原位肝移植肝动脉重建临床分析

Hepatic artery reconstruction in orthotopic liver transplantation

目的总结分析原位肝移植肝动脉重建经验，提高肝移植疗效和受体存活率。方法总结1995年5月至2006年12月实施的183例肝移植临床资料，常规动脉重建163例，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．右动脉汇合部吻合25例，胃十二指肠．肝固有动脉汇合部吻合134例，腹腔动脉干吻合4例。采用髂动脉．腹主动脉搭桥20例。术后根据凝血酶原时间（胛），应用普通肝素或低分子肝素抗凝。术中、术后应用多普勒超声监测肝动脉血供。结果183例肝移植患者中有6例发生肝动脉并发症，发生率为3．28％（6／183），其中肝动脉血栓形成（hepatica artery thrombosis，HAT）5例，肝动脉狭窄（hepatic artery stenosis，HAS）1例。常规通路动脉重建组动脉并发症发生率1．84％（3／163），髂动脉-腹主动脉搭桥组为15．0％（3／20），两者比较差异有统计学意义（Х^2=9．73，P〈0．01）。6例并发症患者中有1例HAT于术后19d死于多器官功能衰竭，另5例通过介入治疗治愈，死亡率16．7％。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减少HAT和HAS的发生，多普勒超声的早期发现和放射介入的及时治疗可以挽救移植物，避免再移植。

Objective To summarize experience for hepatic artery reconstruction in orthotopic liver transplantation （OLT）. Method A retrospective analysis was made for 183 cases of orthotopic liver transplantation performed in our institute from May 1995 to december 2006. All the arterial reconstructions were performed with 6-0 polypropylene sutures in an interrupted fashion under a 3.5 magnification surgical loupe, Donor hepatic arteries were anastomosed at the origin of the celiac artery with a Carrel＇s patch or at the level of splenic artery confluence, Extra-anatomic arterial reconstruction was based on recipient aorta using donor iliac artery graft. OLT with routine anatomic arterial construction served as control. Heparin or low-molecule-weight heparin as a prophylactic anticoagulation therapy was maintained during and after operation if prothrombin time is less than eighteen seconds. Follow-up Doppler uhrasonography was used daily in the early postoperative period. Results Overall incidence of hepatic artery complications was 3.28%. Hepatic artery thrombosis （HAT） was observed in 5 cases. Hepatic artery stenosis（HAS） occurred in 1 patient. Routine anatomic arterial construction was performed in 89. 07% （163） of cases, and HAT developed in 3（ 1.84% ） cases. Extra-anatomic arterial reconstruction was carried out in 10. 93% （20） of the patients; the presence of HAT was identified in 3 （ 15. 0% ） cases （Х^2 = 9. 73,P 〈 0. 01 ）. Thrombolysis, balloon angioplasty, and vascular stenting via hepatic artery were performed, One patient suffering from identified hepatic artery thrombosis died of liver failure 19 days post-op. The other 5 patients were cured successfully with patent blood flow by interventional therapy, Mortality related to hepatic artery complication was 16. 7%, Conclusion HAT and HAS may be minimized by using gastroduodenal branch-patch anastomosis and postoperative anticoagulation, Close follow-up by Doppler ultrasonography helps to make a prompt diagnosis and reduce HAT- and HAS related graft loss.