Outflow reconstruction with arterial patch in domino liver transplantation: a new technical option

Domino liver transplantation（LT）, using livers from familial amyloidotic polyneuropathy（FAP） patients, is a well described technique useful to expand donor pool. One of the main difficulties of this type of LT arises from the necessity to share the vascular pedicles between the graft and the donor. The most important challenge resides in restoring a proper hepatic venous outflow in the FAP-liver recipient.This is specially challenging when using the piggy-back technique, because the hepatic stumps may be too short. To overcome this issue, surgeons explored several techniques using different types of venous grafts. We describe a new technical option by using an arterial graft from the deceased donor. By using both iliac arteries a long graft is created and sutured as needed to the hepatic vein stump. We describe herein this new technique employed in a domino liver recipient who underwent retransplantation for ischemic cholangitis. The procedure was performed using the piggy-back technique; the venous stump of the FAP liver was reconstructed with the arterial graft. The patient had uneventful postoperative and mid-term hepatic function, and anastomosis was patent 24 months after LT.

Efficacy and safety of low-dose aspirin on preventing transplant renal artery stenosis: a prospective randomized controlled trial

Background:Transplant renal artery stenosis(TRAS)is a vascular complication after kidney transplantation associated with poor outcomes.This study aimed to analyze the efficacy and safety of low-dose aspirin for preventing TRAS.Methods:After kidney transplantation,patients were enrolled from January 2018 to December 2020 in Henan Provincial People’s Hospital.A total of 351 enrolled recipients were randomized to an aspirin group with low-dose intake of aspirin in addition to standard treatment(n=178),or a control group with only standard treatment(n=173).The patients was initially diagnosed as TRAS(id-TRAS)by Doppler ultrasound,and confirmed cases were diagnosed by DSA(c-TRAS).Results:In the aspirin and control groups,15.7%(28/178)and 22.0%(38/173)of the recipients developed id-TRAS,respectively,with no statistical difference.However,for c-TRAS,the difference of incidence and cumulative incidence was statistically significant.The incidence of c-TRAS was lower in the aspirin group compared with the control group(2.8%[5/178]vs.11.6%[20/173],P=0.001).Kaplan–Meier estimates and Cox regression model identified the cumulative incidence and hazard ratio(HR)of TRAS over time in two groups,showing that recipients treated with aspirin had a significantly lower risk of c-TRAS than those who were not treated(log-rank P=0.001,HR=0.23,95%confidence interval[CI]:0.09–0.62).The levels of platelet aggregation rate(P<0.001),cholesterol(P=0.028),and low-density lipoprotein cholesterol(P=0.003)in the aspirin group were decreased compared with the control group in the third-month post-transplantation.For the incidence of adverse events,there was no statistical difference.Conclusion:Clinical application of low-dose aspirin after renal transplant could prevent the development of TRAS with no significant increase in adverse effects.Trial Registration:Clinicaltrials.gov,NCT04260828.

Compensatory enlargement in transplant coronary artery disease: an intravascular ultrasound study

Background It is unclear to what extent the ＂Glagov phenomenon＂ occurs in transplant coronary artery disease （TCAD）. The objective of this study was to evaluate the relationship between intimal hyperplasia and compensatory enlargement in TCAD. Methods Intravascular ultrasound imaging was performed on 190 cardiac transplant recipients at （1.4±0.6） months and again （12.1±0.7） months after cardiac transplantation. Studies 1 year apart were matched at 625 sites. There were 545 coronary artery sites that had an increase in intimal area 〉10% from baseline to one year, and this comprised the data set of the present study. Results At the first year, 91% of coronary artery sites with intimal growth had a total cross-sectional area stenosis ≤40%, but 38% of the sites showed a decrease of 〉10% in lumen area. Receiver operating characteristic curve demonstrated that the change in cross-sectional area stenosis cut-off level at year 1 was 8% with a sensitivity of 75% and a specificity of 82% in predicting lumen loss. At a total cross-sectional area stenosis of 20%, sensitivity was 65% with a specificity of 81% in predicting lumen loss. Conclusions In TCAD, vessel enlargement as a compensatory mechanism for plaque growth is generally inadequate. Instead of continued vessel expansion, luminal narrowing develops when there is more than 8% cross-sectional area filled with intimal hyperplasia. In distinction to native coronary artery atherosclerotic disease, the transition point in transplant vasculopathy where the lumen is diminished by increasing intimal growth, occurs at a lower threshold, 20% vs 40% of vessel crossectional area.