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Anastomosis of the Common Hepatic Artery and Round Ligament as Portal Vein Arterialization for Hepatic Artery Occlusion After Deceased Donor Liver Transplantation: A Case Report
Anastomosis of the Common Hepatic Artery and Round Ligament as Portal Vein Arterialization for Hepatic Artery Occlusion After Deceased Donor Liver Transplantation: A Case Report Shohei Yoshiya*, Tomoharu Yoshizumi, Norifumi Iseda, Kazuki Takeishi, Takeo Toshima, Yoshihiro Nagao, Shinji Itoh, Noboru Harada, Toru Ikegami, and Masaki Mori Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
ABSTRACT Background. Hepatic artery occlusion (HAO) is a life-threatening complication after liver transplantation. We report a case of portal vein arterialization (PVA) with anastomosis of the recipient common hepatic artery (CHA) and a graft of the round ligament to achieve intrahepatic arterial flow. Case presentation. A 57-year-old man had a medical history of decompensated liver cirrhosis secondary to cholestatic liver disease owing to biliary anastomotic stricture after living donor liver transplantation and end-stage renal failure. He underwent deceased donor liver and renal transplantation with anastomosis of the recipient proper hepatic artery and the graft CHA. He experience symptoms from HAO on postoperative day 23 and underwent emergency surgery to re-anastomose the hepatic artery. Despite several instances of re-anastomoses, intrahepatic arterial flow was not able to be achieved and therefore PVA with anastomosis of the recipient CHA and the graft round ligament was performed. Although liver enzyme levels rapidly declined after surgery and the finding of liver infarction was not observed, a large amount of watery stool was observed owing to portal hypertension, which was an adverse effect of PVA. As enhanced computed tomography on POD 31 showed a pseudoaneurysm of the anastomotic site, occlusion with coils was performed to arrest hemorrhage, and a contrast study after coil occlusion showed intrahepatic arterial blood flow via collateral arteries. Thereafter, the patient needed treatment for ischemic biliary duct stenosis and was discharged home on POD 98. Conclusion. PVA using a round ligament for HAO after liver transplantation might play a role as a bridge treatment until retransplantation or maturation of collaterals.
H
EPATIC artery occlusion (HAO) is a life-threatening complication after liver transplantation (LT), and it can lead to early graft loss or bile duct necrosis with or without
This study was supported by Japan Society for the Promotion of Science KAKENHI (grant number JP18K08619). The funding source had no role in the collection, analysis, or interpretation of the data, or in the decision to submit the article for publication. *Address correspondence to Shohei Yoshiya, Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 8128582, Japan. Tel: þ81-92-642-5466; fax: þ81-92-642-5482. E-mail: [email protected] ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
severe sepsis [1]. Therefore, early recanalization of arterial flow, such as surgical anastomotic revision, is required in patients with HAO to prevent the undesirable effects of arterial blood flow deficiency. We report a case of portal vein arterialization (PVA) with anastomosis of the recipient common hepatic artery (CHA) and a graft of the round ligament to achieve intrahepatic arterial flow for HAO after LT. CASE REPORT The patient was a 57-year-old man with decompensated liver cirrhosis secondary to cholestatic liver disease due to biliary anastomotic stricture. He had started dialysis for end-stage renal failure 4 months previously. He had undergone living donor LT for liver cirrhosis due to 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.12.003
1
2
YOSHIYA, YOSHIZUMI, ISEDA ET AL
