Complications After Endovascular Treatment of Hepatic Artery Stenosis Following Liver Transplantation
Leighton E Goldsmith, J Seal, C Brinster, T A Smith, H A Bazan, W C Sternbergh, III
Ochsner Clinic Foundation, New Orleans, LA
BACKGROUND Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis and a subsequent 30-50% risk of graft loss. Endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment. However, these complex interventions are not risk-free.
METHODS A retrospective review of all patients undergoing angiography and possible intervention for HAS after liver transplantation between 9/2009 - 3/2016 was performed at a single institution which has the largest US volume of liver transplantation since 2011. Severe HAS was identified by routine duplex surveillance (PSV >400-450 cm/s, resistive Index <0.5 and + tarvus parvus waveforms) and frequently confirmed with CTA. A Student t-test was performed to compare continuous variables and the Fisher’s exact test was performed for categorical variables.
RESULTS In 1,085 liver transplant recipients during the study period, 107 angiograms were performed in 79 patients (7.3%) for severe de-novo or recurrent HAS. The mean recipient age was 51.6±12.2 yr. The median time to vascular intervention from liver transplant was 71 days (range 5 days to 45 months). Interventions were performed in 100/107 (93.5%) of these cases, either with PTA alone (33/100) or with stent placement (65/100). Immediate technical success was 90%. Major complications occurred in 8/107 (7.5%) cases, consisting of target vessel dissection (6/8) or rupture (2/8). For these major complications, successful acute endovascular treatment was possible in 7/8 (87.5%) patients. Ruptures were treated with covered stent placement (2.5-3mm Jomed) or balloon tamponade, while dissections were treated with bare metal or drug-eluting stents (typically coronary balloon-expandable). No open surgical intervention was required to manage any of these complications. In follow-up, 4/8 (50%) patients progressed to hepatic artery thrombosis, compared to 1/70 (1.4%) in patients undergoing intervention without a major complication P< 0.001). One patient required re-transplantation. Severe vessel tortuosity was present in 5/8 (62.5%) of interventions with a major complication compared to 34/99 (34.3%) in those without (p = 0.137).
CONCLUSIONS While endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery may be a risk factor for such complications. Vessel injury can be acutely managed successfully using endovascular techniques, however, these patients have a significant risk of subsequent hepatic artery thrombosis and need close surveillance. Advanced endovascular skills and immediate availability of rescue devices are essential for good outcomes.
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