Hepatic artery stenosis angioplasty and implantation of Wingspan neurovascular stent: A case report and discussion of stenting in tortuous vessels

BACKGROUND Hepatic artery stenosis is a complication of orthotopic liver transplant occurring in 3.1%-7.4%of patients that can result in graft failure and need for retransplantation.Endovascular therapy with angioplasty and stenting has been used with a high degree of technical success and good clinical outcomes,but tortuous hepatic arteries present a unique challenge for intervention.Suitable stents for this application should be maneuverable and conformable while also exerting adequate radial force to maintain a patent lumen.CASE SUMMARY Herein we report our experience with a neurovascular Wingspan stent system in a challenging case of recurrent hepatic artery stenosis and discuss the literature of stenting in tortuous transplant hepatic arteries.CONCLUSION Wingspan neurovascular stent is self-expanding,has good conformability,and adequate radial resistance and as such it could be added to the armamentarium of interventionalists in the setting of a tortuous and stenotic transplant hepatic artery.

Safety and efficacy of an integrated endovascular treatment strategy for early hepatic artery occlusion after liver transplantation

Background:Hepatic artery occlusion(HAO)after liver transplantation(LT)is typically comprised of hepatic artery thrombosis(HAT)and stenosis(HAS),both of which are severe complications that coexist and interdependent.This study aimed to evaluate an integrated endovascular treatment(EVT)strategy for the resolution of early HAO and identify the risk factors associated with early HAO as well as the procedural challenge encountered in the treatment strategy.Methods:Consecutive orthotopic LT recipients(n=366)who underwent transplantation between June 2017 and December 2018 were retrospectively investigated.EVT was performed using an integrated strategy that involved thrombolytic therapy,shunt artery embolization plus vasodilator therapy,percutaneous transluminal angioplasty,and/or stent placement.Simple EVT was defined as the clinical resolution of HAO by one round of EVT with thrombolytic therapy and/or shunt artery embolization plus vasodilator therapy.Otherwise,it was defined as complex EVT.Results:Twenty-six patients(median age 52 years)underwent EVT for early HAO that occurred within 30 days post-LT.The median interval from LT to EVT was 7(6–16)days.Revascularization time(OR=1.027;95%CI:1.005–1.050;P=0.018)and the need for conduit(OR=3.558;95%CI:1.241–10.203,P=0.018)were independent predictors for early HAO.HAT was diagnosed in eight patients,and four out of those presented with concomitant HAS.We achieved 100%technical success and recanalization by performing simple EVT in 19 patients(3 HAT+/HAS-and 16 HAT-/HAS+)and by performing complex EVT in seven patients(1 HAT+/HAS-,4 HAT+/HAS+,and 2 HAT-/HAS+),without major complications.The primary assisted patency rates at 1,6,and 12 months were all 100%.The cumulative overall survival rates at 1,6,and 12 months were 88.5%,88.5%,and 80.8%,respectively.Autologous transfusion<600 mL(94.74%vs.42.86%,P=0.010)and interrupted suture for hepatic artery anastomosis(78.95%vs.14.29%,P=0.005)were more prevalent in simple EVT.Conclusions:The integrated EVT strategy was a feasible approach providing effective resolution with excellent safety for early HAO after LT.Appropriate autologous transfusion and interrupted suture technique helped simplify EVT.

Hepatic artery complications after orthotopic liver transplantation： interventional treatment or retransplantation？

Background The main therapeutic treatments for hepatic artery complications after orthotopic liver transplantation （OLT） include thrombolysis, percutaneous transluminal angioplasty, stent placement, and liver retransplantation. The prognosis of hepatic artery complications after OLT is not only related to the type, extent, and timing but also closely associated with the selection and timing of the therapeutic methods. However, there is no consensus of opinion regarding the treatment of these complications. The aim of this study was to determine optimal treatment for hepatic artery complications after OLT. Methods The clinical data of 25 patients diagnosed with hepatic artery thrombosis （HAT） and hepatic artery stenosis （HAS） between October 2003 and March 2007 were retrospectively reviewed. Treatments included liver retransplantation and interventions which contain thrombolysis, percutaneous transluminal angioplasty and stent placement. Results Among five patients with HAT, 3 were treated with thrombolysis. One recovered, one died after thrombolysis and another one died of multi-organ failure after retransplantation because of recurrent HAT. The remaining 2 patients underwent successful retransplantation and have survived after that. Among 12 patients presented with HAS within 1 month postoperatively, 2 patients underwent retransplantation due to irreversible liver failure and another 10 patients were treated with interventions. The liver function failed to improve in 3 patients and retransplantations were performed in 4 patients after stent placement because of ischemic cholangitis. Among 6 patients undergoing liver retransplantations, two died of intracranial hemorrhage and infection respectively. Eight patients presented with HAS after 1 month postoperatively, 5 patients were treated with interventional management and recovered after stent placement. Among another 3 patients presented with HAS, 2 patients’ liver function was stable and one patient received late liver retransplantation due to ischemic bile duct lesion. Conclusions Individualized therapeutic regimens should be adopted in treating hepatic artery complications after OLT, according to postoperative periods, types and whether ischemic bile duct lesion exists or not. Liver retransplantation is the best treatment for patients with hepatic artery thrombosis. Interventional treatments of late HAS without irreversible liver failure or bile duct ischemia are appropriate, whereas retransplantation is recommended for early HAS.