原位肝移植术中肝动脉变异及术后肝动脉血栓形成的处理

Management of the problem related to the abnormal hepatic artery in orthotopic liver transplantation

目的 探讨肝移植术中肝动脉变异及术后肝动脉血栓形成的处理。方法 统计 2 0 0 0年 8月至 2 0 0 2年 1 2月期间进行肝移植术的 6 7例次供、受者肝动脉的变异情况 ;分析肝动脉的重建方式 ,探讨肝动脉变异与手术后肝动脉血栓形成的关系、肝动脉血栓形成的危险因素及肝动脉血栓形成后的处理。结果 6 7例次供者肝脏和 6 5例受者肝脏共出现肝动脉变异 1 2例次 ,发生频率最高的为右肝动脉起源于肠系膜上动脉 (5例 )及左肝动脉起源于胃左动脉 (3例 )。肝动脉的重建方式如下 :供者及受者肝总动脉与胃十二指肠动脉分叉处成型后吻合 5 8例 ;腹主动脉与肝动脉搭桥 2例 ;利用变异的肝动脉分支吻合 7例。手术后发生肝动脉血栓形成 3例 ,均经腹股沟处股动脉插管行肝动脉溶栓治疗 ,此 3例患者中死亡 1例。结论 避免变异的肝动脉损伤、选择适当的肝动脉吻合方式可以保证移植肝脏的动脉血供。肝动脉血栓形成与肝动脉变异无关。作为肝动脉血栓形成后的保守治疗方法 ,肝动脉内溶栓治疗有可能避免 2次移植。

Objective To investigate the incidence of anatomic variations of hepatic artery and the management of hepatic artery thrombosis (HAT) in orthotopic liver transplantation (OLT).Methods A consecutive series of 67 OLT was reported in 65 patients from Aug. 2000 to Dec. 2002. The variations of the hepatic artery, the relationship between the anomalous hepatic artery and HAT, the risk factors of HAT and the management of HAT after OLT were analyzed.Results Anomalous hepatic artery was found in 12 cases among 67 donors and 65 recipients. Anatomic variations of hepatic artery, most frequently observed, were the right hepatic artery originating from the superior mesenteric artery ( 7.5 %) and left hepatic artery originating from left gastric artery ( 4.5 %). Hepatic arterial anastomosis was variable and dependent on donor and recipient anatomy, arterial reconstruction was mainly of two types: the end-to-end anastomosis (58/67) and using the anomalous hepatic artery branch (7/67). Bypass between hepatic artery and aorta was used in 2 cases because of the hepatic artery occlusion in the recipient. Interrupted sutures of 7/0 polypropylene always were used. The diagnosis of HAT was made in 3/67 patients ( 4.48 %). All these 3 cases were not from the anomalous hepatic artery patients. Of the 3 cases of HAT receiving hepatic artery thrombolysis, one case died from the renal failure. HAT in 3 cases happened in the first 20 cases. Conclusions There was no increased incidence of hepatic artery complications in the presence of hepatic artery anomalies in the donor. Hepatic artery thrombolysis was a useful method for the HAT patients and it is possible to save the patient's life without retransplantation.