Hepatic artery thrombosis in pediatric liver transplantation: Graft salvage after thrombectomy

Abstract

Hepatic artery thrombosis (HAT) is a devastating complication that may occur after orthotopic liver transplantation (OLT). A higher incidence has been reported in children. Salvage of the graft by thrombectomy has been suggested as an alternative to re-transplantation. In this study we report the outcome of three children who underwent thrombectomy for HAT. Between January 1992 and June 1998, 14 children (< 17 yrs of age) underwent liver transplantation. Three developed HAT (one a whole-liver graft recipient, age 17; two living-related graft recipients, ages 4 and 4.5 yr). In the first patient, thrombosis of the hepatic artery was associated with scattered areas of parenchymal necrosis on computed tomography. In the two living-related patients, HAT was found incidentally during re-exploration for bleeding (day 2 and day 10). Thrombectomy was performed in all three patients. At 18-24 months after thrombectomy, all three children had normal graft function. In the first patient, complete regeneration of the liver has been documented by computed tomography and a late asymptomatic recurrent thrombosis is suggested by absence of arterial flow on Doppler examination. The hepatic artery is patent in the two living-related recipients. One of these living-related recipients developed ischemic bile duct stricture and underwent successful percutaneous balloon dilatation. We conclude that long-term normal graft function can be achieved by thrombectomy in pediatric liver recipients with HAT, even in the presence of limited parenchymal damage.

Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver transplantation

“…To the best of our knowledge, this is the largest reported series of surgical thrombectomy for early HAT in pediatric OLT. In previous reports on thrombectomy for HAT after pediatric OLT, success rates have varied from 20% to 100% 12, 22, 26, 27, 30‐34. However, most of these studies included only small numbers of patients.…”

Hepatic artery thrombosis and liver malignancy in pediatric liver transplantation

“…Clinical evidence of this complication may come in the form of fulminant allograft failure, biliary disruption or obstruction, or systemic sepsis. If these signs and symptoms are caught early, medical and procedural interventions may be used to ameliorate the effects of HAT, including the use of systemic heparin anticoagulation, surgical thrombectomy, and reconstruction of the arterial anastomosis [6][7][8]. However, if HAT is recognized within the first week of transplant and interventions fail, the patient can be listed for urgent retransplantation [7,[9][10].…”

“…If these signs and symptoms are caught early, medical and procedural interventions may be used to ameliorate the effects of HAT, including the use of systemic heparin anticoagulation, surgical thrombectomy, and reconstruction of the arterial anastomosis [6][7][8]. However, if HAT is recognized within the first week of transplant and interventions fail, the patient can be listed for urgent retransplantation [7,[9][10]. Although the incidence, etiology, and management of HAT have been evaluated in a variety of studies, none have investigated the underlying diagnosis leading to transplantation and its possible role in the pathogenesis of this disease.…”

Management of the pediatric liver transplant patient

“…If HAT is confirmed early in the posttransplantation course, a surgical decision will be made whether to attempt surgical reconstruction or thrombolysis therapy. 18 Medical strategies to reduce the risk for HAT, including anticoagulation with heparin and use of low-molecular-weight dextran or acetylsalicylic acid, have never been of proven benefit. [19][20][21] Although portal vein thrombosis is not as common as HAT, it also has a variety of presentations.…”