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Abstract Background Hepatic artery thrombosis (HAT) is one of the critical conditions after an orthotopic liver transplant (OLT) and leads to severe problems if not corrected promptly. However, multiple treatments have been proposed for HAT, in which surgical revascularization with either auto-hepatic conduit interposition (AHCI) or revision of the anastomosis is more familiar indeed indicated for some patients and in specific situations. In this study, we want to evaluate the success and outcomes of treating early HAT (E-HAT), which defines HAT within 30 days after OLT with either of the surgical revascularization techniques. Method In this retrospective study, we collected information from the medical records of patients who underwent either of the surgical revascularization procedures for E-HAT after OLT. Patients who needed early retransplantation (RT) or died without surgical intervention for E-HAT were excluded. Demographic data, OLT surgery information, and data regarding E-HAT were gathered. The study outcomes were secondary management for E-HAT in case of improper inflow, biliary complications (BC), RT, and death. Results A total of 37 adult patients with E-HAT after OLT included in this study. These E-HATs were diagnosed within a mean of 4.6 ± 3.6 days after OLT. Two patients had their HA revised for the initial management of E-HAT; however, it changed to AHCI intraoperatively and finally needed RT. Two and nine patients from the AHCI and revision groups had re-thrombosis (12.5% vs. 47.3%, respectively, p = 0.03). RT was used to manage rethrombosis in all patients of AHCI and two patients of the revision group (22.2%). In comparison to the AHCI, revision group had statistically insignificant higher rates of BC (47.4% vs. 31.2%); however, RT for nonvascular etiologies (12.5% vs. 5.3%) and death (12.5% vs. 10.5%) were nonsignificantly higher in AHCI group. All patients with more than one HA exploration who were in the revision group had BC; however, 28.5% of patients with just one HA exploration experienced BC (p

Background: Hepatic artery thrombosis (HAT) is one of the critical conditions after an orthotopic liver transplant (OLT) and leads to severe problems if not corrected promptly. However, multiple treatments have been proposed for HAT, in which surgical revascularization with either auto-hepatic conduit interposition (AHCI) or revision of the anastomosis is more familiar indeed indicated for some patients and in specific situations. In this study, we want to evaluate the success and outcomes of treating early HAT (E-HAT), which defines HAT within 30 days after OLT with either of the surgical revascularization techniques. Method: In this retrospective study, we collected information from the medical records of patients who underwent either of the surgical revascularization procedures for E-HAT after OLT. Patients who needed early retransplantation (RT) or died without surgical intervention for E-HAT were excluded. Demographic data, OLT surgery information, and data regarding E-HAT were gathered. The study outcomes were secondary management for E-HAT in case of improper inflow, biliary complications (BC), RT, and death. Results: A total of 37 adult patients with E-HAT after OLT included in this study. These E-HATs were diagnosed within a mean of 4.6 ± 3.6 days after OLT. Two patients had their HA revised for the initial management of E-HAT; however, it changed to AHCI intraoperatively and finally needed RT. Two and nine patients from the AHCI and revision groups had re-thrombosis (12.5% vs. 47.3%, respectively, p = 0.03). RT was used to manage rethrombosis in all patients of AHCI and two patients of the revision group (22.2%). In comparison to the AHCI, revision group had statistically insignificant higher rates of BC (47.4% vs. 31.2%); however, RT for nonvascular etiologies (12.5% vs. 5.3%) and death (12.5% vs. 10.5%) were nonsignificantly higher in AHCI group. All patients with more than one HA exploration who were in the revision group had BC; however, 28.5% of patients with just one HA exploration experienced BC (p < 0.001). Conclusion: Arterial conduit interposition seems a better approach for the initial management of E-HAT in comparison to revision of the HA anastomosis due to the lower risk of re-thrombosis and the number of HA explorations; indeed, BC, RT, and death remain because they are somewhat related to the ischemic event of E-HAT than to a surgical treatment itself. [ABSTRACT FROM AUTHOR]

Early detection of liver transplantation (LT) vascular complications enables timely management. Our aim was to assess if routine Doppler ultrasound (rDUS) improves the detection of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT) and hepatic venous outflow obstruction (HVOO). We retrospectively analysed timing and outcomes, number needed to diagnose one complication (NND) and positive predictive value (PPV) of rDUS on post-operative day (POD) 0,1 and 7 in 708 adult patients who underwent primary LT between 2010-2022. We showed that HAT developed in 7.1%, PVT in 8.2% and HVOO in 3.1% of patients. Most early complications were diagnosed on POD 0 (26.9%), 1 (17.3%) and 5 (17.3%). rDUS correctly detected 21 out of 26 vascular events during the protocol days. PPV of rDUS was 53.8%, detection rate 1.1% and NND was 90.5. Median time to diagnosis was 4 days for HAT and 47 days for PVT and 21 days for HVOO. After intervention, liver grafts were preserved in 57.1%. In conclusion, rDUS protocol helps to detect first week's vascular events, but with low PPV and a high number of ultrasounds needed. [ABSTRACT FROM AUTHOR]

Hepatic artery anastomosis in liver transplantations requires a meticulous technique to minimize the risk of hepatic artery thrombosis (HAT). The microscope helped improve anastomosis techniques in pediatric patients with small caliber vessels. The aim of this review was to compare microsurgical and non-microsurgical techniques on the incidence of HAT in liver transplantations. The secondary objective was to compare HAT incidence between pediatric and adult cohorts and between plastic and transplant surgeons. A systematic review of the literature using Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was conducted on studies involving HAT in liver transplantations with microsurgery. Three reviewers performed a full article review and data extraction for studies meeting the eligibility criteria of the study. Forty-five studies were incorporated in the final analysis. A total of 7346 patients and 7506 liver transplants were included. The mean age was 17 years old with an equivalent distribution between pediatric (51%, n = 3218) and adult patients (49%, n = 3145). A total of 6351 of these transplantations underwent microsurgical repair, against 1157 with non-microsurgical techniques. The overall HAT rate was 4.9%, including 4.2% in the microsurgical group (n = 268) and 8.5% in the non-microsurgical group (n = 98), a statistically significant increase of 4.3%. The occurrence of HAT was 2.6% with a plastic surgeon versus 4.6% with other types of surgeons. When using microsurgical techniques, the HAT rate was 4.2% with living donors versus 7.7% with deceased donors. HAT and subsequent liver transplant failure are lower when microsurgical techniques, living donors, and plastic surgeons with a microsurgical training are involved in the operation. [ABSTRACT FROM AUTHOR]

Introduction: Hepatic artery occlusion (HAO) is a significant complication post‐liver transplantation. Doppler ultrasound (DUS) has been widely used as an initial screening test for detecting HAO; however, its performance is often not sufficient. Although other diagnostic tests such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), and angiogram are more accurate, they are invasive and have several limitations. Contrast‐enhanced ultrasound (CEUS) is an emerging tool for detecting HAO; however, the results from previous studies were limited due to a small number of patients. Therefore, we aimed to evaluate its performance by performing a meta‐analysis. Method: We performed a systemic review and meta‐analysis of studies evaluating the performance of CEUS for the detection of HAO in an adult population. A literature search of EMBASE, Scopus, CINAHL, and Medline was conducted through March 2022. Pooled sensitivity, specificity, log diagnostic odd ratio (LDOR), and area under summary receiver operating curve (AUC) were calculated. Publication bias was assessed by Deeks' funnel plot. Result: Eight studies were included, with 434 CEUS performed. Using a combination of CTA, MRA, angiography, clinical follow‐up, and surgery as the gold standard, the sensitivity, specificity, and LDOR of CEUS for detection of HAO were.969 (.938,.996),.991 (.981, 1.001), and 5.732 (4.539, 6.926), respectively. AUC was.959. The heterogeneity between studies appeared universally low, and no significant publication bias was found (p =.44). Conclusion: CEUS appeared to have an excellent performance for the detection of HAO and could be considered as an alternative when DUS is non‐diagnostic or when CTA, MRA, and angiogram are not feasible. [ABSTRACT FROM AUTHOR]

