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Objective:
Significant hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT) can lead to thrombosis with subsequent liver failure in 30% of patients. While operative intervention or re-transplantation has been the traditional solution, endovascular therapy has emerged as a less-invasive treatment strategy. Prior smaller studies have been conflicting in the relative efficacy of angioplasty (PTA) versus primary stent placement for HAS.
Methods:
This was a single center retrospective review of all endovascular interventions for HAS after OLT over a 54 month period (August 2009-December 2013). Patients with ultrasound imaging with evidence of severe HAS (peak systolic velocity > 400 cm/sec, resistive index of <0.5) underwent endovascular treatment with primary stent placement or PTA. Outcomes calculated were technical success, primary and primary assisted patency rates, re-interventions, and complications.
Results:
Sixty-two interventions for HAS were performed in 42 patients with a mean follow-up of 19.1 ± 15.2 months. The rate of treated HAS was 6.4% (42/654). Primary technical success was achieved in 95% (59/62) of cases. Initial treatment was with PTA alone (n=16) or primary stent (n=26). Primary patency rates after initial stent placement were 91%, 81.3%, 77%, and 77% at 1,6,12, and 24 months, respectively, significantly better (P=0.01) when compared to initial PTA (68.8%, 57.1%, 44%) see Figure. There were 20 re-interventions in 14 patients (8 stents, 6 PTA). The time to initial re-intervention in patients with PTA alone vs. initial stent was 51 and 105.8 days, respectively. Overall primary patency rates (Kaplan-Meier) were 82%, 70%, 63%, and 50% at 1,6,12, and 24 months, respectively. Overall primary-assisted patency was 96% and 93% at 12 and 24 months. Major complications were one arterial rupture and two hepatic artery dissections. Long-term risk of HAT in the entire patient cohort was 4.8%.
Conclusions:
Hepatic artery stenosis after liver transplantation can be treated endovascularly with high technical success and excellent primary-assisted patency. This series represents the largest reported cohort of endovascular interventions for HAS to date. Initial use of a stent significantly decreased the need for re-intervention. Avoidance of hepatic artery thrombosis (HAT) is possible in >95% of patients with endovascular treatment and close follow-up.