A simplified technique for hepatic revascularization of the liver graft with inadequate recipient hepatic artery

Sir: Among the vascular anomalies encountered during orthotopic liver transplantation (OLT), those involving the recipient's hepatic artery stand out because they are so difficult to solve. We describe the case of a 38-year-old male patient who underwent OLT due to posthepatitis liver cirrhosis. The patient was in Child's "B" stage with ascites and significant hemostasis impairment. The surgical technique used was the usual one, described by Starzl and Putnam [2]; arterial reconstruction was performed by anastomosis of the donor's celiac trunk to the recipient's common hepatic artery. The postoperative course was good and the patient was discharged 16 days later. The patient was readmitted 30 days after the OLT due to a cholangitis with dilatation and segmental stenosis of the intrahepatic bile ducts in the transhepatic cholangiography. Laboratory tests revealed cholestasis with increased bilirubin and alkaline phosphatase. An arteriography was performed that showed thrombosis of the common hepatic artery with the liver graft revascularizing from the superior mesenteric artery through the gastroduodenal artery. The patient's condition became progressively worse, with increased jaundice, weight loss, and denutrition. He underwent a second transplant operation 130 days after the first OLT with a diagnosis of sclerosing cholangitis secondary to hepatic ischemia, due to thrombosis of the hepatic artery. The cava preservation technique [4] was used in the operation. The vascular reconstructions were performed by end-to-end anastomosis from the donor's vena cava to the cuff of the recipient's suprahepatic veins, anastomosis of the portal vein following the usual technique, and an end-to-end anastomosis from the donor's common hepatic artery to the recipient's splenic artery, which had been previously cut and ligated at its distal end. The postoperative course was good except for positive viremia for CMV and leakage from the biliary anasto