Background: Since November 2020, Italy was the first country to carry out a protocol and use liver from COVID‐19 donors. We aimed to evaluate the medium‐term outcome of patients who underwent liver transplant (LT) with those grafts. Methods: We consecutively enrolled 283 patients who underwent first LT from November 2020 to December 2022 in our Center (follow‐up 468 days). Twenty‐five of 283 (8.8%, study population) received a graft from donors with previous (4%) or active (96%) SARS‐CoV‐2 infection, and 258/283 (91.2%, control group) received a graft from COVID‐19‐negative donors. SARS‐CoV‐2‐RNA was tested on graft tissue of COVID‐19 donors and their recipients underwent weekly evaluation of SARS‐CoV‐2‐RNA in nasal swabs for the first month after LT. Results: One‐year and 2‐year patient survival was 88.5% and 88.5% in study group versus 94.5% and 93.5% in control group, respectively (p =.531). In study population there was no evidence of donor‐recipient virus transmission, but three (12%) patients (vs. 7 [2.7%] of control group, p =.048) developed hepatic artery thrombosis (HAT): they were SARS‐CoV‐2‐RNA negative at LT and 1/3 grafts tested SARS‐CoV‐2‐RNA positive on liver tissue. COVID‐19 donor was independently associated with HAT (odds ratio (OR) = 4.85, 95% confidence interval (CI) 1.10–19.15; p =.037). By comparing study population with control group, acute rejection and biliary complication rates were not significantly different (16% vs. 8.1%, p =.26; 16% vs. 16.3% p =.99, respectively). Conclusions: Our 1‐year results of transplant strategy including liver grafts from COVID‐19 donors were favorable. HAT was the only complication with significantly higher rate in patients transplanted with COVID‐19 donors compared with control group. [ABSTRACT FROM AUTHOR]

Background: Liver transplantation (LT) in infants can be challenging due to their small size and small vasculature. Although both whole LT (WLT) and split LT (SLT) have been described in infants, the head‐to‐head comparison of these techniques in this population is sparse. Methods: We retrospectively analyzed the records of all patients with age ≤1 year at Indiana University between 2016 and 2022. All SLT were left lateral segment grafts split in situ. Results: A total of 24 infants were transplanted, with 11 SLT and 13 WLT. The median follow‐up time was 52.1 months. Donor and recipient characteristics were comparable except for donor age (19 years vs. 2 years; p <.01) and weight (64 kg vs. 14.2 kg; p <.01). Early allograft dysfunction, primary nonfunction, and hepatic artery thrombosis developed more frequently in the WLT group. There were no biliary complications. There were two early deaths (2 and 4 days) in the WLT group. One‐year graft survival (100% vs. 77%; p =.10) and patient survival (100% vs. 85%; p =.18) were numerically higher in the SLT group. Conclusions: SLT with LLS offers a safe and viable option for liver transplantation in infants and is associated with a trend toward superior outcomes. SLT should be considered as a strategy to reduce waitlist times for infants in the absence of small, deceased donors for WLT. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate duplex US findings of the HA in all three postoperative vascular (HA, PV, HV and IVC) complications of paediatric LT for early detection and some helpful secondary signs to determine these vascular complications. Materials and methods: We collected data from 44 post-LT paediatric patients who underwent daily duplex US for seven consecutive days and three months after LT during January 2017–June 2020. Four duplex US parameters of the HA (extrahepatic PSV, intrahepatic PSV, RI and AT) were compared in patients with and without complications. Results: The PSV of the extrahepatic HA in patients with HA complications was higher than that in patients without complications (P value = 0.019). The PSV at 107.7 cm/s is the optimal cut-off parameter associated with HA complications [a sensitivity of 88.9% and a specificity of 80.0% (ROC area is 0.84)]. The intrahepatic RI was higher on the first day than on the last day and gradually decreased in patients without vascular complications (P value = 0.000). The intrahepatic PSV significantly decreased with time when comparing the first and last days in patients without PV and HV-IVC complications (P value = 0.014 and 0.038). In contrast, patients with vascular complications showed no significant decrease. Conclusion: The extrahepatic PSV relates to HA complications after paediatric LT but not PV and HV-IVC complications. Non-significantly decreased intrahepatic RI and PSV from the first day to the day of complication diagnosis may correlate with the occurrence of vascular complications. [ABSTRACT FROM AUTHOR]

Early detection of liver transplantation (LT) vascular complications enables timely management. Our aim was to assess if routine Doppler ultrasound (rDUS) improves the detection of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT) and hepatic venous outflow obstruction (HVOO). We retrospectively analysed timing and outcomes, number needed to diagnose one complication (NND) and positive predictive value (PPV) of rDUS on post-operative day (POD) 0,1 and 7 in 708 adult patients who underwent primary LT between 2010–2022. We showed that HAT developed in 7.1%, PVT in 8.2% and HVOO in 3.1% of patients. Most early complications were diagnosed on POD 0 (26.9%), 1 (17.3%) and 5 (17.3%). rDUS correctly detected 21 out of 26 vascular events during the protocol days. PPV of rDUS was 53.8%, detection rate 1.1% and NND was 90.5. Median time to diagnosis was 4 days for HAT and 47 days for PVT and 21 days for HVOO. After intervention, liver grafts were preserved in 57.1%. In conclusion, rDUS protocol helps to detect first week’s vascular events, but with low PPV and a high number of ultrasounds needed.

Pyogenic liver abscess (PLA) is a life‐threatening infection in both liver transplant (LT) and non‐LT patients. Several risk factors, such as benign and malignant hepatopancreatobiliary diseases and colorectal tumors have been associated with PLA in the non‐LT population, and hepatic artery stricture/thrombosis, biliary stricture, and hepaticojejunostomy in the LT patients. The objective of this study is to compare the outcomes of patients with PLA in LT and non‐LT patients and to determine the risk factors associated with patient survival. From January 2000 to November 2020, a total of 296 adult patients were diagnosed of PLA in our institution, of whom 26 patients had previously undergone liver transplantation (LTA group), whereas 263 patients corresponded to the non‐LTA population. Seven patients with PLA who had undergone previous kidney transplantation were excluded from this retrospective study. Twenty‐six patients out of 1503 LT developed PLA (incidence of 1.7%). Median age was significantly higher in non‐LTA patients (p =.001). No significant differences were observed in therapy. PLA recurrence was significantly higher in LTA than in non‐LTA (34.6% vs. 14.8%; p =.008). In‐hospital mortality was greater in the LT group than in the non‐LT group (19.2% vs. 9.1% p =.10) and was identified in multivariable analysis as a risk factor for mortality (p =.027). Mortality rate during follow‐up did not show significant differences between the groups: 34.6% in LTA patients versus 26.2% in non‐LTA patients (p =.10). The most common causes of mortality during follow‐up were malignancies, Covid‐19 infection, and neurologic disease. 1‐, 3‐, and 5‐year actuarial patient survival rates were 87.0%, 64.1%, and 50.4%, respectively, in patients of LTA group, and 84.5%, 66.5%, and 51.0%, respectively, in patients with liver abscesses in non‐LTA population (p =.53). In conclusion, LT was a risk factor for in hospital mortality, but not during long‐term follow‐up. [ABSTRACT FROM AUTHOR]

