Improving the radiological diagnosis of hepatic artery thrombosis after liver transplantation: Current approaches and future challenges

Hepatic artery thrombosis(HAT)is a devastating vascular complication following liver transplantation,requiring prompt diagnosis and rapid revascularization treatment to prevent graft loss.At present,imaging modalities such as ultrasound,computed tomography,and magnetic resonance play crucial roles in diagnosing HAT.Although imaging techniques have improved sensitivity and specificity for HAT diagnosis,they have limitations that hinder the timely diagnosis of this complication.In this sense,the emergence of artificial intelligence(AI)presents a transformative opportunity to address these diagnostic limitations.The development of machine learning algorithms and deep neural networks has demonstrated the potential to enhance the precision diagnosis of liver transplant complications,enabling quicker and more accurate detection of HAT.This article examines the current landscape of imaging diagnostic techniques for HAT and explores the emerging role of AI in addressing future challenges in the diagnosis of HAT after liver transplant.

Efficacy and safety of targeted therapy plus immunotherapy combined with hepatic artery infusion chemotherapy (FOLFOX) for unresectable hepatocarcinoma

BACKGROUND The advent of cutting-edge systemic therapies has driven advances in the treatment of hepatocellular carcinoma(HCC),and therapeutic strategies with multiple modes of delivery have been shown to be more efficacious than mono-therapy.However,the mechanisms underlying this innovative treatment modality have not been elucidated.AIM To evaluate the clinical efficacy of targeted therapy plus immunotherapy combined with hepatic arterial infusion chemotherapy(HAIC)of FOLFOX in patients with unresectable HCC.METHODS We enrolled 53 patients with unresectable HCC who received a combination of targeted therapy,immunotherapy,and HAIC of FOLFOX between December 2020 and June 2021 and assessed the efficacy and safety of the treatment regimen.RESULTS The objective response rate was 60.4%(32/53),complete response was 24.5%(13/53),partial response was 35.9%(19/53),and stable disease was 39.6%(21/53).The median duration of response and median progression-free survival were 9.1 and 13.9 months,respectively.The surgical conversion rate was 34.0%(18/53),and 1-year overall survival was 83.0%without critical complicating diseases or adverse events(AEs).CONCLUSION The regimen of HAIC of FOLFOX,targeted therapy,and immunotherapy was curative for patients with unresectable HCC,with no serious AEs and a high rate of surgical conversion.

How to deal with right hepatic artery coming from the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review

Background: Anatomical variations in the liver arterial supply are quite common and can affect the surgical strategy when performing a minimally invasive pancreaticoduodenectomy(MIPD). Their presence must be preemptively detected to avoid postoperative liver and biliary complications. Data sources: Following the PRISMA guidelines and the Cochrane protocol we conducted a systematic review on the management of an accessory or replaced right hepatic artery(RHA) arising from the superior mesenteric artery when performing an MIPD. Results: Five studies involving 118 patients were included. The most common reported management of the aberrant RHA was conservative(97.0%);however, patients undergoing aberrant RHA division without reconstruction did not develop liver or biliary complications. No differences in postoperative morbidity or long-term oncological related overall survival were reported in all the included studies when comparing MIPD in patients with standard anatomy to those with aberrant RHA. Conclusions: MIPD in patients with aberrant RHA is feasible without increase in morbidity and mortality. As preoperative strategy is crucial, we suggested planning an MIPD with an anomalous RHA focusing on preoperative vascular aberrancy assessment and different strategies to reduce the risk of liver ischemia.

Donor hepatic artery reconstruction based on human embryology:A case report

BACKGROUND Embryonic hepatic artery anatomy simplifies its identification during liver transplantation.Injuries to the donor hepatic artery can cause complications in this process.The hepatic artery's complex anatomy in adults makes this step challenging;however,during embryonic development,the artery and its branches have a simpler relationship.By restoring the embryonic hepatic artery anatomy,surgeons can reduce the risk of damage and increase the procedure's success rate.This approach can lead to improved patient outcomes and lower complication rates.CASE SUMMARY In this study,we report a case of donor liver preparation using a donor hepatic artery preparation based on human embryology.During the preparation of the hepatic artery,we restored the anatomy of the celiac trunk,superior mesenteric artery,and their branches to the state of the embryo at 5 wk.This allowed us to dissect the variant hepatic artery from the superior mesenteric artery and left gastric artery during the operation.After implanting the donor liver into the recipient,we observed normal blood flow in the donor hepatic artery,main hepatic artery,and variant hepatic artery,without any leakage.CONCLUSION Donor hepatic artery preparation based on human embryology can help reduce the incidence of donor hepatic artery injuries during liver transplantation.

