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Excision and immediate revascularization for hepatic artery pseudoaneurysm following liver transplantation
Excision and Immediate Revascularization for Hepatic Artery Pseudoaneurysm Following Liver Transplantation C.A. Bonham, S. Kapur, D. Geller, J.J. Fung, and A. Pinna
V
ASCULAR complications following liver transplantation cause significant morbidity and mortality.1 Hepatic artery pseudoaneurysm (PA) is one such rare complication. It most frequently occurs in an infected field, and is thus usually treated by ligation.2,3 Recent evidence has shown an advantage of early revascularization of the liver for hepatic artery thrombosis.4,5 With this in mind, we have pursued an aggressive policy of excision and early revascularization for hepatic artery PA. MATERIALS AND METHODS Between December 1989 and December 1997, 2073 orthotopic liver transplants were performed at the University of Pittsburgh. Patient selection, organ procurement, recipient operation, and postoperative care were performed following routine protocols as described elsewhere. Immunosuppression was based on a standard protocol using tacrolimus and steroids. Fifteen patients were identified with 16 PA. Treatment was ligation or embolization, or excision and immediate revascularization with donor iliac artery or autogenous saphenous vein.
RESULTS
The most frequent presentation for hepatic artery PA was hemorrhage. Intra-abdominal or GI bleeding signaled the PA in 75% of patients. The remainder were diagnosed incidentally on routine radiologic exams. Thirteen of the 16 PAs developed in the presence of intra-abdominal infection. Twelve patients had bile leaks, and one had infectious pancreatitis. When infection was present, the PA presented within the first 2 months after transplantation. In contrast, late presentation was associated with a noninfectious etiology. Survival analysis revealed no significant differences between patients with infectious etiology and patients without infection. The only factor affecting survival was treatment. Seven patients underwent ligation or embolization. Five of these had concomitant infection. Six of the seven died of septic complications. The sole survivor had embolization of an intraparenchymal PA resulting from a liver biopsy. Eight patients were treated with excision and immediate
© 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
revascularization. Six of these patients had bile leaks leading to PA formation. One repair failed, necessitating ligation. This patient subsequently died. The remaining seven patients recovered and were discharged from the hospital with normal graft function. No patients treated in this fashion required retransplantation. Bile duct complications have not developed in the survivors. CONCLUSION
The best treatment for hepatic artery PA is an unsettled matter. Classic vascular surgery principles dictate against attempts to place a graft in an infected field. However, ligation carries the prospect of extremely high morbidity and mortality, especially early after transplantation. In contrast, 88% of patients treated by excision and immediate revascularization survived. Bile leaks were repaired at the time of arterial reconstruction. Excision and immediate revascularization appears to offer the best chance of survival, regardless of the presence of intra-abdominal infection. This treatment option should be attempted in all patients, with ligation used as a last resort. REFERENCES 1. Langnas AN, Marujo W, Stratta RJ, et al: Am J Surg 161:76, 1991 2. Madariaga J, Tzakis AG, Zajko AB, et al: Transplantation 54:824, 1992 3. Houssin D, Ortega D, Richardson A, et al: Transplantation 46:469, 1988 4. Pinna AD, Smith CV, Furukawa H, et al: Transplantation 62:1584, 1996 5. Langnas AN, Marujo W, Stratta RJ, et al: Transplantation 51:86, 1991 From the Thomas E. Starzl Transplantation Institute and the Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA (C.A.B., S.K., D.G., J.J.F.); and Department of Surgery, University of Miami, Miami, Florida, USA (A.P.). Address reprint requests to Dr C. Andrew Bonham, 4C Falk Clinic, 3601 5th Avenue, Pittsburgh, PA 15213.
0041-1345/99/$–see front matter PII S0041-1345(98)01698-4 443
Transplantation Proceedings, 31, 443 (1999)
V
ASCULAR complications following liver transplantation cause significant morbidity and mortality.1 Hepatic artery pseudoaneurysm (PA) is one such rare complication. It most frequently occurs in an infected field, and is thus usually treated by ligation.2,3 Recent evidence has shown an advantage of early revascularization of the liver for hepatic artery thrombosis.4,5 With this in mind, we have pursued an aggressive policy of excision and early revascularization for hepatic artery PA. MATERIALS AND METHODS Between December 1989 and December 1997, 2073 orthotopic liver transplants were performed at the University of Pittsburgh. Patient selection, organ procurement, recipient operation, and postoperative care were performed following routine protocols as described elsewhere. Immunosuppression was based on a standard protocol using tacrolimus and steroids. Fifteen patients were identified with 16 PA. Treatment was ligation or embolization, or excision and immediate revascularization with donor iliac artery or autogenous saphenous vein.
RESULTS
The most frequent presentation for hepatic artery PA was hemorrhage. Intra-abdominal or GI bleeding signaled the PA in 75% of patients. The remainder were diagnosed incidentally on routine radiologic exams. Thirteen of the 16 PAs developed in the presence of intra-abdominal infection. Twelve patients had bile leaks, and one had infectious pancreatitis. When infection was present, the PA presented within the first 2 months after transplantation. In contrast, late presentation was associated with a noninfectious etiology. Survival analysis revealed no significant differences between patients with infectious etiology and patients without infection. The only factor affecting survival was treatment. Seven patients underwent ligation or embolization. Five of these had concomitant infection. Six of the seven died of septic complications. The sole survivor had embolization of an intraparenchymal PA resulting from a liver biopsy. Eight patients were treated with excision and immediate
© 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
revascularization. Six of these patients had bile leaks leading to PA formation. One repair failed, necessitating ligation. This patient subsequently died. The remaining seven patients recovered and were discharged from the hospital with normal graft function. No patients treated in this fashion required retransplantation. Bile duct complications have not developed in the survivors. CONCLUSION
The best treatment for hepatic artery PA is an unsettled matter. Classic vascular surgery principles dictate against attempts to place a graft in an infected field. However, ligation carries the prospect of extremely high morbidity and mortality, especially early after transplantation. In contrast, 88% of patients treated by excision and immediate revascularization survived. Bile leaks were repaired at the time of arterial reconstruction. Excision and immediate revascularization appears to offer the best chance of survival, regardless of the presence of intra-abdominal infection. This treatment option should be attempted in all patients, with ligation used as a last resort. REFERENCES 1. Langnas AN, Marujo W, Stratta RJ, et al: Am J Surg 161:76, 1991 2. Madariaga J, Tzakis AG, Zajko AB, et al: Transplantation 54:824, 1992 3. Houssin D, Ortega D, Richardson A, et al: Transplantation 46:469, 1988 4. Pinna AD, Smith CV, Furukawa H, et al: Transplantation 62:1584, 1996 5. Langnas AN, Marujo W, Stratta RJ, et al: Transplantation 51:86, 1991 From the Thomas E. Starzl Transplantation Institute and the Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA (C.A.B., S.K., D.G., J.J.F.); and Department of Surgery, University of Miami, Miami, Florida, USA (A.P.). Address reprint requests to Dr C. Andrew Bonham, 4C Falk Clinic, 3601 5th Avenue, Pittsburgh, PA 15213.
0041-1345/99/$–see front matter PII S0041-1345(98)01698-4 443
Transplantation Proceedings, 31, 443 (1999)