Variations in graft arterial anatomy can increase the risk of postoperative hepatic arterial thrombosis (HAT), especially in presence of a replaced or accessory right hepatic artery (RHA). We retrospectively analyzed 223 cases of liver transplantations with the presence of an RHA on the graft. Patient outcomes were compared according to the four different reconstruction methods used: (i) the re‐implantation of the RHA into the splenic or gastroduodenal artery (n = 106); (ii) the interposition of the superior mesenteric artery (SMA) (n = 83); (iii) dual anastomosis (n = 24); (iv) use of an aortic patch including the origins of both the SMA and the coeliac trunk (n = 10). A competing risk analysis and Inverse Probability Weighting (IPW) were used. We found that the interposition of the SMA method was associated with a significantly lower incidence of HAT, at 4.8% compared to the re‐implantation method at 17.9%, dual anastomosis at 12.5%, and aortic patch at 20%, p =.03. In the competing risk analysis with IPW, the only risk factor for RHA thrombosis was the type of reconstruction. Taking the SMA interposition group as the reference, the sub‐hazard ratio (sHR) was 5.05 (CI 95 [1.72; 14.78], p <.01) for the re‐implantation group, sHR = 2.37 (CI 95 [0.51; 11.09], p =.27) for the dual anastomosis group and sHR = 2.24 (CI 95 [0.35; 14.33], p =.40) for the aortic patch group. There were no differences for intraoperative transfusion, hospitalization duration (p =.37) or incidence of severe complications (p =.1). The long‐term graft (p =.69) and patient (p =.52) survival was not different. In conclusion, the SMA interposition method was associated with a lower incidence of RHA thrombosis. [ABSTRACT FROM AUTHOR]

Introduction: Everolimus, a selective inhibitor of mamalian target of rapamycin (mTORi), is considered to be an alternative immunosuppressive regimen in the liver transplantation (LT) setting. However, most of the transplant centers avoid its early use (i.e., during the first month) after LT mainly due to safety issues. Methods: We searched for all articles published between 01/2010 and 7/2022 to evaluate the effectiveness and safety of initial/early administration of everolimus after LT. Results: Seven studies (three randomized controlled trials and four prospective cohort studies) were included: initial/early everolimus‐including therapy (group 1) was used in 512 (51%) and calcineurin inhibitor (CNI) based therapy (group 2) in 494 (49%) patients. No significant difference was found between group 1 and group 2 patients regarding the rates of biopsy‐proven acute rejection episodes (Odds Ratio [OR]: 1.27, 95% CI:.67‐2.41, p =.465) and hepatic artery thrombosis (OR:.43, 95% CI:.09‐2.02, p =.289). Everolimus was associated with higher rates of dyslipidemia (14.2% vs. 6.8%, p =.005) and incisional hernia (29.2% vs. 10.1%, p <.001). Finally, no difference was found between the two groups regarding recurrence of hepatocellular carcinoma (Risk Rates [RR]: 1.22 95%CI:.66‐2.29, p =.524) and mortality (RR:.85 95%CI:.48‐1.50, p =.570). Conclusion: Use of initial/early everolimus seems to be effective with a satisfactory safety profile, making its administration a reasonable therapeutic option in the LT setting. [ABSTRACT FROM AUTHOR]

Introduction: Coronavirus disease 2019 (COVID-19) establishes a prothrombotic state. Hepatic artery thrombosis (HAT) after liver transplantation (LT) is a potentially fatal complication. Case presentation: A 14-year-old girl with negative polymerase chain reaction (PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on admission underwent an uneventful LT. Per protocol, unfractionated heparin (UFH) was administered for postoperative anticoagulation, however, anticoagulation goals were not achieved with the usual and even higher doses of UFH. On day 3 post-LT, she developed respiratory distress. On day 5 post-LT, HAT was detected, and thrombectomy and arterial and bile duct re-anastomoses were performed. On day 6 post-LT, the patient had fever. PCR for SARS-CoV-2 was repeated, and the result was positive. On day 27 post-LT, bile leakage that required biliodigestive diversion was observed. Two years post-LT, the patient is asymptomatic, her hepatic artery is patent and her liver enzymes are normal. Discussion: In this patient, the temporally association of COVID-19 with the impossibility of achieving anticoagulation goals with usual doses of UFH and the development of HAT is striking. It is difficult to determine whether HAT was triggered by the COVID-19-related procoagulant state or whether the patient is one of the few pediatric LT recipients who present with HAT. Conclusions: Considering the severity of HAT after LT, the current reality of the COVID-19 pandemic, and the changes in coagulation associated with SARS-CoV-2 infection, we deemed it necessary to emphasize the importance of maintaining a strict therapeutic dose of anticoagulation for pediatric LT recipients who develop COVID-19. [ABSTRACT FROM AUTHOR]

Introduction: The frequency and outcomes of anhepatic patients listed for transplantation in the United States have not been studied. The United Network for Organ Sharing (UNOS) records anhepatic status for patients listed as Status 1A for hepatic artery thrombosis (HAT) or primary non‐function (PNF). Methods: Using the UNOS database from 2005 to 2020, demographics and waitlist outcomes of anhepatic candidates relisted as Status 1A for HAT or PNF were assessed. Results: Among 1364 adult Status 1A patients relisted for PNF or HAT across 120 distinct transplant centres, 75 (5.5%) patients were anhepatic and 1289 (94.5%) were non‐anhepatic. A substantial number of centres (n = 51) had experience with ≥1 anhepatic patient relisted for either PNF or HAT, with individual centre rates ranging from 0% to 11.4%. Waitlist mortality was more than twice as high for anhepatic patients: 42.5% versus 17.0% non‐anhepatic patients (p <.001). The post‐transplant outcomes of anhepatic patients were markedly inferior to non‐anhepatic patients. For example, 41.9% of anhepatic patients died during the index admission versus 23.4% of the non‐anhepatic group (p =.006). Patient survival for the anhepatic and non‐anhepatic groups was 48.3% versus 66.2% at 1‐year and 29.3% versus 46.2% at 5‐years, respectively (log‐rank test for overall survival p =.014). Conclusions: Rescue hepatectomy after initial liver transplantation is not only associated with high waitlist mortality, but also markedly worse post‐transplant outcomes. With less than half of anhepatic patients surviving to the first year post‐LT, further research is warranted to better delineate which patients should be considered for rescue hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Shortages of liver allografts for children awaiting transplantation have led to high LT waitlist mortality. Prior studies have shown that usage of TVG can reduce waiting time and waitlist mortality, but their use is not universal. We sought to compare patient and graft survival between WLG and TVG and to identify potential associated risk factors in a contemporary pediatric LT cohort. Methods: We performed a retrospective analysis of patient survival, graft survival, and biliary and vascular complications for LT recipients <18 years old entered into the Society of Pediatric Liver Transplantation prospective multicenter database. Results: Of 1839 LT recipients, 1029 received a WLG and 810 received a TVG from either a LD or a DD. There was no difference in patient survival or graft survival by graft type. Three‐year patient survival and graft survival were 96%, 93%, and 96%, and 95%, 89%, and 92% for TVG‐LD, TVG‐DD, and WLG, respectively. Biliary complications were more frequent in TVG. Hepatic artery thrombosis was more frequent in WLG. Multivariate analysis revealed primary diagnosis was the only significant predictor of patient survival. Predictors for graft survival included time‐dependent development of biliary and vascular complications. Conclusions: There were no significant differences in patient and graft survival based on graft types in this North American multi‐center pediatric cohort. Widespread routine use of TVG should be strongly encouraged to decrease mortality on the waitlist for pediatric LT candidates. [ABSTRACT FROM AUTHOR]