hepatitis C virus and hepatocellular carcinoma with a right lobe graft donated from his brother 11 years previously. He underwent deceased donor liver and renal transplantation, and hepatic artery reconstruction was performed with anastomosis of the recipient proper hepatic artery and the graft CHA. On postoperative day (POD) 7, he experienced acute peritonitis due to transverse colon perforation and underwent colostomy. Drain management was continued. On POD 23, a blood test showed marked elevation of liver enzymes as follows: an aspartate aminotransferase level of 615 U/L and an alanine aminotransferase level of 368 U/L. Moreover, intrahepatic artery flow could not be detected with Doppler ultrasonography and enhanced computed tomography. Therefore, emergency angiography was performed. Imaging findings showed disruption of arterial flow in the CHA (Fig 1A) and led to a diagnosis of HAO. Emergency surgery to re-anastomose the hepatic artery was performed. However, intrahepatic arterial flow was not able to be achieved, probably because of intrahepatic arterial dissection, despite several times of re-anastomoses. As a result, PVA with
anastomosis of the recipient CHA and a graft of the round ligament was performed to achieve intrahepatic arterial flow in an act of desperation (Fig 1C and 1D). The patient’s postoperative course is shown in Fig 2. Liver enzyme levels rapidly declined after surgery, and the finding of liver infarction was not observed. However, because a large amount of watery stomal drainage was observed owing to portal hypertension, which was an adverse effect of PVA, strict water and electrolyte control was important. On POD 31, sudden and massive bloody drainage was detected, and enhanced computed tomography showed a pseudoaneurysm of the anastomotic site. Emergency angiography was performed, and occlusion of the pseudoaneurysm with coils was performed to arrest the hemorrhage and to rescue the patient. Surprisingly, a contrast study after coil occlusion showed intrahepatic arterial blood flow via collateral arteries (Fig 1B). Four days after the second angiography, the amount of stomal drainage was decreased, and solid stool was observed. Thereafter, treatment
A
D
B
E
Graft round ligament
CHA Main PV Aorta
F
C Graft round ligament
Intrahepatic artery
Recipient CHA
CHA
Fig 1. (A) Angiography shows disruption of arterial flow in the common hepatic artery (CHA), which led to the diagnosis of hepatic artery occlusion. (B) Schema of anastomosis of the recipient CHA and the graft round ligament. (C) Intraoperative findings. Anastomosis of the recipient CHA and the graft round ligament was performed as portal vein arterialization. Intraoperative Doppler ultrasound (right inserts) shows arterial flow in the round ligament and portal vein. (D and E) Computed tomography findings after anastomosis of the recipient CHA and the graft round ligament. White arrow indicates CHA and black arrow indicates the graft round ligament. White arrowheads indicate portal vein in the left lobe and black arrowhead indicates portal vein in the right lobe in the early phase. (F) Angiography after coil occlusion of a pseudoaneurysm. Arterial flow via the CHA round ligament was interrupted with coils. Arrowheads indicate intrahepatic arterial flow via collateral arteries.
ANASTOMOSIS OF COMMON HEPATIC ARTERY
3
Fig 2. Postoperative course after emergency surgery. Liver enzymes rapidly declined after surgery. There was a large amount of watery stomal drainage after surgery, but the amount of stomal drainage decreased, and solid stool was observed after endovascular treatment. The patient was discharged home on postoperative day 98 after treatment for ischemic biliary duct strictures. ALT, alanine aminotransferase; AST, aspartate aminotransferase. for ischemic biliary duct stenosis was required, but the patient was discharged home on POD 98 after PVA.
