor and recipient native HAS, or branches of the HAS. The 30-day mortality rate for operations using an arterial conduit was 30.6%. Three conduits thrombosed at 9,25 and 155 months, respectively, but one liver graft survived without re-transplantation. The arterial conduits had 1-and 5-year patency rates of 88.5% and 80.8%. The 1-and 5-year patient survival rates were 66.7% and 44%. We can thus conclude that an arterial conduit is a viable alternative option for hepatic revascularisation in both primary and re-transplantation. Despite a lower patency rate than that of native HA in the primary OLT group, the outcomes of arterial conduit patency and patient survival rates are both acceptable at 1 and 5 years, especially in the much larger re-OLT group.

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“…The high incidence of HA throm bosis encountered herein may be related to the combined use of an arterial conduit and an aortohepatic bypass, both of which represent risk factors of HA thrombosis. 12,19 In addition, these findings are consistent with previous studies referring to the use of cryopreserved artery or vein for primary arterial reconstruction after LT, which also reported high rates of HA thrombosis. 16,20 Interestingly, despite the dramatic incidence of CIAA thrombosis reported in this study, it was not systematically associated with graft failure or loss.…”

“…In this preliminary investigation, all patients having indications for surgical repair but with no available preserved allografts available were successfully treated with arterial reconstruction using a CIAA. Alternative surgical repair options include the use of preserved arterial allografts, 11 prosthetic conduits, 12 and venous autografts. 10 Preserved arterial allografts could be effectively used in the setting of RAR, 11,18 but such grafts may only be used during the 30 days after their procurement; after this short period of time, they must be discarded because of graft endothelium destruction.…”

“…9 However, in cases of major hemodynamic instability, associated visceral damage, or failure of endovascular tre atment, surgical revascularization remains the sole option, and, once advocated, the classical options are the use of venous autografts, preserved allografts, and prosthetic conduits. [10][11][12] Each of these options has its own drawback, as prosthetic conduits expose patients to risks of infection, 13 preserved arterial allografts are not permanently available, 11 and venous autografts are generally assumed to have a worse outcome than arterial grafts. 14 Cryopreserved iliac artery allografts (CIAAs) have the advantage of being possibly preserved for years and therefore available any time provided that a cryopreserved artery tissue bank is established.…”

Liver transplantation in Indian Armed Forces—initial experience

“…12,13 In this series, six patients (18.7%) underwent seven extra-anatomic arterial conduits. Two vascular conduits were performed as graft salvage procedure following hepatic artery thrombosis (HAT) and the others underwent primary vascular conduits.…”

Twenty years of follow-up of aortohepatic conduits in liver transplantation

“…Prior reports of poor results after liver transplantation using aortohepatic conduits likely reflected additional factors (re- No conduit 2197 82% 74% 67% 52% 35% 25% 1758 1416 1092 545 158 16 Conduit 149 72% 65% 59% 50% 33% 24% 102 75 64 40 18 2 NOTE: P ϭ 0.0889. transplants, placement of the conduit after the hepatic artery thrombosis, and patients with a hypercoagulable state). [5][6][7][8] When the influence of the confounding factors is minimized, the results of liver transplantation using aortohepatic conduits become very close to those of the control group. The trend of lower graft survival in the first 5 years and the higher incidence of postoperative renal failure may be related to a sicker recipient population (a higher Model for End-Stage Liver Disease score, more patients with fulminant hepatic failure, more hemodynamically unstable patients, and a higher rate of respiratory failure).…”