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.

Single organ hepatic artery vasculitis as an unusual cause of epigastric pain:A case report

BACKGROUND Single-organ vasculitis(SOV)is characterized by inflammation of a blood vessel,affecting one organ,such as the skin,genitourinary system,or the aorta without systemic features.Gastrointestinal SOV is rare,with hepatic artery involvement reported only in two prior published cases.Herein,we presented a case of isolated hepatic artery vasculitis presenting after Pfizer-BioNTech mRNA corona virus disease 2019(COVID-19)vaccination.CASE SUMMARY A 50-year-old woman with hypertension presented to our Emergency Department with recurrent diffuse abdominal pain that localized to the epigastrium and emesis without diarrhea that began eight days after the second dose of the PfizerBioNTech COVID-19 vaccine.Blood work revealed an elevated C-reactive protein(CRP)of 19 mg/L(normal<4.8 mg/L),alkaline phosphatase 150 U/L(normal 25-105 U/L),gamma-glutamyl transferase(GGT)45 U/L(normal<43 U/L)and elevated immunoglobulins(Ig)G 18.4 g/L(normal 7-16 g/L)and IgA 4.4 g/L(normal 0.7-4 g/L).An abdominal computed tomography revealed findings in keeping with hepatic artery vasculitis.A detailed review of her history and examination did not reveal infectious or systemic autoimmune causes of her presentation.An extensive autoimmune panel was unremarkable.COVID-19polymerase chain reaction nasopharyngeal swab,human immunodeficiency virus,viral hepatitis and Heliobacter pylori serology were negative.At six months,the patient’s symptoms,and blood work spontaneously normalized.CONCLUSION High clinical suspicion of SOV is required for diagnosis in patients with acute abdominal pain and dyspepsia.

Prevention and treatment of hepatic artery thrombosis after liver transplantation

BACKGROUND: Hepatic artery thrombosis (HAT) which is a serious complication after orthotopic liver transplanta- tion (OLT) remains a significant cause of graft loss. The purpose of this study was to sum up our experiences in the prevention, diagnosis and management of HAT after liver transplantation. METHODS: From April 1993 to September 2003, a total of 198 patients underwent OLT at our hospital. The hepatic artery was anastomosed using 7/0 prolane with running continuous suture in 96 patients (group 1) and with inter- rupted suture in 102 (group 2). Ultrasonography was per- formed every day in two weeks after operation and selec- tively afterwards. RESULTS: HAT occurred in 6 patients (6.3%, 6/96) of group 1, and in 1 (1%, 1/102) of group 2 (x2=4.027, P= 0.045). Six patients received emergency thrombectomy, and 1 conservative therapy but died from tumor recurrence eventually. Biliary complication developed in 3 patients af- ter thrombectomy of whom 2 died of liver failure and one waited for retransplantation. In the other 3 patients after thrombectomy, 1 died of renal failure, and 2 survived. The mortality of patients with HAT was 57.1% (4/7). CONCLUSIONS: The technique of hepatic arterial anasto- mosis is the key factor for the prevention of HAT. Routine ultrasonography is very important in early detection of HAT after OLT. Biliary complication is a severe outcome secondary to HAT.

Microsurgical reconstruction of hepatic artery in living donor liver transplantation:experiences and lessons

BACKGROUND: Hepatic artery (HA) reconstruction is one of the key steps for living donor liver transplantation (LDLT). The incidence of HA thrombosis has been reduced by the introduction of nucrosurgical techniques under a high resolution microscope or loupe. METHODS: We report our experience in 101 cases of HA reconstruction in LDLTs using the graft-artery-undamp and posterior-wall-first technique. The reconstructions were completed by either a plastic surgeon or a transplant surgeon. RESULTS: The rate of HA thrombosis was 2% (2/101). The risk factors for failed procedures appeared to be reduced by participation of the transplant surgeon compared with the plastic surgeon. For a graft with duplicate arteries, we considered no branches should be discarded even with a positive clamping test. CONCLUSIONS: HA reconstruction without clamping the graft artery is a feasible and simplified technique, which can be mastered by transplant surgeons with considerable microsurgical training.

