Distal Gastroduodenal Arterial Inflow as a Salvage Strategy for Extensive Intraoperative Arterial Dissection in Living Donor Liver Transplantation

Abstract

A meticulously performed hepatic arterial anastomosis with long-term patency is 1 of the cornerstones of successful liver transplantation. Multiple arterial anastomoses, small-caliber hepatic arteries, and unhealthy arteries secondary to atherosclerosis or prior arterial interventions such as transarterial chemoembolization (TACE) are recognized risk factors for hepatic artery thrombosis (HAT). Arterial inflow during living donor liver transplantation (LDLT) is complicated by the small size of the graft arteries. Inflow in these cases is usually achieved through the recipient right hepatic artery (RHA), left hepatic artery (LHA), or proper hepatic artery (PHA) to achieve a size-matched anastomosis.Subintimal dissection of the hepatic artery (SDA) can occur during recipient hepatectomy as a result of atherosclerotic recipient arteries, difficult hilar dissection in the setting of severe portal hypertension, or previous TACE. Alternate size-matched arteries in close vicinity of the liver graft are needed to complete arterial reconstruction. The proximal gastroduodenal artery (GDA), right gastroepiploic artery, left gastric artery, or splenic artery are the most common reported alternatives to deal with this problem. (1,2) We have used distal GDA inflow as the first choice for arterial reconstruction when there is extensive dissection of the common hepatic artery (CHA) extending proximal to the GDA. The technique is based on how SDA progresses and the ability of the distal GDA to provide sufficient arterial inflow through the pancreaticoduodenal arcade. We report our experience of using this novel technique in 9 patients undergoing LDLT who developed intraoperative SDA.

Distal Gastroduodenal Arterial Inflow as a Salvage Strategy for Extensive Intraoperative Arterial Dissectıon in Living Donor Liver Transplantation

“…We read with great interest the study by Cherukuru and colleagues (1) and the Letter to the Editor regarding this study by Bhatti and colleagues. (2) In these 2 studies, it is claimed that the distal gastroduodenal artery (GDA) can be used as a source of arterial inflow when the recipient artery has subintimal dissection (SDA).…”

Technique of Hepatic Artery Anastomosis in Living Donor Liver Transplantation: Review of Its Results in Over 1200 Adult and Pediatric Transplants

“…If there was any tension in the HA anastomosis due to short arterial stump in the graft or recipient, recipient's HA was mobilized completely from surrounding tissues that sometimes necessitated division of gastroduodenal artery (GDA) to achieve a good lie and the same technique of anastomosis was performed. When there was arterial dissection extending to common hepatic artery (CHA) and a good stump was not available for anastomosis, an alternative arterial inflow from GDA, left gastric artery (LGA) or infrarenal aorta was utilized with or without interposition cryopreserved artery graft [17]. When there were multiple arteries in the graft, the largest of the HAs was anastomosed first to recipient HA.…”