DISCUSSION
PVA is a salvage technique used in a de-arterialized liver to achieve arterial flow only if all other possible strategies for reconstruction of the artery have been ruled out [2]. PVA increases portal venous oxygen saturation and prevents hepatic infarction and biliary duct ischemia because of anastomoses of the terminal portal vein and the arterial peribiliary plexus [3]. With regard to PVA for HAO in LT, Bhangui et al [3] described the following types of PVA methods: the right gastroepiploic artery to the right gastroepiploic vein; the hepatic artery to the portal vein; the left colic artery to the left colic vein; an arterioportal shunt in the mesenteric vascular branches; the gastroduodenal artery to the portal vein; the left genital artery to the inferior mesenteric vein; and the right iliac artery to the superior mesenteric vein. To the best of our knowledge, there have been no reports on PVA using a round ligament graft. Adverse effects of PVA are portal hypertension-related complications, such as refractory ascites, intra-abdominal or variceal bleeding, PVA shunt thrombosis due to insufficient inflow, and aneurysmal dilatation of portal branches. We previously used an opened round ligament as a patch graft in all-in-one venoplasty for a right lobe graft in living donor LT, and we reported the safety and efficacy of the round ligament in venoplasty [4]. Cross-sectional images of the round ligaments from donors in our previous study [5] showed that approximately one-third of the round ligaments in adults contained an open umbilical vein. CD31 immunohistochemical staining showed that the open umbilical vein was backed by endothelial cells. This finding suggests that the round ligament contains an open umbilical vein that can be used as a temporary vascular graft until
retransplantation or maturation of the collateral arteries in case of HAO after LT. Moreover, regarding the technical aspects, mobility of the round ligament can be modulated to some extent by disbranching several Glissonean branches. Therefore, anastomosis with a round ligament might be easier if there are severe inflammatory changes around the recipient hepatic artery. In conclusion, we report the first case of PVA using a round ligament for HAO after LT. Use of this method might play a role as a bridge treatment until retransplantation or maturation of collaterals. ACKNOWLEDGMENT We thank Ellen Knapp, PhD, from Edanz Group (www. edanzediting.com/ac) for editing a draft of this manuscript.
REFERENCES [1] Bekker J, Ploem S, de Jong KP. Early hepatic artery thrombosis after liver transplantation: a systematic review of the incidence, outcome and risk factors. Am J Transplant 2009;9: 746e57. [2] Iseki J, Touyama K, Noie T, Nakagami K, Takagi M, Hakamada K, et al. Partial portal arterialization for the prevention of massive liver necrosis following extended pancreatobiliary surgery: experience of two cases. Surg Today 1992;22:568e71. [3] Bhangui P, Salloum C, Lim C, Andreani P, Ariche A, Adam R, et al. Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience. HPB (Oxford) 2014;16:723e38. [4] Toshima T, Yoshizumi T, Shimokawa M, Ikegami T, Harada N, Itoh S, et al. Feasibility of all-in-one venoplasty with a venous cuff using an opened round ligament for the right lobe graft in living donor liver transplantation. Liver Transpl 2019;25:171e5. [5] Ikegami T, Wang H, Imai D, Bekki Y, Yoshizumi T, Yamashita Y, et al. Pathological analysis of opened round ligaments as venous patch grafts in living donor liver transplantation. Liver Transpl 2013;19:1245e51.
ABSTRACT Background. Hepatic artery occlusion (HAO) is a life-threatening complication after liver transplantation. We report a case of portal vein arterialization (PVA) with anastomosis of the recipient common hepatic artery (CHA) and a graft of the round ligament to achieve intrahepatic arterial flow. Case presentation. A 57-year-old man had a medical history of decompensated liver cirrhosis secondary to cholestatic liver disease owing to biliary anastomotic stricture after living donor liver transplantation and end-stage renal failure. He underwent deceased donor liver and renal transplantation with anastomosis of the recipient proper hepatic artery and the graft CHA. He experience symptoms from HAO on postoperative day 23 and underwent emergency surgery to re-anastomose the hepatic artery. Despite several instances of re-anastomoses, intrahepatic arterial flow was not able to be achieved and therefore PVA with anastomosis of the recipient CHA and the graft round ligament was performed. Although liver enzyme levels rapidly declined after surgery and the finding of liver infarction was not observed, a large amount of watery stool was observed owing to portal hypertension, which was an adverse effect of PVA. As enhanced computed tomography on POD 31 showed a pseudoaneurysm of the anastomotic site, occlusion with coils was performed to arrest hemorrhage, and a contrast study after coil occlusion showed intrahepatic arterial blood flow via collateral arteries. Thereafter, the patient needed treatment for ischemic biliary duct stenosis and was discharged home on POD 98. Conclusion. PVA using a round ligament for HAO after liver transplantation might play a role as a bridge treatment until retransplantation or maturation of collaterals.