Asymptomatic process of hepatic artery thrombosis in a patient after orthotopic liver transplantation

BACKGROUND: Hepatic artery thrombosis is one of the serious complications after liver transplantation. It wil mostly cause a failure of the transplantation. This case o hepatic artery thrombosis showed a stable clinical course and minimal histological change, and now has been survi ving for 4 years with normal liver function. We investigated the possible causes for asymptomatic hepatic artery throm bosis in one patient after orthotopic liver transplantation ( OLT) and discussed the diagnosis of ischemia of OLT pathologically and clinically. METHODS: Liver function test, color Doppler ultrasono graphy, and hepatic arteriography were performed during the development of hepatic arteriothrombosis. Possible fac- tors for the asymptomatic process of the thrombosis were analyzed. RESULTS: On the 4th postoperative day, thrombosis form ed at the anastomotic stoma of the hepatic artery, and on the 11th postoperative day, the artery was completely oc- cluded. Serial liver biopsies revealed intrahepatic cholesta- sis, hydropic degeneration of hepatocytes, atrophy of the biliary epithelium, and fibrosis in the portal area. Monitor- ing of liver function showed nothing abnormal except ele- vation of γ-GT and ALP levels. On the 71st day after OLT, arteriography demonstrated that the hepatic artery re- mained completely occluded in addition to the establish- ment of collateral circulation and compensation of the por- tal vein. The patient didn' t show any symptoms of arterial thrombosis. CONCLUSION: Collateral circulation and compensation o the portal vein are beneficial to allograft survival and avoidence of retransplantation after thrombosis of the he- patic artery. Color Doppler ultrasonography within 2 weeks after OLT is helpful to the early diagnosis of hepatic arterio- thrombosis.

Interventional treatment of acute hepatic artery occlusion after liver transplantation

BACKGROUND: With the development of the associated technology, interventional treatment has become an important method for the treatment of hepatic artery occlusion in some countries. This study was undertaken to evaluate the role of interventional methods in the diagnosis and treatment of acute hepatic artery occlusion after liver transplantation. METHODS: The diagnosis and treatment of 9 cases of acute hepatic artery occlusion after liver transplantation were retrospectively analyzed. RESULTS: In 109 cases of liver transplantation, 9 were diagnosed by angiography. Among them, 7 were diagnosed by Doppler ultrasound. After transcatheter thrombolysis, the hepatic arteries were partially or totally patent again in 6 cases of hepatic artery occlusion after liver transplantation, and stent placements in the hepatic artery were performed in 5 cases. All stents proved patent and no patient required another liver transplantation. CONCLUSIONS: Angiography plays an important role in diagnosing hepatic artery complications after liver transplantation. Interventional therapy is a valuable method in the treatment of acute hepatic artery occlusion after liver transplantation.

The effects of ischemia-reperfusion injury and hepatic artery ischemia on CD14 expression in canine auto-transplantation livers

Objective： To study the effect of ischemia-reperfusion injury（IRI） and hepatic artery ischemia（HAI） on CD14 expression in canine auto-transplantation livers. Methods：Liver orthotopic auto-transplantation models were applied with 30 healthy male Xi＇ an canines which were randomly divided into a control group, simultaneous reperfusion（SR） group and HAI group, CD14 protein expression, Malonaldehyde （MDA） Contents in hepatic tissues and ALT values in serum were detected, and the pathological changes of hepatic tissues was investigated under the light microscopy. Results：The level of CD14 protein expression in SR and HAI group tended to be time-dependent and both higher than controls with statistical significance（P 〈 0.01）; The peak values of these two groups both occurred at 4 h, but the level in HAI group （11.94 ± 0.43） was evidently higher than that in SR group（3.04 ± 0.34）. MDA contents in liver tissue, ALT values in serum and pathological changes showed the same changing tendency as CD 14 expression. Conclusion：（1） Up-regulation of CD14 expression may be the receptor-mechanism of Kupffer cells（KCs） activation in liver transplantation. （2） HAI can upregulate CD14 expression after portal vein reperfusion, improve the activity of KCs further more, increase OFRs production and cooperate with portal reperfusion, and finally aggravate the grafts injury.

