The Relevance of the Order of Revascularization in Liver Grafting

Abstract

A study was conducted comparing the effects of initial arterialization vs. initial portal revascularization in unstored warm ischemic (for 30 min) livers, livers stored for 4 hr at 0 degrees C in Collins solution and livers rendered warm ischemic for 1 hr before removal and replacement as autografts. All livers that received initial arterialization showed uniform diffuse perfusion, whereas those with initial portal perfusion were patchy and well perfused only in the right lobe. In the experimental animal, initial arterialization using an end-to-end method was much easier and required less retraction. The energy charge and ATP levels dropped sharply during brief warm ischemia but returned rapidly to normal on revascularization. Although the decline in energy charge was less in stored livers, the return to normal was slower and incomplete. Plasma levels of AST indicated much greater damage in the stored livers and were lowest in recipients in unstored livers that were arterialized first. After longer warm ischemia, energy charge values declined and only completely returned to 60% of preoperative values within 2 hr of grafting. Despite this, the survival rate of these animals was very poor and only one survived overnight. Seven of the 12 survived the procedure, but in five death occurred within 30 min of full revascularization. In this group, AST levels rose sharply after revascularization to a mean level of 1,000 U.(ABSTRACT TRUNCATED AT 250 WORDS)

The sequence of revascularization in liver transplantation: It does make a difference

“…In a prospective randomized study, Ducerf et al7 showed more stable hemodynamics (assessed by mean arterial pressure, central venous pressure, cardiac index, systemic vascular resistance, and pulmonary capillary pressure) and lower peak values of serum aspartate aminotransferase after IAR, compared to IPR. Similar to previous animal studies,1 they also observed a more homogenous graft reperfusion in the IAR group. No differences were found between the IAR and IPR group with respect to the intraoperative blood products required for transfusion or the use of antifibrinolytic drugs.…”

“…Various reperfusion protocols have been analyzed in 3 experimental studies, using different animal models 1–3. Hickman and Innes1 compared 2 sequential protocols in pigs: initial arterial revascularization (IAR) vs. initial portal revascularization (IPR). These investigators found better homogenous perfusion of the liver graft after IAR, compared to IPR.…”

Retrograde reperfusion via vena cava lowers the risk of initial nonfunction but increases the risk of ischemic-type biliary lesions in liver transplantation – a randomized clinical trial

“…Leukocyte accumulation in simultaneous reperfused sinusoids and postsinusoidal venuoles was decreased by 17% and 64%, respectively [21]. On the other hand, several clinical studies have shown an advantage for liver allografts being re‐arterialized before portal reperfusion [47–50]. One experimental study showed that the major part of reperfusion injury is constituted during the portal venous reperfusion and that this injury can be, at least partially, attenuated by initial arterial reperfusion [51].…”

Effect of early arterialization of the porcine liver allograft on reperfusion injury, hepatocellular injury, and endothelial cell dysfunction

“…However, several clinical and experimental studies have shown an advantage for liver allografts rearterialized before portal reperfusion. 4,7,8,13 In this study, we investigated the impact of the timing of rearterialization in liver transplantation using more sensitive parameters of injury, including markers of hepatocellular injury, reperfusion injury, and endothelial cell function.…”