Managing Recipient Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation

Abstract

Recipient hepatic artery intimal dissection (HAD) followed by hepatic artery thrombosis (HAT) is a serious complication of liver transplantation. Once this is recognized intraoperatively, the accepted approach is to use an alternative arterial inflow, which may not be possible in all patients. We describe a new classification and technique for the management of HAD during living donor liver transplantation. On the basis of the longitudinal extent of intimal dissection, HAD was classified into 4 types. Management was based on the type of dissection, availability of an adequate length of hepatic artery (HA), and an alternate source of inflow. The dissected HA itself was used for arterial anastomosis in patients with preserved pulsatile flow in the dissected artery and a lack of an alternative source of arterial inflow. The technique of using the dissected artery was based on close approximation of the tunica intima to the media with the first 2 sutures of the arterial anastomosis. Of 47 (2.4%) patients who developed HAD, 22 (46.8%) had a type 2 dissection for whom the other (right or the left) undissected HA was used for the anastomosis, and 20 (42.6%) had major (type 3 or 4) dissection. The dissected artery was used for the anastomosis in 9 (45%) of these patients. Postoperative HAT developed in only 1 of 9 patients. Pre-existing portal vein thrombosis and prior transarterial embolization were found to be major risk factors for the development of HAD. Using the technique described, the dissected artery can be successfully used for a satisfactory HA anastomosis with low thrombosis rates.

Long-Term Suitability of Left Gastric Artery Inflow for Arterial Perfusion of Living Donor Right Lobe Grafts

“…Now, accumulated microvascular expertise allows for small donor artery reconstruction [ 2 , 4 , 7 ]. Supporting evidence from published case series shows that cumulative microvascular experience regardless of surgeon specialty reduces HAT rates [ 4 , 7 , 8 , 10 ].…”

“…RLDLT rates are rising, our technique is better, but graft HAT continues to challenge outcomes after living donation [ 10 , 18 ]. It is time that we consider and recommend an alternative technique to standard reconstruction with HAT complications and sequela that are irreversible even when salvage is successful.…”

“…Some assess intimal injury with severity grading at grafting to guide intimal repair. Other studies have also reported tacking or trimming surgical techniques for less severe hepatic artery injuries [ 10 ]. Agarwal et al report using the repaired dissected HA for primary anastomosis in 9 patients with moderate to severe ID at transplant.…”

“…Studies report partial or occlusive HAT complicating TACE treatment that may take six months for recanalization [ 12 – 14 ]. In addition to these pretransplant conditions, all recipients have slightly increased risk for HAT events during the acute recovery period with a transient hypercoagulable state [ 2 , 4 , 10 , 15 , 16 ]. Living donor graft recipient HAT and sequela ends with retransplant in 38.1% of those affected.…”

Technical Advancements in Living Donor Liver Transplant

“…TARE/TACE which have been linked to a higher incidence of hepatic arterial dissection. (38) Evolution of techniques to tackle hepatic arterial dissection have been described by Banshodani and Gupta (39,40). Gupta et al proposed a useful classification for hepatic arterial dissection that may be used as an aid to surgical management including at technique to approximate the dissected arterial intima to the media as a way of reversing dissection (40).…”