Purpose: Although liver transplantation (LT) outcomes have improved significantly over the last decades, early vascular complications are still associated with elevated risks of graft failure. Doppler ultrasound (DUS) enables detection of vascular complications, provides hepatic artery Resistive Index (RI). The aim of our study was to evaluate the association of the RI parameters of DUS performed in the first post-transplant week with post-transplant outcomes. Methods: All consecutive patients undergoing a first LT between 2001 and 2019 at a single center were included. Patients were divided into two groups: RI < 0.55 and RI ≥ 0.55. Patients were also divided according to the presence or absence of hepatic artery thrombosis (HAT). Graft survival was compared between groups. Results: Overall, 338 patients were included. HAT occurred in 23 patients (6.8%), of which 7 were partial and 16, complete. Biliary complications were more common in patients with HAT (10 [43.5%]) vs. 38 [12.1%] [p < 0.001]). Graft survival was lower for patients with HAT (p = 0.047). Also, RI < 0.55 was associated with increased incidence of HAT (p < 0.001). Additionally, patients with RI < 0.55 on post-operative day 1 had decreased graft survival as compared to patients with RI > 0.55 (p = 0.041). RI on post-operative day 3 and 5 was not predictive of inferior graft outcomes. Conclusions: Intensive use of DUS in the early post-LT period offers the possibility of early diagnosis of vascular complications, guiding medical and surgical management of HAT. Additionally, according to our data, low RI (< 0.55) on the first postoperative day also is a predictor of HAT and decreased graft-survival. [ABSTRACT FROM AUTHOR]

Background: Percutaneous drainage (PD) and antibiotics are the therapy of choice (non-surgical therapy [non-ST]) for pyogenic liver abscesses (PLA), reserving surgical therapy (ST) for PD failure. The aim of this retrospective study was to identify risk factors that indicate the need for ST. Methods: We reviewed the medical charts of all of our institution’s adult patients with a diagnosis of PLA between January 2000 and November 2020. A series of 296 patients with PLA was divided into two groups according to the therapy used: ST (n = 41 patients) and non-ST (n = 255). A comparison between groups was performed. Results: The overall median age was 68 years. Demographics, clinical history, underlying pathology, and laboratory variables were similar in both groups, except for the duration of PLA symptoms < 10 days and leukocyte count which were significantly higher in the ST group. The in-hospital mortality rate in the ST group was 12.2% vs. 10.2% in the non-ST group (p = 0.783), with biliary sepsis and tumor-related abscesses as the most frequent causes of death. Hospital stay and PLA recurrence were statistically insignificant between groups. One-year actuarial patient survival was 80.2% in the ST group vs. 84.6% in the non-ST (p = 0.625) group. The presence of underlying biliary disease, intra-abdominal tumor, and duration of symptoms for less than 10 days on presentation comprised the risk factors that indicated the need to perform ST. Conclusions: There is little evidence regarding the decision to perform ST, but according to this study, the presence of underlying biliary disease or an intra-abdominal tumor and the duration of PLA symptoms < 10 days upon presentation are risk factors that should sway the surgeons to perform ST instead of PD. [ABSTRACT FROM AUTHOR]

The aim of our study was to assess risk factors for hepatic artery thrombosis (HAT) and to evaluate the impact of HAT management on long-term outcomes after pediatric living donor liver transplantation (LDLT). We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. We compared preoperative data, surgical factors, complications, and patient and graft survivals in patients with HAT (HAT Group) and without HAT (non-HAT Group). A total of 27 patients (6.75%) developed HAT. Acute liver failure, a hepatic artery (HA) anastomosis diameter below 2 mm, and intraoperative HA flow dysfunction were significantly more common in the HAT Group (p < 0.05, p = 0.02026, and p = 0.0019, respectively). In the HAT Group, 21 patients (77.8%) underwent urgent surgical revision. The incidence of biliary stenosis and retransplantation was significantly higher in the HAT Group (p = 0.00002 and p < 0.0001, respectively). Patient and graft survivals were significantly worse in the HAT Group (p < 0.05). The close monitoring of HA flow with Doppler ultrasound during the critical period of 2 to 3 weeks after LDLT and the immediate attempt of surgical revascularization may attenuate the elevated risk of biliary stenosis, graft loss, and the need for retransplantation due to HAT. [ABSTRACT FROM AUTHOR]

Background and Objectives: Patients undergoing liver transplantation (LT) often require increased blood product transfusion due to pre-existing coagulopathy and intraoperative fibrinolysis. Strategies to minimise intraoperative bleeding and subsequent blood product requirements include platelet transfusion and tranexamic acid (TXA). Prophylactic TXA administration has been shown to reduce bleeding and blood product requirements intraoperatively. However, its clinical use is still debated. The aim of this study was to report on a single-centre practice and analyse clinical characteristics and outcomes of LT recipients according to intraoperative treatment of TXA or platelet transfusion. Materials and Methods: This was a retrospective observational cohort study in which we reviewed 162 patients' records. Characteristics, intraoperative requirement of blood products, postoperative development of thrombosis and outcomes were compared between patients without or with intraoperative TXA treatment and without or with platelet transfusion. Results: Intraoperative treatment of TXA and platelets was 53% and 57.40%, respectively. Patients who required intraoperative administration of TXA or platelet transfusion also required more transfusion of blood products. Neither TXA nor platelet transfusion were associated with increased postoperative development of hepatic artery and portal vein thrombosis, 90-day mortality or graft loss. There was a significant increase in the median length of intensive care unit (ICU) stay in those who received platelet transfusion only (2.00 vs. 3.00 days; p = 0.021). Time to extubate was significantly different in both those who required TXA and platelet transfusion intraoperatively. Conclusions: Our analysis indicates that LT recipients still required copious intraoperative transfusion of blood products, despite the use of intraoperative TXA and platelets. Our findings have important implications for current transfusion practice in LT recipients and may guide clinicians to act upon these findings, which will support global efforts to encourage a wider use of TXA to reduce transfusion requirements, including platelets. [ABSTRACT FROM AUTHOR]

• What is currently known about this topic? Pediatric living donor liver transplantation (PLDLT) in infants and small children is a challenging procedure and requires particular technical refinements. Early vascular complications are still the main cause of patient and graft loss, especially in low body weight recipients, and centers responsible for the care of such patients utilize different strategies to mitigate the problem and achieve better outcomes.. • What new information is contained in this article? This paper analyzes the PLDLT outcomes in children with low body weight (<7 kg). It represents the largest population of PLDLT reported so far. With proper management and different technical strategies to avoid "large-for-size syndrome", that can increase the occurrence of early vascular complications, the long-term survival of small babies was similar to the group of patients with higher body weight. This series shows that, even challenging, PLDLT in small babies is feasible, with good outcomes. infants who require liver transplantation represent a treatment challenge because chronic liver disease at this early age affects the child's growth and development during a critical phase. The aim is to compare demographics, operative data, and long-term outcomes according to recipient weight at the time of LDLT. This retrospective study included primary LDLT analyzed in 2 groups: BW ≤ 7 kg (n = 322) and BW > 7 kg (n = 756). A historical comparison between periods was also investigated. BW ≤ 7 kg had significantly lower height/age and weight/age z-scores, with median PELD score of 19. Transfusion rates were higher in the BW ≤ 7 kg group (30.9 ml/kg versus 15.5 ml/kg, P < 0.001). Higher frequencies of PV complications were seen in the BW ≤ 7 kg cohort. HAT and retransplantation rates were similar. Those with BW ≤ 7 kg required longer ICU and hospital stays. Patient and graft survival were similar. Patient survival in BW≤ 7 kg was significantly better in the most recent period. Malnutrition and advanced liver disease were more frequent in BW ≤ 7 kg. Despite increased rates of PVT and longer hospital stay, patient and graft long-term survival were similar between groups. [ABSTRACT FROM AUTHOR]