Hepatic artery reconstruction in pediatric liver transplantation:Experience from a single group

Background:The reconstruction of hepatic artery is a challenging part of the pediatric liver transplantation procedure.Hepatic artery thrombosis(HAT)and stenosis are complications which may result in ischemic biliary injury,causing early graft lost and even death.Methods:Two hundred and fifty-nine patients underwent liver transplantation in 2017 in a single liver transplantation group.Among them,225 patients were living donor liver transplantation(LDLT)and 34 deceased donor liver transplantation(DDLT).Results:In LDLT all reconstructions of hepatic artery were microsurgical,while in DDLT either microsurgical reconstruction or traditional continuous suture technique was done depending on different conditions.There were five(1.9%)HATs:four(4/34,11.8%)in DDLT(all whole liver grafts)and one(1/225,0.4%)in LDLT(P=0.001).Four HATs were managed conservatively using anticoagulation,and 1 accepted salvage surgery with re-anastomosis.Until now,3 HAT patients remain in good condition,whereas two developed biliary complications.One of them needed to be re-transplanted,and the other patient died due to biliary complications.Conclusions:Microsurgical technique significantly improves the reconstruction of hepatic artery in pediatric liver transplantation.The risk for arterial complications is higher in DDLT.Conservative therapy can achieve good outcome in selected HAT cases.

Stent-grafts placement for treatment of massive hemorrhage from ruptured hepatic artery after pancreaticoduodenectomy

AIM:To present a series of cases with life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm after pancreaticoduodenectomy(PD) treated with placement of stent-grafts.METHODS:Massive hemorrhage from ruptured hepatic artery pseudoaneurysm after PD in 9 patients(6 men,3 women) at the age of 23-75 years(mean 48 years),were treated with placement of percutaneous endovascular balloon-expandable coronary stent-grafts.All patients were not suitable for embolization because of a non-patent portal vein.One or more stent-grafts,ranging 3-6 mm in diameter and 16-55 mm in length,were placed to exclude ruptured pseudoaneurysm.Followup data,including clinical condition,liver function tests,and Doppler ultrasound examination,were recorded at the outpatient clinic.RESULTS:Immediate technical success was achieved in all the 9 patients.All stent-grafts were deployed in the intended position for immediate cessation of bleeding and preservation of satisfactory hepatic arterial blood flow.No significant procedure-related complications occurred.Recurrent bleeding occurred in 2 patients at 16 and 24 h,respectively,after placement of stent-grafts and treated with surgical revision.One patient died of sepsis 12 d after the interventional procedure.The remaining 6 patients were survived when they were discharged.The mean follow-up time was 10.5 mo(range 4-16 mo).No patient had recurrent bleeding after discharge.Doppler ultrasound examination verified the patency of hepatic artery and stent-grafts during the follow-up.CONCLUSION:Placement of stent-grafts is an effective and safe procedure for acute life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm.

Effect of hepatic artery resection and reconstruction on the prognosis of patients with advanced hilar cholangiocarcinoma

BACKGROUND Hilar cholangiocarcinoma(HC)is a good adaptation certificate of hepatic arterectomy,and hepatic arterectomy is conductive to the radical resection of cholangiocarcinoma,which simplifies the operation and helps with a combined resection of the peripheral portal tissue.With continuous development of surgical techniques,especially microsurgical technique,vascular invasion is no longer a contraindication to surgery in the past 10 years.However,hepatic artery reconstruction after hepatic arterectomy has been performed to treat liver tumor in many centers with better results,but it is rarely applied in advanced HC.AIM To determine the prognosis of patients with advanced HC after hepatic artery resection and reconstruction.METHODS A total of 98 patients with HC who underwent radical operation in our hospital were selected for this retrospective analysis.According to whether the patients underwent hepatic artery resection and reconstruction or not,they were divided into reconstruction(n=40)and control(n=58)groups.The traumatic indices,surgical resection margin,liver function tests before and after the operation,and surgical complications were compared between the two groups.RESULTS Operation time,blood loss,hospital stay,and gastrointestinal function recovery time were higher in the reconstruction group than in the control group(P<0.05);The R0 resection rates were 90.00%and 72.41%in the reconstruction and control groups,respectively(P<0.05).Serum alanine aminotransferase was lower in the reconstruction group on day one and three postoperatively,whereas serum aspartate aminotransferase was lower on the third day(P<0.05).Preoperatively,the Karnofsky performance status scores were similar between the groups(P>0.05),but was higher in the reconstruction group(P<0.05)two weeks postoperatively.There was no difference in the complication rate between the two groups(27.50%vs 32.67%,P>0.05).Two-year survival rate(42.50%vs 39.66%)and two-year survival time(22.0 mo vs 23.0 mo)were similar between the groups(P>0.05).CONCLUSION Radical surgery combined with reconstruction after hepatic artery resection improves R0 resection rate and reduces postoperative liver injury in advanced HC.However,the operation is difficult and the effect on survival time is not clear.

