Complications After Endovascular Treatment of Hepatic Artery Stenosis Following Liver Transplantation
Leighton E. Goldsmith, MD, J Seal, MD, C Brinster, MD, T A. Smith, MD, H A. Bazan, MD, W C. Sternbergh, III, MD.
Ochsner Clinic Foundation, New Orleans, LA, USA.
OBJECTIVES: Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis and a subsequent 30-50% risk of graft loss. Endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment. However, these complex interventions are not risk-free.
METHODS: A retrospective review of all patients undergoing angiography and possible intervention for HAS after liver transplantation between 9/2009 - 3/2016 was performed at a single institution which has the largest US volume of liver transplantation since 2011. Severe HAS was identified by routine duplex surveillance (PSV >400-450 cm/s, RI <0.5 and + tarvus parvus waveforms). Student t-tests were performed comparing continuous variables and the Fisher’s exact test was performed for categorical variables.
RESULTS: In 1,085 liver transplant recipients during the study period, 107 angiograms were performed in 79 patients (7.3%) for severe de-novo or recurrent HAS. The mean recipient age was 51.6±12.2 yr. The median time to vascular intervention from liver transplant was 71 days (range 5 days to 45 months). Interventions were performed in 100/107 (93.5%) of these cases, either with PTA alone (33/100) or with stent placement (65/100). Immediate technical success was 90%. Major complications occurred in 8/107 (7.5%) cases, consisting of target vessel dissection (6/8) or rupture (2/8). For these major complications, successful acute endovascular treatment was possible in 7/8 (87.5%) patients. Ruptures were treated with covered stent placement (2.5-3mm Jomed) or balloon tamponade, while dissections were treated with bare metal or drug-eluting stents (typically coronary balloon-expandable). No open surgical intervention was required to manage these complications. In follow-up, 4/8 (50%) patients progressed to HAS, compared to 1/70 (1.4%) in patients undergoing intervention without a major complication (P< 0.001). One patient required re-transplantation. Severe vessel tortuosity was present in 5/8 (62.5%) of interventions with a major complication compared to 34/99 (34.3%) in those without (p = 0.137).
CONCLUSIONS: While endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery may be a risk factor for such complications. Vessel injury can be acutely managed successfully using endovascular techniques, however, these patients have a significant risk of subsequent HAS and need close surveillance. Advanced endovascular skills and availability of rescue devices are essential for good outcomes.
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