Aim. The study aim was to assess the negative dynamics of the hepatic artery resistive index as a reliable predictor of early thrombosis in liver transplant recipients from a postmortem donor, to determine risk factors and to identify a group of patients with an increased risk of this complication.Material and methods. From July 2018 to August 2021, 92 orthotopic liver transplants from a deceased donor were performed at the Surgical Clinic of the City Clinical Hospital n.a. S.P. Botkin. All liver grafts were taken from donors with brain death. Control Doppler ultrasound examination of hepatic blood flow in all patients was performed on days 1, 3, 5, 7, if necessary, daily. The hepatic arteries resistive index was considered normal at values from 0.55-0.79, high at 0.8-0.89, extremely high above 0.9. Depending on the resistive index value on the 1st postoperative day and its further dynamics, we divided the patients into 3 groups. In each group, we analyzed the incidence of hepatic artery thrombosis and assessed the impact of various risk factors on the resistive index elevation on the 1st day after surgery and on its growth during dynamic observation in the early postoperative period.Results. Of 92 liver transplants, in three cases, we recorded hepatic artery thrombosis (3.2%), which was not associated with technical difficulties of arterial reconstruction. No mortality was recorded in all three cases. In patients with a normal or high resistive index on the 1st day, without its increase during dynamic observation, the incidence of arterial thrombosis was 0%. In patients with a normal or high resistive index on the 1st day, and its increase during dynamic observation, as well as in patients with an extremely high resistive index on the 1st day, the incidence of arterial thrombosis was 18.1% and 11.1%, respectively. The risk factors of thrombosis were the age of the recipient over 50 years old in an extremely high resistive index on the 1st postoperative day (p=0.024), and the age of the donor over 50 years old in the growth of the resistive index during follow-up (p=0.04).Conclusion. The lack of positive dynamics in the hepatic artery resistive index reduction may be an additional predictor of arterial thrombosis after liver transplantation. This fact makes it possible to identify a high-risk group of arterial thrombosis, to take additional preventive measures in these patients and to improve the immediate results of treatment in this group of patients.

Hepatic artery thrombosis (HAT) following living donor liver transplantation (LDLT) is a lethal complication. We present the case of a patient who underwent salvage redo hepatic artery reconstruction using an aorto-hepatic jump graft because of HAT following LDLT. A 64-year-old female patient diagnosed with hepatitis C virus-associated liver cirrhosis and hepatocellular carcinoma underwent salvage LDLT using a modified right liver graft. Partial graft infarct was identified at posttransplant day 4, and by day 9, it had spread. Celiac arteriography showed complete occlusion of the graft hepatic artery. We performed redo hepatic artery reconstruction using a fresh iliofemoral artery homograft 10 days after the LDLT operation because such a vessel homograft was available at our institutional tissue bank. The infrarenal aorta was dissected and an iliofemoral artery graft was anastomosed. Soon after hepatic artery revascularization, liver function progressively improved, and the infarct area at the liver graft was reduced. The patient has been doing well for 10 years without any vascular complications. In conclusion, our experience with this case suggests that salvage redo hepatic artery reconstruction using an aorto-hepatic jump graft is a feasible option to treat HAT following LDLT, as in deceased donor liver transplantation.

After liver transplantation (LT), synthesis of coagulation factors by the graft recovers faster for pro thrombotic than anti thrombotic factors, resulting in a potential pro thrombotic imbalance. We studied the thrombotic and hemorrhagic complications in our pediatric LT series, providing supplementation of fresh frozen plasma (FFP) and/or antithrombin (AT) in the prophylactic antithrombotic regimen. This was a retrospective observational single center study. All isolated pediatric LTs performed between 1/11/2009 and 31/12/2019 (n = 181) were included. Postoperatively, in addition to low molecular weight heparin, 22 patients (12%) received FFP (10 ml/kg twice daily for 10 days), 27 patients (15%) were given FFP (reduced duration) and AT (50–100 IU/kg/day if AT activity remained <70%), and 132 (73%) received AT only. Complications, outcome, and coagulation profiles in postoperative days 0–10 were analyzed. In all three treatment groups, AT activity normalized by day 4 while prothrombin remained <70% of normal until day 9. Hepatic artery thrombosis (HAT), portal vein thrombosis (PVT), and hemorrhagic complications occurred in 2.8%, 3.3%, and 3.9% of LTs. One- and 5-year patient and graft survival were 88% (±2.4% Standard Error) and 84% (±2.5%), and 86% (±2.6%) and 84% (±2.7%), respectively, without difference between groups. HAT were associated with low AT on days 0 and 1, and PVT with low AT on day 0. Low antithrombin activity after LT was associated with postoperative thromboses. FFP and/or AT supplementation allowed early normalization of AT activity, while thrombotic or hemorrhagic complications were rare, suggesting efficient and safe management of post-LT coagulopathy. [ABSTRACT FROM AUTHOR]

• The incidence of hepatic artery thrombosis in whole liver transplantation with donor age less than one year of age. • Recanalization can be performed using anticoagulant therapy. • HAT does not reduce the survival rate of recipients and grafts. The incidence of hepatic artery thrombosis (HAT) in recipients is high after pediatric LT using young donors. In this study we investigated the management and outcome of HAT after whole-LT using donors less than one year of age. And evaluate the safety of pediatric donors, and increase the utilization of pediatric donors overall. We retrospectively analyzed the clinical data encompassing children who underwent whole-liver transplantation in our department from January 2014 to December 2019. Recipients receiving a liver from a donor ≥1 month and ≤12 months were included, and a total of 110 patients were included in this study. The results showed an incidence for HAT of 20% and the median time to HAT diagnosis was 3.0 (2.0, 5.3) days post-operation. Anticoagulant therapy was used for 19 cases and 94.7% of them achieved hepatic artery recanalization or collateral formation. The median time of recanalization was 12 (5, 15) days. Bile leakage and biliary strictures occurring in the HAT group were higher than in the non HAT group (13.6% vs. 1.1% and 31.8% vs. 3.4%). There were no significant differences in the survival rates of recipients or grafts among the two groups (P = 0.474, P = 0.208, respectively). We confirmed that the incidence of HAT in LT recipients use donors less than 1 year is high, but recanalization can be performed using anticoagulant therapy. Although biliary complications increased significantly after HAT, the survival rates of patients and grafts were satisfactory. Level III. [ABSTRACT FROM AUTHOR]

Liver transplantation (LT) is an effective way to cure end-stage liver diseases (ESLDs), which have generally been regarded as examples of acquired bleeding disorders. However, postoperative thrombosis after LT is recognised and remains life-threatening complication. This study aimed to show that blood loss during LT is a predictor of postoperative thrombosis and to establish a predictive model. We analysed the medical records of all patients who underwent LT at the First Affiliated Hospital of Xi'an Jiaotong University from January 2017 to April 2019 to identify the risk factors for post-transplant thrombosis. The predictive nomogram was established based on independent predictors identified by logistic regression analysis. Blood loss during LT of ≥31.25 mL/kg can predict postoperative thrombosis, and the nomogram achieved an accurate prediction. [ABSTRACT FROM AUTHOR]