Diagnosis and outcomes of collateral arterial formation after irreversible early hepatic artery thrombosis in pediatric liver recipients

BACKGROUND： Early hepatic artery thrombosis （eHAT） has been recognized as an important cause of graft loss and mortality. However, the incidence, etiology and outcome are not dear, especially for children. The present study was to investigate the formation of collateral artery flow after irreversible eHAT and its impact on patient＇s prognosis. METHODS： We analyzed eHAT after liver transplantation in children from October 2006 to April 2015 in our center, illustrated the formation of collateral hepatic artery flow after irreversible eHAT and explored the diagnosis, complications, treatment and prognosis. The basic and follow-up ultrasonographic images were also compared. RESULTS： Of the 330 pediatric liver recipients, 22 （6.67%） de- veloped eHAT within 1 month. Revascularization attempts in- duding surgical thrombectomy, interventional radiology and conservational treatment （thrombolysis） were successful in 5 patients. Among the 17 patients who had irreversible eHAT, follow-up ultrasonography revealed that collateral artery flow was developed as early as 2 weeks after eHAT. Liver abscess and bile duct complication occurred secondary to eHAT in variable time. CONCLUSIONS： Collateral arterial formation is a compensatory adaptation to eHAT to supply blood to liver grafts. However, the severe bile duct damage secondary to eHAT is irreversible and retransplantation is unavoidable.

Effect of hepatic artery embolization on liver hypertrophy response in a rabbit liver VX2tumor model

BACKGROUND:Portal vein embolization not only induces hypertrophy of the non-embolized liver,but also enhances tumor growth.The latter could be prevented by embolizing the hepatic arteries supplying the tumor-bearing liver segments.This study aimed to determine the effects of transcatheter arterial embolization(TAE)on tumor volume and liver regeneration in a rabbit VX2 tumor model.METHODS:Twenty-three rabbits underwent subcapsular tumor implantation with a VX2 tumor.Two weeks after implantation,18 rabbits were used for TAE experiments,5were for sham controls.Tumor response and liver regeneration response of the embolized cranial and non-embolized caudal liver lobes were assessed by CT volumetry,liver to body weight index,and the amount of proliferating hepatocytes.RESULTS:All super-selective arterial tumor embolization procedures were performed successfully.Despite embolization,the tumor volume increased after an initial steady state.The tumor volume after embolization was smaller than that of the sham group,but this difference was not significant.Massive necrosis of the tumor,however,was seen after embolization,without damage of the surrounding liver parenchyma.There was a significant atrophy response of the tumor bearing cranial lobe after super-selective arterial embolization of the tumor with a concomitant hypertrophy response of the non-embolized,caudal lobe.This regeneration response was confirmed histologically by a significantly higher number of proliferating hepatocytes on the Ki-67 stained slides.CONCLUSIONS:Super-selective,bland arterial coil embolization causes massive necrosis of the tumor,despite increase of volume on CT scan.Atrophy of the tumor bearing liver lobe is seen after arterial embolization of the tumor with a concomitant hypertrophy response of the non-embolized lobe,despite absence of histological damage of the tumor-surrounding liver parenchyma.

Arcuate ligament syndrome inducing hepatic artery thrombosis after liver transplantation

BACKGROUND: Hepatic artery thrombosis (HAT) is a frequent complication following liver transplantation, but it is rarely caused by arcuate ligament compression of the celiac artery. This article mainly describes our experience in managing a patient with celiac artery stenosis and HAT after liver transplantation. METHODS: A 44-year-old man with a 15-year history of hepatitis B was admitted to our hospital for hepatocellular carcinoma. Before the operatiori, he received transarterial chemoembolization once, and pretransplant MR angiography indicated a suspected stenosis at the initiation of the celiac artery, while color Doppler showed normal blood flow in the arterial system. In this case, orthotopic liver transplantation was performed for radical cure of hepatocellular carcinoma. However, B-ultrasonography detected poor blood flow in the intra- and extra-hepatic artery on the first posttransplant day, and during exploratory laparotomy a thrombus was found in the hepatic artery. Thus, re-transplantation was conducted with a bypass between the graft hepatic artery and the recipient abdominal aorta with the donor's splenic artery. RESULTS: The patient made an uneventful recovery and color Doppler showed good blood flow in the artery and portal system. Histology confirmed extensive thrombosis in the left and right hepatic artery of the explanted graft, indicating HAT. CONCLUSIONS: Although HAT caused by celiac trunk compression is rarely reported in liver transplantation, the diagnosis should be considered in patients with pretransplant hepatic artery stenosis on angiography and abnormal blood flow on B-ultrasonography. Once HAT is formed, treatment such as thrombectomy or retransplantation should be performed as early as possible.

