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Contemporary Management of Median Arcuate Ligament in Liver Transplantation
Benoy I Babu1, Gabriel C Oniscu1
1Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
Abstract:
Median arcuate ligament (MAL) can impair arterial inflow during orthotopic liver transplantation (OLT). Furthermore, approaches to ensure optimal vascular inflow in the presence of MAL is not standardized.
Methods:
We undertook a systematic review according to the Cochrane systematic review protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We analyzed the incidence of MAL, investigations, treatment options, and potential complications associated with MAL intervention in patients undergoing OLT. After the exclusion criteria were implemented, the dataset from the final 21 manuscripts yielded 117 patients who underwent a liver transplant in the presence of MAL.
Results:
The incidence of MAL in patients undergoing OLT is between 1.6% and 12%. In 63.2% of cases, an open approach for MAL intervention was undertaken. Hepatic artery thrombosis developed in 17% (7) patients without MAL intervention versus 2.6% (2) after MAL intervention. Seven grafts (5.9%) were lost after OLT in patients with MAL. Three (3.9%) patients developed arterial stenosis post-MAL intervention.
Conclusions:
We propose an algorithm for intraoperative assessment and management of liver transplant arterial inflow in the presence of MAL based on the hepatic artery flow changes with respiration, following clamping of the recipient gastroduodenal artery. In the presence of a 30%-50% flow variation on respiration, the arterial inflow should be established preserving additional inflow from the recipient gastroduodenal artery. Consider an open MAL release if the flow remains insufficient. A poor arterial flow with no variation with respiration and lack of evidence of aortoiliac atherosclerosis indicates the need for arterial jump graft.
Insights
Median arcuate ligament (MAL) can complicate liver transplants. A systematic review found MAL intervention reduces hepatic artery thrombosis and graft loss, proposing a new management algorithm for optimal arterial inflow.
Area of Science:
- Hepatology
- Vascular Surgery
- Transplantation
Background:
- Median arcuate ligament (MAL) syndrome can compromise arterial blood flow during orthotopic liver transplantation (OLT).
- Standardized approaches for managing arterial inflow in OLT patients with MAL are lacking.
Purpose of the Study:
- To systematically review the incidence, investigation, and management of MAL in OLT.
- To propose an intraoperative algorithm for assessing and managing liver transplant arterial inflow in the presence of MAL.
Main Methods:
- Systematic review adhering to Cochrane and PRISMA guidelines.
- Analysis of 21 manuscripts involving 117 patients undergoing OLT with MAL.
- Evaluation of MAL incidence, interventions, and complications.
Main Results:
- MAL incidence in OLT ranges from 1.6% to 12%.
- Hepatic artery thrombosis occurred in 17% of patients without MAL intervention versus 2.6% post-intervention.
- Graft loss was 5.9% in patients with MAL; arterial stenosis occurred in 3.9% post-intervention.
Conclusions:
- MAL intervention is associated with reduced hepatic artery thrombosis and graft loss in OLT.
- A proposed algorithm guides intraoperative assessment and management of arterial inflow based on hepatic artery flow dynamics.
- The algorithm suggests preserving gastroduodenal artery inflow or considering MAL release/arterial jump graft based on flow variations.
