Arcuate ligament compression as a cause of early-onset thrombosis of the hepatic artery after liver transplantation

Vilatobá, Mario; Zamora-Valdés, Daniel; Guerrero‐Hernández, Manuel; Romero-Talamás, Héctor; Leal-Villalpando, Rafael Paulino; Mercado, Miguel Ángel

doi:10.1016/s1665-2681(19)31594-7

Cited by 16 publications

(24 citation statements)

References 15 publications

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“…In OLT, MALC may lead to arterial complications requiring an urgent surgical division of the MAL and thrombectomy. In some cases, however, even with immediate actions taken, the liver allograft cannot be saved and re-OLT is inevitable [14,18,19,21].…”

Section: Discussionmentioning

confidence: 99%

“…In a recent large cohort of 481 oesophagectomies reported by Lainas et al, celiac artery stenosis was associated with oesophageal conduit necrosis following Ivor Lewis procedure, of which 50% was due to MALC [7]. In OLT only scarce clinical evidence is available with regards to the incidence, clinical relevance, diagnosis, and treatment of MALC [14,15,16,17,18,19,20,21].…”

Section: Introductionmentioning

confidence: 99%

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Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study

Czigány

Boecker

Santana

et al. 2019

JCM

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Median arcuate ligament compression (MALC) potentially causes arterial complications in orthotopic liver transplantation (OLT). Here we aimed to investigate the incidence of MALC and its impact on clinical outcome after OLT. In addition, we performed an international survey among 52 European liver transplant centers to explore local protocols on the management of these patients. Data of 286 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-07/2017). Preoperative computed-tomography images were evaluated. Celiac axis stenosis due to MALC was found in 34 patients (12%). Intrinsic stenosis was present in 16 (6%) patients. Twenty-six patients (77%) with MALC underwent standard arterial revascularization with median arcuate ligament (MAL)-division. Patients treated for MALC had comparable baseline data and no difference was found in early- and long-term outcome compared to the rest of our cohort. Our survey found heterogeneous strategies regarding diagnosis and treatment of MALC. Only 29% of the centers reported the division of MAL in these patients as routine procedure. Even though there is no consensus on diagnosis and management of MALC among European centers, a surgical division of MAL is feasible and safe and should be considered in OLT recipients with MALC.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study

Czigány

Boecker

Santana

et al. 2019

JCM

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“…Both interventions can restore the blood flow in the hepatic artery. [ 3 , 4 , 16 – 18 ] Some reports suggest that retaining GDA completely without dissection of MAL does not increase the incidence of arterial thrombosis, compared with that with arterial reconstruction. [ 16 ]…”

Section: Discussionmentioning

confidence: 99%

“…[ 2 ] This indicates that MALS may disturb the graft blood supply from HA, delay the recovery of graft function, and eventually lead to biliary complications. MALS is considered a high-risk factor for hepatic artery thrombosis (HAT) in liver transplant recipients [ 3 , 4 ] ; however, few associated cases have been reported till date.…”

Section: Introductionmentioning

confidence: 99%

Median arcuate ligament syndrome and arterial anastomotic bleeding inducing hepatic artery thrombosis after liver transplantation

et al. 2018

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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.

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“…Because no calcifications were demonstrated at the site of the celiac stenosis by CT angiography, the differential diagnosis would include non-calcified atherosclerotic plaque as well as the median arcuate ligament syndrome. 7 – 9 Some authors have noted that celiac artery compression by the arcuate ligament occurs in as many as 10% of patients undergoing liver transplantation. 7 It is rarely symptomatic, owing to efficient arterial collateralization from the superior mesenteric and the gastroduodenal arteries; however, in patients without sufficient collateralization, symptomatic hepatic arterial insufficiency and/or thrombosis may result.…”

Section: Discussionmentioning

confidence: 99%

Delayed diagnosis of celiac stenosis causing hepatic transplant ischaemic necrosis: diagnosis by spectral Doppler findings

et al. 2017

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Following presentation with abnormal liver function enzymes, confusion and fatigue, a 65-year-old male with alcoholic cirrhosis underwent spectral Doppler sonography that showed tardus parvus-like morphology in the main and left hepatic arteries, although peak systolic velocities and resistive indices remained normal. The patient’s continuing clinical symptoms prompted CT angiography, which demonstrated an unexpected, haemodynamically significant stenosis of the celiac artery. Although the stenosis was successfully stented and the hepatic arterial waveforms normalized, the transplanted liver had already undergone ischaemic necrosis, with resulting failure and the need for retransplantation. Recognition of abnormal waveforms, despite normal peak systolic velocities and resistive indices, with prompt definitive imaging evaluation of the arterial tree beyond just the main hepatic artery, may lead to the diagnosis of unexpected flow-limiting lesions in time to allow revascularization and thus prevent ischaemic transplant failure.

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Arcuate ligament compression as a cause of early-onset thrombosis of the hepatic artery after liver transplantation

Cited by 16 publications

References 15 publications

Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study

Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study

Median arcuate ligament syndrome and arterial anastomotic bleeding inducing hepatic artery thrombosis after liver transplantation

Delayed diagnosis of celiac stenosis causing hepatic transplant ischaemic necrosis: diagnosis by spectral Doppler findings

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