Endovascular treatment of hepatic artery thrombosis following liver transplantation

Abstract

Summary Hepatic artery thrombosis (HAT) is the most frequent vascular complication following orthotopic liver transplantation. Urgent retransplantation has been considered as the mainstay therapy. Surgical revascularization is an effective alternative in asymptomatic patients. Endovascular therapies including intra‐arterial thrombolysis, percutaneous transluminal angioplasty (PTA), and stent placement have shown encouraging results in recent years; however, their use remains controversial because of potential risk of hemorrhage. Until June 2009, 69 cases were published in 16 reports describing therapeutic potential of endovascular modalities. Interventions were performed as early as within 4 h to as late as 120 days in patients ranging from 4 months to 64 years of age. Majority of published reports suggested the use of urokinase. Thrombolysis was successful in 47 out of 69 (68%) patients. Bleeding was the most common complication including fatal intra‐abdominal hemorrhage in three patients. Twenty‐nine out of 47 (62%) patients underwent further intervention in the form of PTA, stenting, or both. The follow‐up patency ranged from 1 month to 26 months. In conclusion, whenever possible, efforts should be made to rescue the liver grafts through urgent revascularization (surgical and/or endovascular) depending on patient’s condition and interventional expertise at the transplant center; reserving the option of retransplantation for failure, complications, and cases with severe clinical symptoms or allograft dysfunction.

Vascular complications following liver transplantation: A literature review of advances in 2015

“…Many studies show contradictory results [1,9,17,28,41] but, a metaanalysis on HAT found no significant difference with an incidence of 3.1% and 4.6% in LDLT and DDLT, respectively [28] . Furthermore, it was reported that arterial anastomosis with operation microscope or loupe mangnification did not show any difference in incidence HAT [9,17,28,41] . Late HAT shows a lower incidence, ranging from 1% to 25% [38,42] .…”

“…They reported that there were no differences in incidence among transplantation centers worldwide [2,28] . Median times to the occurrence detection of early and late HAT were respectively 6.9 postoperative days (range: 1-17.5) and 6 mo (range: 1.8-79 mo) [17] . In literature, it does not confirm that HAT incidence in LDLT is significantly lower or higher compared to HAT incidence in DDLT.…”

“…It has been classified, as described above, into two types depending on the time of pre sentation following OLT: Early HAT [within the first 30 d of liver transplantation (LT)] and late HAT (after 30 d of LT) [13,17,28] . The hepatic artery supplies the biliary tree of the transplant, explaining the high frequency of biliary complications in HAT (i.e., biliary ischemia, necrosis, stricture, sepsis) and eventually hepatic insufficiency and graft loss [31] .…”

Strategies to optimize the use of marginal donors in liver transplantation

“…Early HAT is generally related to technical problems and can have serious consequences [115] . Emergent interventions are usually needed with early HAT because of its related ischemia/necrosis of the bile duct system [114] . Although urgent re-transplantation is considered the main treatment for early HAT, endovascular interventions including percutaneous transluminal angioplasty (PTA), intra-arterial thrombolysis (IAT) in selective cases, and stent placement may be alternative treatments [117,118] .…”

“…HAT represents more than 50% of all arterial complications following LT and it is divided into early (< 4 wk from LT) and late HAT (> 4 wk from LT) [114][115][116] . Early HAT is generally related to technical problems and can have serious consequences [115] .…”