H
EPATIC artery occlusion (HAO) is a life-threatening complication after liver transplantation (LT), and it can lead to early graft loss or bile duct necrosis with or without
This study was supported by Japan Society for the Promotion of Science KAKENHI (grant number JP18K08619). The funding source had no role in the collection, analysis, or interpretation of the data, or in the decision to submit the article for publication. *Address correspondence to Shohei Yoshiya, Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 8128582, Japan. Tel: þ81-92-642-5466; fax: þ81-92-642-5482. E-mail: [email protected] ª 2020 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e3 (2020)
severe sepsis [1]. Therefore, early recanalization of arterial flow, such as surgical anastomotic revision, is required in patients with HAO to prevent the undesirable effects of arterial blood flow deficiency. We report a case of portal vein arterialization (PVA) with anastomosis of the recipient common hepatic artery (CHA) and a graft of the round ligament to achieve intrahepatic arterial flow for HAO after LT. CASE REPORT The patient was a 57-year-old man with decompensated liver cirrhosis secondary to cholestatic liver disease due to biliary anastomotic stricture. He had started dialysis for end-stage renal failure 4 months previously. He had undergone living donor LT for liver cirrhosis due to 0041-1345/20 https://doi.org/10.1016/j.transproceed.2019.12.003
1
2
YOSHIYA, YOSHIZUMI, ISEDA ET AL
hepatitis C virus and hepatocellular carcinoma with a right lobe graft donated from his brother 11 years previously. He underwent deceased donor liver and renal transplantation, and hepatic artery reconstruction was performed with anastomosis of the recipient proper hepatic artery and the graft CHA. On postoperative day (POD) 7, he experienced acute peritonitis due to transverse colon perforation and underwent colostomy. Drain management was continued. On POD 23, a blood test showed marked elevation of liver enzymes as follows: an aspartate aminotransferase level of 615 U/L and an alanine aminotransferase level of 368 U/L. Moreover, intrahepatic artery flow could not be detected with Doppler ultrasonography and enhanced computed tomography. Therefore, emergency angiography was performed. Imaging findings showed disruption of arterial flow in the CHA (Fig 1A) and led to a diagnosis of HAO. Emergency surgery to re-anastomose the hepatic artery was performed. However, intrahepatic arterial flow was not able to be achieved, probably because of intrahepatic arterial dissection, despite several times of re-anastomoses. As a result, PVA with
anastomosis of the recipient CHA and a graft of the round ligament was performed to achieve intrahepatic arterial flow in an act of desperation (Fig 1C and 1D). The patient’s postoperative course is shown in Fig 2. Liver enzyme levels rapidly declined after surgery, and the finding of liver infarction was not observed. However, because a large amount of watery stomal drainage was observed owing to portal hypertension, which was an adverse effect of PVA, strict water and electrolyte control was important. On POD 31, sudden and massive bloody drainage was detected, and enhanced computed tomography showed a pseudoaneurysm of the anastomotic site. Emergency angiography was performed, and occlusion of the pseudoaneurysm with coils was performed to arrest the hemorrhage and to rescue the patient. Surprisingly, a contrast study after coil occlusion showed intrahepatic arterial blood flow via collateral arteries (Fig 1B). Four days after the second angiography, the amount of stomal drainage was decreased, and solid stool was observed. Thereafter, treatment
A
D
B
E
Graft round ligament
CHA Main PV Aorta
F
C Graft round ligament
Intrahepatic artery
Recipient CHA
CHA
Fig 1. (A) Angiography shows disruption of arterial flow in the common hepatic artery (CHA), which led to the diagnosis of hepatic artery occlusion. (B) Schema of anastomosis of the recipient CHA and the graft round ligament. (C) Intraoperative findings. Anastomosis of the recipient CHA and the graft round ligament was performed as portal vein arterialization. Intraoperative Doppler ultrasound (right inserts) shows arterial flow in the round ligament and portal vein. (D and E) Computed tomography findings after anastomosis of the recipient CHA and the graft round ligament. White arrow indicates CHA and black arrow indicates the graft round ligament. White arrowheads indicate portal vein in the left lobe and black arrowhead indicates portal vein in the right lobe in the early phase. (F) Angiography after coil occlusion of a pseudoaneurysm. Arterial flow via the CHA round ligament was interrupted with coils. Arrowheads indicate intrahepatic arterial flow via collateral arteries.
