Repeated graft loss caused by recurrent hepatic artery thrombosis after liver transplantation

Abstract

Hepatic artery thrombosis (HAT) is a main cause of graft loss and patient mortality after orthotopic liver transplantation (OLT). Several surgical and nonsurgical risk factors have been associated with HAT. Retransplantation often is the only possible treatment for this complication; however, the incidence of recurrence of HAT after retransplantation and the underlying conditions of this occurrence have never been investigated. Of 629 consecutive recipients transplanted at a single institution, 24 underwent retransplantion for HAT: in 4 of them (16%), HAT recurred in the second graft; 3 of these patients lost their first graft because of late HAT, whereas another one lost 4 consecutive grafts for early HAT. Antiphospholipid syndrome and paroxysmal nocturnal hemoglobinuria were diagnosed in three and one of these patients, respectively. Recurrent HAT is an uncommon occurrence that, in our experience, was linked to specific thrombophilic conditions; careful screening of these disorders should be included in the pretransplant workup, and adequate prophylaxis is advisable. (Liver Transpl 2003;9:629-631.)H epatic artery thrombosis (HAT) is the main case of early graft loss after orthotopic liver transplantation (OLT), with an incidence rate ranging from 2% to 20% in the various series. Technical factors, such as hepatic artery diameter of less than 3 mm, placement of an iliac artery conduit, and bench reconstruction of anatomic abnormalities, were associated with the development of this complication. 1-3 Coagulation abnormalities that follow liver transplantation, such as the deficiency of protein C, protein S, or antithrombin III or the antiphospholipid syndrome were reported in the past as possible causes of thrombotic complications of the graft. [4][5][6][7] Retransplantation is a life-saving procedure in these circumstances; however, the incidence rate of the recurrence of HAT in consecutive grafts and its possible causes were never investigated. We report here on four cases of recurrent HAT leading to repeated graft loss and analyse the conditions underlying this unusual occurrence.

Can antiplatelet prophylaxis reduce the incidence of hepatic artery thrombosis after liver transplantation?

“…in 127 LTs, patient death (84 cases) or graft loss (43 cases) occurred in the first 30 postoperative days without evidence of HAT (median graft survival, 9 days; range, 0–30 days); 3 LTs were followed by HAT, in which a kinking of the hepatic artery was demonstrated (these complications were excluded from the analysis as they were considered the consequences of a technical failure); 10 LTs employed split‐liver grafts from cadaveric donor (split‐liver transplantation involves a higher risk of HAT)3; 2 LTs were performed on pediatric recipients (the incidence of HAT is significantly higher in pediatric LT)4; 3 LTs were performed on patients who were diagnosed with paroxysmal nocturnal hemoglobinuria after the loss of 3 consecutive grafts due to HAT5; and 1 LT involved arterial anastomosis done with a Gore‐Tex graft. The analysis therefore included 838 adult LTs with a median follow‐up of 1,704 days (range, 33–7,017 days) (Table 1).…”

Successful liver transplantation for Budd-Chiari syndrome in a patient with paroxysmal nocturnal hemoglobinuria treated with the anti-complement antibody eculizumab

“…Transjugular intrahepatic portosystemic shunts, surgical shunts, and liver transplantation may lead to transient improvement, but these modalities are ultimately unsuccessful because of ongoing hypercoagulability and recurrent thrombosis. The rare reports of outcomes in patients undergoing liver transplant for BCS secondary to PNH not only detail instances of recurrent BCS but also indicate the occurrence of early portal vein occlusion and hepatic artery thrombosis requiring retransplantation5–10 (Table 1). Given the high risk of thrombotic complications, most centers regard PNH as a contraindication to liver transplantation.…”

Successful Hepatoatrial Anastomosis During a Consecutive Liver Retransplant in the Same Patient Shows Good Long-Term Results: Case Report and 2-Year Follow-Up

“…Our clinical results are similar to those reported in the literature. [11][12][13] This patient was retransplanted almost 1 year from the previous liver retransplant. Influenced by experience coming from other centers, we postponed the liver retransplant by nearly half a year so as to achieve a better outcome.…”