Hepatic artery and biliary complications in liver transplant recipients undergoing pretransplant transarterial chemoembolization

Abstract

Liver transplantation (LT) is the treatment of choice for patients with cirrhosis and hepatocellular carcinoma (HCC) not amenable to resection. Locoregional therapies for HCC are often used to reduce tumor burden, bridge patients to LT, and down-stage HCC so that patients are eligible for LT. We hypothesized that prior endovascular antitumor therapy may increase the risk of hepatic artery (HA) and biliary complications after LT. The aim of this study was to compare HA and biliary complications in LT recipients with HCC who received transarterial chemoembolization (TACE) before LT with complications in LT recipients with HCC who did not receive TACE before LT. This was a retrospective cohort study of HCC patients at two transplant centers. The prevalence of HA complications (HA thrombosis, stenosis, or pseudoaneurysm) and biliary complications (nonanastomotic stricture, bile leak, and diffuse injury) were compared between patients treated with or without TACE. There were 456 HCC patients with a median age of 61 years (77% were male, and 63% had hepatitis C virus), and 328 (72%) received TACE before LT. The overall prevalence of HA complications was 4.7% in the no-TACE group and 7.9% in the TACE group (P = 0.22). All HA stenosis complications (n = 14) occurred in the TACE group (P = 0.018 versus the no-TACE group). An older donor age and a lower albumin level significantly increased the odds of HA complications. There was a nonstatistically significant increased odds of HA complications in the TACE group versus the no-TACE group according to an adjusted analysis (odds ratio = 2.02, 95% confidence interval = 0.79-5.16, P = 0.14). The overall prevalence of biliary complications was 16.4% in the no-TACE group and 19.8% in the TACE group (P = 0.40). In conclusion, a lower pre-LT albumin level and an older donor age were significantly associated with higher odds of HA complications after LT. TACE was not associated with higher odds of overall HA complications but was associated with a higher prevalence of HA stenosis. Further studies are warranted to confirm the HA stenosis findings and elucidate the pathogenesis.

Reply

“…However, the inclusion of 2 centers in our study improves the generalizability; the findings at each independent center are consistent with our overall findings. As reported in Table 2, 2 we did not find a significant association between the number of TACE procedures and the median number of days between last TACE and LT with respect to post-LT HA complications.…”

“…In our study, we report a 7.9% HA complication rate in patients treated with TACE and a 4.7% rate in the no-TACE group. 2 However, all HA stenosis events occurred in patients who had undergone TACE (P 5 0.018 versus the no-TACE group).…”

Strategies to improve outcome of patients with hepatocellular carcinoma receiving a liver transplantation

“…TACE is the most frequently used locoregional bridging therapy for LT. It has been hypothesized an increased risk of arterial and biliary complications after LT in patients with a previous TACE due to an endothelial damage, but this was not confirmed in a recent study with 456 HCC transplanted patients [88] . The use of TACE with drug eluting beads has improved the performance of the technique with complete tumour necrosis rates as high as 76.2%, and with a better safety profile [67,89] .…”

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“…Our goal for early TACE administration (< 7 days) before liver transplantation is to reduce tumor spread from intraoperative manipulation. 8,9 The rate of retransplantation is significantly higher in our TACE group, as the intimal injury is more severe and extends to the celiac trunk. Therefore, the need for retransplantation is greater than in patients without this intervention.…”