ANASTOMOSIS OF COMMON HEPATIC ARTERY
3
Fig 2. Postoperative course after emergency surgery. Liver enzymes rapidly declined after surgery. There was a large amount of watery stomal drainage after surgery, but the amount of stomal drainage decreased, and solid stool was observed after endovascular treatment. The patient was discharged home on postoperative day 98 after treatment for ischemic biliary duct strictures. ALT, alanine aminotransferase; AST, aspartate aminotransferase. for ischemic biliary duct stenosis was required, but the patient was discharged home on POD 98 after PVA.
DISCUSSION
PVA is a salvage technique used in a de-arterialized liver to achieve arterial flow only if all other possible strategies for reconstruction of the artery have been ruled out [2]. PVA increases portal venous oxygen saturation and prevents hepatic infarction and biliary duct ischemia because of anastomoses of the terminal portal vein and the arterial peribiliary plexus [3]. With regard to PVA for HAO in LT, Bhangui et al [3] described the following types of PVA methods: the right gastroepiploic artery to the right gastroepiploic vein; the hepatic artery to the portal vein; the left colic artery to the left colic vein; an arterioportal shunt in the mesenteric vascular branches; the gastroduodenal artery to the portal vein; the left genital artery to the inferior mesenteric vein; and the right iliac artery to the superior mesenteric vein. To the best of our knowledge, there have been no reports on PVA using a round ligament graft. Adverse effects of PVA are portal hypertension-related complications, such as refractory ascites, intra-abdominal or variceal bleeding, PVA shunt thrombosis due to insufficient inflow, and aneurysmal dilatation of portal branches. We previously used an opened round ligament as a patch graft in all-in-one venoplasty for a right lobe graft in living donor LT, and we reported the safety and efficacy of the round ligament in venoplasty [4]. Cross-sectional images of the round ligaments from donors in our previous study [5] showed that approximately one-third of the round ligaments in adults contained an open umbilical vein. CD31 immunohistochemical staining showed that the open umbilical vein was backed by endothelial cells. This finding suggests that the round ligament contains an open umbilical vein that can be used as a temporary vascular graft until
retransplantation or maturation of the collateral arteries in case of HAO after LT. Moreover, regarding the technical aspects, mobility of the round ligament can be modulated to some extent by disbranching several Glissonean branches. Therefore, anastomosis with a round ligament might be easier if there are severe inflammatory changes around the recipient hepatic artery. In conclusion, we report the first case of PVA using a round ligament for HAO after LT. Use of this method might play a role as a bridge treatment until retransplantation or maturation of collaterals. ACKNOWLEDGMENT We thank Ellen Knapp, PhD, from Edanz Group (www. edanzediting.com/ac) for editing a draft of this manuscript.
REFERENCES [1] Bekker J, Ploem S, de Jong KP. Early hepatic artery thrombosis after liver transplantation: a systematic review of the incidence, outcome and risk factors. Am J Transplant 2009;9: 746e57. [2] Iseki J, Touyama K, Noie T, Nakagami K, Takagi M, Hakamada K, et al. Partial portal arterialization for the prevention of massive liver necrosis following extended pancreatobiliary surgery: experience of two cases. Surg Today 1992;22:568e71. [3] Bhangui P, Salloum C, Lim C, Andreani P, Ariche A, Adam R, et al. Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience. HPB (Oxford) 2014;16:723e38. [4] Toshima T, Yoshizumi T, Shimokawa M, Ikegami T, Harada N, Itoh S, et al. Feasibility of all-in-one venoplasty with a venous cuff using an opened round ligament for the right lobe graft in living donor liver transplantation. Liver Transpl 2019;25:171e5. [5] Ikegami T, Wang H, Imai D, Bekki Y, Yoshizumi T, Yamashita Y, et al. Pathological analysis of opened round ligaments as venous patch grafts in living donor liver transplantation. Liver Transpl 2013;19:1245e51.