Rationale:Median arcuate ligament (MAL) may compress the coeliac trunk inducing median arcuate ligament syndrome (MALS). MALS is a risk factor for hepatic artery thrombosis (HAT) in liver transplant recipients.Patient concerns:A thin female complained about upper abdominal pain for two months.Diagnoses:The patient was diagnosed as primary biliary cirrhosis.Interventions:The patient received two liver transplantations. During the first liver transplantation, the hepatic artery (HA) pulsations were normal. Doppler B ultrasonography showed normal blood flow in the HA in the first week. A 4 cm hematoma was detected in the first porta hepatis. On the ninth day, the hematoma had increased to 9 cm along with development of HAT. Exploratory laparotomy was performed. Bleeding at the site of arterial anastomosis was considered to be the reason for the hematoma. Doppler imaging revealed no blood flow in the liver. Computed tomography angiography demonstrated MALS. Salvage liver transplantation combined with dissection of MAL was performed. The maximum velocity of HA increased to 87 cm/s.Outcomes:The patient was discharged from the hospital 17 days after the second transplantation. At discharge, the liver function was normal and Doppler showed good blood flow in the HA.Lessons:MALS can cause HAT after liver transplantation. Before the liver transplantation, we should use Doppler B ultrasonography and sagittal CT imaging to judge whether the patient is with MALS. Also, before arterial anastomosis in liver transplantation is conducted, we should observe the impacts on the HA caused by pre-blocking gastroduodenal artery, which determines if we are supposed to do MAL dissection or bridge HA with aorta.
Rationale:Severe cardiac dysfunction or severe pulmonary hypertension is a contraindication of liver transplantation (LT). Extracorporeal membrane oxygenation (ECMO) is an advanced therapy for severe lung and/or cardiocirculatory dysfunction or failure. The application of ECMO to patients during the LT perioperative period may help recipients with severe cardiac disease to maintain the heart function and alleviate the reperfusion syndrome.Patient concerns:A female liver recipient complained about weakness for 6 months.Diagnoses:The patient was diagnosed as hepatitis B virus (HBV)-related hepatic cirrhosis (MELD 24, Child–Pugh C) with severe mitral regurgitation, severe tricuspid regurgitation, left atrium and left ventricle enlargement, cardiac insufficiency, pulmonary arterial hypertension, and hypoxemia.Interventions:The patient underwent LT from a cardiac deceased donor. The surgery was completed by venoarterial ECMO. The femoral vessels cannulation was done after the dissection of the patient's liver and before the venous blocking. Venous cannula reached to the position below renal vein, while arterial cannula reached to common iliac artery. We regulated the ECMO index according to the patient's condition. The dosage of heparin was adjusted on the basis of the activated clotting time. Respiratory support, milrinone, furosemide, and mannitol were used to improve the circulation. The bleeding volume of surgery was 1200 mL. The cardiocirculatory function and other vital signs remained good in the perioperative period. In the first 24 hours after surgery, central venous pressure decreased from 17 to 7 cmH2O. Thirty hours after surgery, the ECMO was removed. Eighteen hours later, the recipient did not need respiratory support.Outcomes:No complications of transplantation or ECMO were found.Lessons:It is feasible to utilize ECMO as a cardiocirculatory function support in the LT. ECMO does not increase the risk of hemorrhage. ECMO can play an important role in ensuring the security of the liver recipients in the surgery and in the postoperative period.
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