Background: In pediatric liver transplant recipients, hepatic artery thrombosis and portal vein thrombosis are major causes of acute graft failure and mortality within 30 days of transplantation. There is, however, a strong possibility of graft salvage if flow can be re‐established to reduce ischemic injury. The current standard treatment is surgical revascularization, and if unsuccessful, retransplantation. Due to our success in treating these complications with catheter‐directed therapies, we sought to summarize and publish the outcomes of all patients who experienced hepatic artery thrombosis or portal vein thrombosis within 30 days of liver transplantation. Methods: We conducted a retrospective cohort analysis of 27 pediatric liver transplant recipients who experienced hepatic artery thrombosis (n = 13), portal vein thrombosis (n = 9), or both (n = 5) between September 2012 and March 2021. We collected and tabulated data on the patients and therapies performed to treat them, including success rates, primary and secondary patency, and clinical outcomes. Results: Among these patients, 6 were managed with anticoagulation and relisting for transplant and 21 had a primary revascularization attempt. Surgical recanalization was attempted in 7 patients of which 3 had successful recanalization (43%) and catheter‐directed recanalization was attempted in 14 patients with 100% success in re‐establishing blood flow to the graft. Additionally, patency was increased, and mortality was decreased in patients treated with catheter‐directed recanalization compared to surgical revascularization or anticoagulation alone. Conclusion: This data illustrates the need to further investigate catheter‐directed thrombolysis as a potential first‐line treatment for postoperative HAT and PVT in pediatric liver transplant recipients. [ABSTRACT FROM AUTHOR]

We have preferentially used the right gastroepiploic artery (RGEA) as an alternative for the recipient hepatic artery (HA) inflow during living donor liver transplantation (LDLT), but it was not always available. We herein present a case of adult LDLT with HA reconstruction using a greater saphenous vein (GSV) conduit because of the absence of the RGEA due to prior subtotal gastrectomy. A 55-year-old male patient diagnosed with hepatitis B virus-associated liver cirrhosis and secondary biliary cirrhosis underwent LDLT using a modified right liver graft. The upper abdominal cavity was heavily adhered due to prior abdominal surgeries, thus we had to sacrifice the common bile duct and the right HA completely. A 6-cm-long GSV segment was harvested from the left ankle and interposed between the recipient gastroduodenal artery and the graft HA. The patient recovered from LDLT and HA complications did not occur. However, 8 years after LDLT, chronic rejection occurred, thus repeated deceased donor liver transplantation was performed. This patient has been doing well for 2 years after retransplantation. In conclusion, we suggest that interposition of an autologous GSV conduit can be an alternative for establishing HA inflow in LDLT when other inflow source is not available.

Hepatic Artery Stenosis (HAS) after liver transplantation (LT), if untreated, can lead to hepatic artery thrombosis (HAT) that carries significant morbidity. To identify risk factors associated with HAS and determine if endovascular therapy (EVT) reduces the occurrence of HAT. This is a retrospective cohort study of adult LT patients between 2013 and 2018. The primary outcome was development of HAT, and secondary outcomes included graft failure and mortality. Logistic regression was used to ascertain the odds ratio of developing HAS. Outcomes between intervention types were compared with Fisher's-exact test. The odds of HAS doubled in DCD-donor recipients (OR=2.27; P = 0.04) and transplants requiring vascular reconstruction for donor arterial variation (OR=2.19, P = 0.046). Of the 63 identified HAS patients, 44 underwent EVT, 7 with angioplasty alone, 37 combined with stenting. HAT was not significantly different in those who underwent angioplasty with or without stenting than conservative treatment (P = 0.71). However, compared to patients without HAS, patients with HAS had higher odds of biliary stricture and decreased graft and overall patient survival (log-rank P < 0.001 & P = 0.019, respectively). HAS is significantly higher in DCD-graft recipients. EVT was not associated with reduction in HAT progression. HAS has poor graft and overall survival. [ABSTRACT FROM AUTHOR]

Background: The purposes of the study were to determine the variations in hepatic arterial supply, to delineate the optimal methods of arterial anastomoses and reconstructions in liver transplantation and to analyse the incidence of arterial complications. Methods: The surgical anatomy of the extrahepatic arterial vascularization was investigated retrospectively in 209 donors and patients who underwent liver transplantation at Fundeni Clinical Institute (Bucharest, Romania) from January 1, 2015 to December 31, 2017. The vascular anatomy of the hepatic grafts was classified according to Michels’ description and other rare variations. Results: Anatomical variants of the classical pattern were detected in 26.3% of the livers (n = 55). The most common variant was a replaced right hepatic artery arising from the superior mesenteric artery (n = 17; 8.13%), followed by a common hepatic artery from superior mesenteric artery (n = 6; 2.87%). Arterial reconstructions were reported in 97 cases (45.5%). In recipients, used sites were intermediate: common hepatic artery (CHA) in 73.8% (n = 158), distal: proper hepatic artery (PHA) or common hepatic artery/gastro-duodenal artery bifurcation (CHA/GDA bifurcation) in 16.4% (n = 35) and proximal: coeliac trunk-splenic artery-aorta (CT–SA–A) in 9.3% (n = 20) of patients. Most common reconstructions were short graft artery (CT) on the recipient CHA (n = 33, 34.02%) and long graft artery: complex reconstruction between CT and superior mesenteric artery (SMA) - accessory right hepatic artery (RHA) from SMA on CHA (n = 12, 12.37%) and right hepatic graft artery on PHA or CHA/GDA bifurcation (n = 16, 16.49%). Conclusion: The information about the different hepatic arterial patterns, as well as establishing specific methods for arterial anastomoses and reconstructions is important in the determination of better outcomes.

Background: Hepatic artery thrombosis (HAT) represents a devastating and often fatal complication of liver transplantation. Due to the small vessel caliber in pediatric patients, the use of an operating microscope has largely become the standard for hepatic artery reconstruction to reduce the rate of HAT. Recent evidence, however, suggests that loupe magnification for anastomosis may be equally effective. We aimed to determine the effect of magnification on the rate of hepatic artery thrombosis in pediatric liver transplantation. Methods: A systematic search of the literature was conducted. Thousand eighty‐eight unique titles were assessed by two independent reviewers. Studies directly comparing rates of HAT from loupe magnification and operating microscope‐assisted anastomoses were eligible for meta‐analysis. Results: Among primary transplants, the rate of HAT was 6.0%. Operating microscope anastomosis was associated with a 2.6% decrease in the rate of HAT compared to that of loupe magnification (4.9% and 7.4%, respectively, p <.040). When re‐transplants were included, the rate of HAT was 5.8%. Operating microscope anastomosis was associated with a 1.0% decrease in the rate of HAT compared to that of loupe magnification (5.3% and 6.3%, respectively, p <.279). Meta‐analysis of eligible studies demonstrated a reduction in the rate of HAT with the use of an operating microscope (p <.03). Conclusions: Anastomosis under an operating microscope may be associated with decreased rates of HAT in children undergoing primary liver transplantation. Further high‐quality studies comparing the two techniques are needed. [ABSTRACT FROM AUTHOR]