Technical tailoring of pancreaticoduodenectomy in patients with hepatic artery anatomic variants

BACKGROUND:Pancreaticoduodenectomy is the treatment of choice for periampullary and pancreatic head tumors.In case of hepatic artery abnormalities,early pancreatic transection during pancreaticoduodenectomy may prove inappropriate Early retroportal lamina dissection improves exposure of the superior mesenteric vessels and anatomic variants of the hepatic artery,where safeguarding is mandatory.METHOD:We describe our early retroportal lamina approach in patients with anatomic variants of the hepatic artery before pancreatic transection.RESULTS:This approach was used during 42 pancreatico duodenectomies with a hepatic artery anatomic variant which was spared in 40 patients.Arterial reconstruction was performed in 2 patients.Five patients with a hepatic artery variant and adenocarcinoma involving the portomesenteric junction required venous resection and reconstruction.CONCLUSIONS:Early retroportal lamina dissection during pancreaticoduodenectomy in patients with hepatic artery anatomic variants enables easier exposure,avoiding injuries that might compromise the liver arterial supply.When the portomesenteric vein is involved,this approach facilitates en bloc 'no touch' venous resection and reconstruction.

Clinical significance of variant hepatic artery in pancreatic resection:A comprehensive review

The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels.A variant of the hepatic artery,which is not a rare finding during pancreatic surgery,is prone to intraoperative injury.Inadvertent injury to the hepatic artery may affect liver perfusion,resulting in necrosis,liver abscess,and even liver failure.The preoperative identification of hepatic artery variations,detailed planning of the surgical approach,careful intraoperative dissection,and proper management of the damaged artery are important for preventing hepatic hypoperfusion.Nevertheless,despite the potential risks,planned artery resection has become acceptable in carefully selected patients.Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods.The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery.Here,we comprehensively reviewed the anatomical basis of hepatic artery variation,its incidence,and its effect on the surgical and oncological outcomes after pancreatic resection.In addition,we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion.Overall,the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Intra-arterial thrombolysis for early hepatic artery thrombosis after liver transplantation

BACKGROUND Early hepatic artery thrombosis(E-HAT)is a serious complication after liver transplantation(LT),which often results in graft failure and can lead to patient deaths.Treatments such as re-transplantation and re-anastomosis are conventional therapeutic methods which are restricted by the shortage of donors and the patient’s postoperative intolerance to re-laparotomy.Due to the advances in interventional techniques and thrombolytics,endovascular treatments are increasingly being selected by more and more centers.This study reviews and reports our single-center experience with intra-arterial thrombolysis as the first choice therapy for E-HAT after deceased donor LT.AIM To evaluate the feasibility and reasonability of intra-arterial thrombolysis for EHAT after deceased donor LT.METHODS A total of 147 patients who underwent deceased donor LT were retrospectively reviewed in our hospital between September 2011 and December 2016.Four patients were diagnosed with E-HAT.All of these patients underwent intraarterial thrombolysis with alteplase as the first choice therapy after LT.The method of arterial anastomosis and details of the diagnosis and treatment of EHAT were collated.The long-term prognosis of E-HAT patients was also recorded.The median follow-up period was 26 mo(range:23 to 30 mo).RESULTS The incidence of E-HAT was 2.7%(4/147).E-HAT was considered when Doppler ultrasonography showed no blood flow signals and a definite diagnosis was confirmed by immediate hepatic arterial angiography when complete occlusion of the hepatic artery was observed.The patients were given temporary thrombolytics(mainly alteplase)via a 5-Fr catheter which was placed in the proximal part of the thrombosed hepatic artery followed by continuous alteplase using an infusion pump.Alteplase dose was adjusted according to activated clotting time.The recanalization rate of intra-arterial thrombolysis in our study was 100%(4/4)and no thrombolysis-related mortality was observed.During the follow-up period,patient survival rate was 75%(3/4),and biliary complications were present in 50%of patients(2/4).CONCLUSION Intra-arterial thrombolysis can be considered first-line treatment for E-HAT after deceased donor LT.Early diagnosis of E-HAT is important and follow-up is necessary even if recanalization is successful.