Retransplantation in Late Hepatic Artery Thrombosis: Graft Access and Transplant Outcome

Abstract

BackgroundDefinitive treatment for late hepatic artery thrombosis (L-HAT) is retransplantation (re-LT); however, the L-HAT–associated disease burden is poorly represented in allocation models.MethodsGraft access and transplant outcome of the re-LT experience between 2005 and 2016 was reviewed with specific focus on the L-HAT cohort in this single-center retrospective study.ResultsNinety-nine (5.7%) of 1725 liver transplantations were re-LT with HAT as the main indication (n = 43; 43%) distributed into early (n = 25) and late (n = 18) episodes. Model for end-stage liver disease as well as United Kingdom model for end-stage liver disease did not accurately reflect high disease burden of graft failure associated infections such as hepatic abscesses and biliary sepsis in L-HAT. Hence, re-LT candidates with L-HAT received low prioritization and waited longest until the allocation of an acceptable graft (median, 103 days; interquartile range, 28-291 days), allowing for progression of biliary sepsis. Balance of risk score and 3-month mortality score prognosticated good transplant outcome in L-HAT but, contrary to the prediction, the factual 1-year patient survival after re-LT was significantly inferior in L-HAT compared to early HAT, early non-HAT and late non-HAT (65% vs 82%, 92% and 95%) which was mainly caused by sepsis and multiorgan failure driving 3-month mortality (28% vs 11%, 16% and 0%). Access to a second graft after a median waitlist time of 6 weeks achieved the best short- and long-term outcome in re-LT for L-HAT (3-month mortality, 13%; 1-year survival, 77%).ConclusionsInequity in graft access and peritransplant sepsis are fundamental obstacles for successful re-LT in L-HAT. Offering a graft for those in need at the best window of opportunity could facilitate earlier engrafting with improved outcomes.

Ischemic Cholangiopathy 11 Years after Liver Transplantation from Asymptomatic Chronic Hepatic Artery Thrombosis

“…One of the most concerning complications is hepatic artery thrombosis (HAT), which is the most common complication necessitating repeat transplanation. 1 HAT is of greatest concern in the immediate transplant setting because it often presents with ischemia and necrosis. Early and late HAT are differentiated by a cutoff of 21 days.…”

Selective retransplantation after late hepatic artery thrombosis

“…An appropriate treatment should first be applied, improving the recipient's condition or revealing those definitively unfit for retransplantation . Conversely, a (too) long waiting time before retransplantation exposes the recipient to the risk of multidrug‐resistant infection and death . In the present series, patients with liver abscess were managed during the waiting period.…”

“…Waiting time until retransplantation is key in the management of patients with HAT, and those with L‐HAT usually wait longer than those with early HAT . This observation is linked to the absence of rescue strategies for L‐HAT within most MELD‐based systems.…”

“…MELD score and the presence of multidrug‐resistant infection predict waiting list and post‐retransplant deaths . Keeping these data in mind, one can draw a window for relisting/retransplanting patients with L‐HAT .…”

“…Keeping these data in mind, one can draw a window for relisting/retransplanting patients with L‐HAT . Some suggest that a median waiting time of 6 weeks leads to the best short‐ and long‐term outcomes . At the time of L‐HAT diagnosis, a biliary infection is often present, leading to poor potential outcomes after a (too) early retransplantation.…”