Introduction: In pediatric liver transplantation (pLT), hepatic artery thrombosis (HAT) is associated with inferior transplant outcome. Hepatic artery reconstruction (HAR) using an operating microscope (OM) is considered to reduce the incidence of HAT. Methods: HAR using an OM was compared to a historic cohort using surgical loupes (SL) in pLT performed between 2009 and 2020. Primary endpoint was the occurrence of HAT. Secondary endpoints were 1‐year patient and graft survival determined by Kaplan–Meier analysis and complications. Multivariate analysis was used to identify independent risk factors for HAT and adverse events. Results: A total of 79 pLTs were performed [30 (38.0%) living donations; 49 (62.0%) postmortem donations] divided into 23 (29.1%) segment 2/3, 32 (40.5%) left lobe, 4 (5.1%) extended right lobe, and 20 (25.3%) full‐size grafts. One‐year patient and graft survival were both 95.2% in the OM group versus 86.2% and 77.8% in the SL group (p =.276 and p =.077). HAT rate was 0% in the OM group versus 24.1% in the SL group (p =.013). One‐year patient and graft survival were 64.3% and 35.7% in patient with HAT, compared to 93.9% and 92.8% in patients with no HAT (both p <.001). Multivariate analysis revealed HAR with SL (p =.022) and deceased donor liver transplantation (DDLT) (p =.014) as independent risk factors for HAT. The occurrence of HAT was independently associated with the need for retransplantation (p <.001) and biliary leakage (p =.045). Conclusion: In pLT, the use of an OM is significantly associated to reduce HAT rate, biliary complications, and graft loss and outweighs the disadvantages of delayed arterial perfusion and prolonged warm ischemia time (WIT). [ABSTRACT FROM AUTHOR]

Liver transplantation is the treatment of choice for patients with end-stage liver disease or acute liver failure. However, vascular complications, such as hepatic artery stenosis and/or thrombosis, graft portal vein stenosis and biliodigestive strictures following liver transplantation are still common despite improvements and innovations in surgical techniques. These complications can lead to graft damage or even death, and they are caused by many factors. Although minimally invasive interventional radiology is an optional treatment for such post-liver transplant complications, there is little research on this method of treatment.

Assessing the viability and monitoring the function of liver graft in the early postoperative period are critical clinical tasks. One possible solution is to determine the changes in concentration of blood glucose, its metabolites and glycerol in the graft using interstitial microdialysis. Objective: to study the dynamics of interstitial glucose, lactate, pyruvate and glycerol in the early post-liver transplant period – depending on the initial graft function (IGF) – and to compare with the results of standard laboratory blood tests. Materials and methods. Four selected clinical observations of deceased donor liver transplantation are presented. Two of the observations showed normal IGF, one observation – early allograft dysfunction (EAD), complicated by hepatic artery thrombosis (HAT), while one observation demonstrated primary non-function (PNF). Collection of microdialysis samples began after arterial reperfusion of the liver graft and continued continuously for 7 days or until death. Standard blood biochemistry and coagulation tests were performed at least once a day. Results. With normal IGF and a smooth postoperative period, interstitial concentrations of glucose, lactate, pyruvate and glycerol remained stable throughout the observation period, ranging from 5 to 20 mmol/L, 1.1 to 7.5 mmol/L, 90 to 380 μmol/L, and 10–100 μmol/L, respectively. EAD was associated with initially higher levels of glucose, lactate, and pyruvate. With HAT development, there was a rapid (within 2–4 hours) five-fold increase in interstitial concentration of lactate with simultaneous decrease in glucose and pyruvate levels to 0.1 mmol/L and 11 μmol/L, respectively. In the case of PNF, there was an initially high concentration of interstitial lactate – 16.4 mmol/L, which increased further to 35.5 mmol/L. Glucose concentration was close to 0. Changes in interstitial glucose, its metabolites and glycerol concentrations chronologically preceded the corresponding changes in peripheral blood composition by 3–5 hours. Conclusion. Microdialysis measurement of interstitial glucose, lactate, pyruvate and glycerol concentrations facilitates real-time monitoring of liver graft viability and function. The high sensitivity of the method could help in accelerating diagnosis of vascular complications (HAT in particular), as well as graft dysfunction with other causes. Therefore, the method is feasible in clinical practice.

Introduction: The middle hepatic artery is an artery which supplies blood to the fourth segment of the liver. Most commonly, it originates from the right hepatic artery. Injury to the middle hepatic artery during liver transplant surgeries may lead to ischaemia and also may lead to life threatening conditions like hepatic artery thrombosis in donor as well as recipient. The variations in the origin of the middle hepatic artery in the living donors were focused in the present study as it has surgical importance in the liver transplantations. Aim: To find out the incidence of the variations in the origin of the middle hepatic artery in living liver donors using Computed Tomography (CT) angiography. Materials and Methods: This was a retrospective observational study conducted from August 2018 to October 2021 in the Department of Anatomy, Deccan College of Medical Sciences, Hyderabad, Telangana, India. The images of CT angiographies of 100 living liver donors were collected from the Department of Radiology, Global Hospital, Hyderabad, Telangana, India. All the CT angiographs of the living liver donors were observed for any variations in the origin of the middle hepatic artery and recorded and the percentage of each variation was calculated. Results: Out of 100 CT angiographs studied, the incidence of the origin of middle hepatic artery was reported as 55% from right hepatic artery, 34% from the left hepatic artery, 5% from replaced left hepatic artery, 2% from the hepatic artery proper, 1% from the common hepatic artery, 1% from left gastric artery. Double middle hepatic arteries were observed in 1% of cases. Accessory middle hepatic artery was observed in 1% cases. Conclusion: To increase the success rate of liver transplantations, the clear knowledge on the possible variations of the middle hepatic artery is needed. The variations of the middle hepatic artery reported in this study are rare and will be useful for the liver transplant surgeons.

The aim of our study was to assess risk factors for hepatic artery thrombosis (HAT) and to evaluate the impact of HAT management on long-term outcomes after pediatric living donor liver transplantation (LDLT). We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. We compared preoperative data, surgical factors, complications, and patient and graft survivals in patients with HAT (HAT Group) and without HAT (non-HAT Group). A total of 27 patients (6.75%) developed HAT. Acute liver failure, a hepatic artery (HA) anastomosis diameter below 2 mm, and intraoperative HA flow dysfunction were significantly more common in the HAT Group (p < 0.05, p = 0.02026, and p = 0.0019, respectively). In the HAT Group, 21 patients (77.8%) underwent urgent surgical revision. The incidence of biliary stenosis and retransplantation was significantly higher in the HAT Group (p = 0.00002 and p < 0.0001, respectively). Patient and graft survivals were significantly worse in the HAT Group (p < 0.05). The close monitoring of HA flow with Doppler ultrasound during the critical period of 2 to 3 weeks after LDLT and the immediate attempt of surgical revascularization may attenuate the elevated risk of biliary stenosis, graft loss, and the need for retransplantation due to HAT.

Background and Objectives: Patients undergoing liver transplantation (LT) often require increased blood product transfusion due to pre-existing coagulopathy and intraoperative fibrinolysis. Strategies to minimise intraoperative bleeding and subsequent blood product requirements include platelet transfusion and tranexamic acid (TXA). Prophylactic TXA administration has been shown to reduce bleeding and blood product requirements intraoperatively. However, its clinical use is still debated. The aim of this study was to report on a single-centre practice and analyse clinical characteristics and outcomes of LT recipients according to intraoperative treatment of TXA or platelet transfusion. Materials and Methods: This was a retrospective observational cohort study in which we reviewed 162 patients’ records. Characteristics, intraoperative requirement of blood products, postoperative development of thrombosis and outcomes were compared between patients without or with intraoperative TXA treatment and without or with platelet transfusion. Results: Intraoperative treatment of TXA and platelets was 53% and 57.40%, respectively. Patients who required intraoperative administration of TXA or platelet transfusion also required more transfusion of blood products. Neither TXA nor platelet transfusion were associated with increased postoperative development of hepatic artery and portal vein thrombosis, 90-day mortality or graft loss. There was a significant increase in the median length of intensive care unit (ICU) stay in those who received platelet transfusion only (2.00 vs. 3.00 days; p = 0.021). Time to extubate was significantly different in both those who required TXA and platelet transfusion intraoperatively. Conclusions: Our analysis indicates that LT recipients still required copious intraoperative transfusion of blood products, despite the use of intraoperative TXA and platelets. Our findings have important implications for current transfusion practice in LT recipients and may guide clinicians to act upon these findings, which will support global efforts to encourage a wider use of TXA to reduce transfusion requirements, including platelets.

