Ex situ arterial reconstruction prior normothermic machine perfusion of liver grafts

Abstract

Purpose Atypical variants of the hepatic artery are common and pose a technical challenge for normothermic machine perfusion (NMP). The transplant surgeon has three options when confronted with hepatic arterial variation in a liver graft to be subjected to NMP: to perform arterial reconstruction (i) prior, (ii) during, or (iii) following NMP. Methods Herein, we report our experience and technical considerations with pre-NMP reconstruction. Out of 52 livers, 9 had an atypical hepatic artery (HA): 3 replaced right HA, 3 replaced left HA, 1 accessory left HA, 1 accessory left and right HA, and 1 replaced left and right HA. Results Reconstruction was conducted during back-table preparation. A single vascular conduit was created in all grafts to allow single arterial cannulation for NMP, necessitating only one arterial anastomosis within the recipient. All grafts were subjected to NMP and subsequently successfully transplanted. Conclusion Our approach is being advocated for as it preserves the ability to alter the reconstruction in case of problems resulting from the reconstruction itself, thereby allowing functional evaluation of the reconstruction prior transplantation, permitting simultaneous reperfusion in the recipient, and providing the shortest possible duration for vascular reconstruction once the graft is rewarming non-perfused within the recipient. In addition, in light of the frequency of technically demanding reconstructions with very small vessels, we consider our technique beneficial as the procedure can be performed under ideal conditions at the back-table.

Using IV-Tubing “Bridge” from Splenic Artery to Superior Mesentery Artery to Create a Single Arterial Cannulation for Normothermic Machine Perfusion When Donor Liver Has Replaced Right Hepatic Artery

“…Anatomical variations of the hepatic artery can be seen in up to 30% of liver grafts, and the most common variation was the replaced right hepatic artery (about 11–21%), which is the chief source of blood supply to the bile duct [ 9 , 10 ]. To keep an intact hepatic arterial vascular inflow, creating a single vascular conduit is necessary for NMP [ 11 ]. Several techniques have been reported by different centers for this mandatory reconstruction of all vessels of abnormal hepatic arterial anatomy [ 3 , 8 , 11 ].…”

“…To keep an intact hepatic arterial vascular inflow, creating a single vascular conduit is necessary for NMP [ 11 ]. Several techniques have been reported by different centers for this mandatory reconstruction of all vessels of abnormal hepatic arterial anatomy [ 3 , 8 , 11 ]. However, these techniques add non-oxygenated CIT to perform and require more specialized instruments during the back-table reconstruction in the donor operation room.…”