Primary Stent Placement for Hepatic Artery Stenosis After Liver Transplantation: Improving Primary Patency and Reintervention Rates

Abstract

Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow-up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow-up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24-68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow-up period (median, 41 months; interquartile range [IQR], 25-86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4-11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow-up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.Hepatic artery stenosis (HAS) occurs in 4%-10% of liver transplantation patients. (1)(2)(3) HAS is considered a risk factor for hepatic artery thrombosis, ischemic biliary complications, graft dysfunction or loss, and death. (4,5) Percutaneous revascularization of HAS can be performed by either percutaneous balloon angioplasty (PBA) or hepatic arterial stent placement. A meta-analysis reviewing literature on this subject between 1970 and 2011 found no statistical difference between PBA and hepatic artery stenting. (6) More recent studies with larger cohorts and longer follow-up have reported similar results. (7-10) However, several centers have moved toward primary stent placement. (7,8) Given the low incidence of HAS, techniques for endovascular revascularization are guided by operator or institutional experience and prospective trials comparing patient selection, procedural technique, or postprocedure management are unlikely to be performed. Unfortunately, even recent literature SARWAR ET AL.Abbreviations: CT, computed tomography; HAS, hepatic artery stenosis; IQR, interquartile range; PBA, percutaneous balloon angioplasty.Address reprint requests to Ammar Sarwar, M.B.B.

Time is of the essence: A single‐center experience of hepatic arterial supply impairment management in pediatric liver transplant recipients

“…Another crucial matter is the role of non‐occlusive arterial flow reduction in the development of ITBL and graft loss. Non‐occlusive arterial complications can potentially lead to HAT development 2,3,25 . Our study demonstrated that prompt identification and restoration of adequate arterial supply in HAS/SASS cases allow to salvage the grafts and avoid sepsis compared with HAT cases.…”

“…Nonocclusive arterial complications can potentially lead to HAT development. 2,3,25 Our study demonstrated that prompt identi- HAT is still a formidable complication and is characterized by high graft loss and ITBL rates. Assumptions about the role of arterial ischemia time have been suggested earlier.…”

“…The reports of routine endovascular approach for pediatric liver graft arterial compilations are limited 27,28 . At the same time, a number of studies demonstrate successful application of interventional endovascular treatment in adult patients with LDLT 2,29‐31 . A previously described severe angioplasty complication–hepatic artery rupture, did not occur in our practice 27,32 .…”

“…SASS was defined as a diminished hepatic arterial flow secondary to diversion of blood flow into a splenic artery 3 . Graft artery stenosis equal or more than 50% of the luminal diameter on angiography was treated as HAS 2 . Patients with the absence of graft arterial flow (total occlusion) were categorized to HAT.…”

“…The main reasons for the impairment of hepatic arterial flow after liver transplantation (LT) are hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), and splenic arterial steal syndrome (SASS). HAS incidence can reach 10% 1,2 in liver transplant recipients. SASS occurs less often, at approximately 1% to 5% 3 .…”