原位肝移植肝动脉并发症的预防和治疗

Prevention and treatment of hepatic artery complications in orthotopic liver transplantation

目的总结分析原位肝移植肝动脉重建及其并发症的防治经验,提高肝移植疗效和受体存活率。方法总结1995年5月至2005年4月实施的122例肝移植临床资料,肝动脉重建采用供者腹腔动脉干Carrell’s袖片或肝总动脉-脾动脉汇合部与受者肝左-右动脉汇合部袖片吻合21 (16．76％),与受者胃十二指肠-肝固有动脉汇合部吻合87例(71．76％),采用髂动脉-腹主动脉搭桥14例(11．48％)。术后根据凝血酶原时间(PT),应用普通肝素或低分子肝素预防性抗凝。术中、术后应用多普勒超声监测肝动脉血供。结果术后肝动脉血栓形成(HAT)3例,肝动脉狭窄(HAS)2例。1例HAT于术后19 d死于多器官功能衰竭,另4例通过放射介入治疗治愈。其余病例随访2～62个月,未见肝动脉血栓形成(HAT)和肝动脉狭窄(HAS)。本组肝动脉并发症发生率为4．10％。结论正确地选择肝动脉重建吻合的部位和术后有效的抗凝治疗可减少HAT和HAS的发生,多普勒超声监测能早期发现HAT和HAS,挽救移植物,避免再移植。

Objective To investigate the prevention and treatment of hepatic artery complications in orthotopic liver transplantation （OLT）. Methods The clinical data of 122 patients receiving OLT in our hospital from May 1995 to April 2005 were retrospectively analyzed. All the arterial reconstructions were performed with 6-0 polypropylene sutures in an interrupted fashion under a 3.5 magnification surgical loupe. The donor hepatic arteries were anastomosed at the origin of he celiac artery with a Carrel＇s patch or at the level of splenic artery confluence. The recipient branch-patch anastomoses were performed in 108 patients （88. 52 %）. The graft hepatic arteries were anastomosed using an interposition graft of donor artery in other 14 patients （11.48%）. Heparin or low-molecule-weight heparin as a prophylactic anticoagulation therapy was maintained during and after the operation if prothrombin time was less than 18 seconds. Follow-up Doppler ultrasonography was performed daily in the early postoperative stage. Results After a follow-up of 2-26 months, the overall incidence of hepatic artery complications was 4.10% （5/122）. Hepatic artery thrombosis （HAT） was found in 3 patients and hepatic artery stenosis （HAS） occurred in 2. Thrombolysis, balloon angioplasty and vascular stenting via hepatic artery were performed in them. One patient died of liver failure. The other 4 patients were successfully cured with patent flow. Conclusions HAT and HAS may be minimized by using recipient branch-patch anastomosis, donor interpositional jump graft for arterialization and postoperative anticoagulation. Close follow-up by Doppler ultrasonography may make a prompt diagnosis and reduce HAT-and HAS-derived loss of grafts.