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Managing Recipient Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation
Shaleen Agarwal1, Rajesh Dey1, Yuktansh Pandey1
1Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, New Delhi, India.
Insights
Hepatic artery intimal dissection (HAD) in liver transplants can be managed by using the dissected artery for anastomosis, especially when alternative inflow is unavailable. This technique shows low rates of post-transplant hepatic artery thrombosis.
Area of Science:
- Hepatology
- Transplantation Surgery
- Vascular Surgery
Background:
- Recipient hepatic artery intimal dissection (HAD) followed by hepatic artery thrombosis (HAT) is a critical complication in liver transplantation.
- Current management often involves alternative arterial inflow, which is not always feasible.
Purpose of the Study:
- To introduce a novel classification and surgical technique for managing HAD during living donor liver transplantation.
- To evaluate the efficacy of using the dissected hepatic artery for anastomosis in specific cases.
Main Methods:
- A new 4-type classification for HAD based on the longitudinal extent of intimal dissection.
- Surgical management tailored to dissection type, HA length, and inflow availability.
- A specific technique approximating intima to media with initial sutures for anastomosis using the dissected HA.
Main Results:
- Of 47 patients with HAD, 22 had type 2 dissection (other HA used), and 20 had major (type 3 or 4) dissection.
- The dissected HA was used for anastomosis in 9 patients (45% of major dissections), with only 1 developing postoperative HAT.
- Pre-existing portal vein thrombosis and prior transarterial embolization were identified as significant risk factors for HAD.
Conclusions:
- The described technique allows successful use of the dissected hepatic artery for anastomosis in liver transplantation.
- This approach offers a viable solution for HAD when alternative inflow is limited, achieving low thrombosis rates.
- Identifying risk factors like portal vein thrombosis can aid in preventing HAD.
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.