Introduction: Before advancements in liver transplantation, conditions such as acute liver failure, decompensated liver cirrhosis, and hepatocellular carcinoma were associated with poor prognosis. Orthotopic liver transplantation has since emerged as a curative treatment. Despite its benefits, liver transplantation can lead to complications, including hepatic artery thrombosis (HAT), which is especially significant in pediatric patients. This study evaluates the utility of microsurgical anastomosis by plastic surgeons in reducing postoperative HAT compared to standard loupe-assisted anastomosis performed by transplant surgeons., Methods: This retrospective chart review included pediatric patients who underwent orthotopic liver transplantation at a single institution between September 2015 and September 2023. Patients were divided into two groups: one receiving standard loupe-assisted anastomosis by transplant surgeons (n = 28) and the other receiving microsurgical anastomosis by plastic surgeons (n = 22). The primary outcomes measured were the rates of HAT. Secondary outcomes included graft survival, patient survival, postoperative hospital stay, resistive indices, bleeding, biliary complications, venous complications, transplant rejection, and reoperation rates., Results: In 50 pediatric patients who underwent orthotopic liver transplantation, we compared outcomes between standard anastomosis (n = 28) and microscope-assisted anastomosis (n = 22). Demographic characteristics were similar between the groups. Hemorrhage occurred significantly more frequently in the standard anastomosis group (35.7%) compared to the microscope-assisted group (9.1%), with a p-value of 0.045. Other complications, including HAT (28.6% vs. 13.6%, p = 0.306), biliary leak (14.3% vs. 27.3%, p = 0.302), and organ rejection (21.4% vs. 13.6%, p = 0.713), did not differ significantly between the groups. Additionally, survival rates were comparable, with 71% in the standard group and 86% in the microscope group (p = 0.306). These findings suggest that while microscope-assisted anastomosis may reduce the risk of hemorrhage, other outcomes remain similar between the techniques., Conclusion: Our findings suggest that microsurgical anastomosis techniques performed by plastic surgeons are non-inferior to standard loupe-assisted techniques in pediatric liver transplantation and may decrease the rate of postoperative hemorrhage. Microsurgical anastomosis is a viable alternative to standard loupe-assisted techniques in pediatric hepatic artery transplants. Further research with larger sample sizes is warranted to confirm these findings and optimize surgical techniques., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Isch et al.)

We report this case of a 5-year-old child post combined liver and renal transplant for primary hyperoxaluria. Patient developed hepatic artery thrombosis on day 3 posttransplant that was managed by reexploration and reanastomosis of the hepatic artery. On day 4, the patient again developed hepatic artery thrombosis that failed to revascularize by surgical exploration and reanastomosis. Tissue plasminogen activator was injected into the hepatic artery intraoperatively to lyse any clot; however, no revascularization could be achieved. Subsequently, catheter angiogram confirmed no flow in the hepatic artery. A4 × 22 mm revive stent retriever was deployed across the site of occlusion and retrieved after 5 minutes of indwell time. Two such passes were made and complete recanalization of the hepatic artery was achieved. The hepatic artery remained patent as confirmed on serial Doppler images post intervention.

Intrahepatic recipient hepatic artery dissection caused by hepatic artery thrombosis is a lethal complication of living-liver donor liver transplantation (LDLT). We herein report a new surgical technique that avoids the ligation of the recipient hepatic arteries in LDLT. Patients undergoing LDLT between 2009 and 2019 were evaluated. In the second half of this period, a technique involving no ligation of the recipient hepatic artery was initiated and its impact on the incidence of intrahepatic recipient hepatic artery dissection was determined. The middle and left hepatic arteries were ligated in 195 cases (53.4%), and the no-ligation technique was used in 170 (46.6%). The incidence of intraoperative hepatic artery dissection was significantly lower in the no-ligation group (n = 0, 0.0%) than in the ligation group (n = 10, 5.1%) (p = 0.0021). After propensity score matching to evaluate the patient characteristics, the incidence of intraoperative hepatic artery dissection was also significantly lower in the no-ligation group (n = 0, 0.0%) than in the ligation group (n = 6, 4.5%) (p = 0.0295). As a result, this new surgical technique is highly recommended to avoid recipient hepatic artery ligation in LDLT. [ABSTRACT FROM AUTHOR]

Background: Need for routine reconstruction of all arteries in grafts with multiple arterial inflows remains an unsettled debate. The aim of following article is to review an anatomical basis of a decision-making strategy to deal with multiple arteries in living donor liver transplantation (LDLT). Methods: LDLT performed between August 2009–2019 were included. Grafts were classified into grafts with single artery (group 1); multiple arteries, all reconstructed (group 2); and multiple arteries, one reconstructed (group 3). Frequency of double arteries in relation to graft type, type of reconstruction, incidence of arterial and biliary complications and survival was compared. Results: 1086 LDLT were analysed (adults: 750, paediatric: 336). 1007 grafts (92.2%) had single artery (group 1), and 79 (7.8%) grafts had multiple arteries. All arteries were reconstructed in 19 (24%) patients (group 2), while 60 grafts (75.9%) had only one artery reconstructed (group 3). Left lobe (18.8%) and left lateral segments (10.7%) grafts were more likely to have multiple arteries (p = 0.001). The likelihood of reconstructing multiple arteries was similar in all graft types, 27.3% in right and 25% and 21.4% in left lobe and left lateral segments, respectively (p > 0.05). There was no difference in biliary complications (p = 0.85), hepatic artery thrombosis (p = 0.82), and post-surgical hospital stay (p = 0.38) between the three groups. The presence of multiple arteries or their selective reconstruction did not affect survival (p = 0.73). Conclusions: Multiple arterial inflows are not an uncommon entity and demonstration of good hilar collateralization helps in avoiding unnecessary arterial reconstruction without adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: Pediatric LT are at particular risk of HAT, and its management still constitutes a matter of debate. Our purpose was to study predisposing factors and outcome of HAT post‐LT, including the impact of surgical revisions on survival and biliary complications. Methods: Among 882 primary pediatric LT performed between 1993 and 2015, 36 HAT were encountered (4.1%, 35 fully documented). Each HAT case was retrospectively paired with a LT recipient without HAT, according to diagnosis, age at LT, type of graft, and era. Results: Five‐year patient survivals were 77.0% versus 83.9% in HAT and non‐HAT paired groups, respectively (P =.321). Corresponding graft survivals were 20.0% versus 80.5% (P <.001), and retransplantation rates 77.7% versus 10.7%, respectively (P <.001). One‐year biliary complication‐free survivals were 16.6% versus 83.8% in the HAT and non‐HAT groups, respectively (P <.001). Regarding chronology of surgical re‐exploration, only HAT cases that occurred within 14 days post‐LT were re‐operated, fourteen of them being explored within 7 days post‐LT (revascularization rate: 6/14), versus two beyond 7 days (no revascularization). When revascularization was achieved, graft and biliary complication‐free survival rates at 1 year were 33.3% and 22.2%, respectively, both rates being 0.0% in case of failure. Conclusions: The pejorative prognosis associated with HAT in terms of graft survival is confirmed, whereas patient survival could be preserved through retransplantation. Results suggest that HAT should be re‐operated if occurring within 7 days post‐LT, but not beyond. [ABSTRACT FROM AUTHOR]