SELECTIVE REVASCULARIZATION OF HEPATIC-ARTERY THROMBOSES AFTER LIVER-TRANSPLANTATION IMPROVES PATIENT AND GRAFT-SURVIVAL

Background. Hepatic artery thrombosis (HAT) can be a devastating compl ication of orthotopic liver transplantation (OLT), but early diagnosis may allow successful revascularization and graft salvage. Methods. We reviewed data on 1,026 liver transplants at our institution. For pati ents in whom HAT was diagnosed within 30 days after OLT, we recorded i ndications for ultrasonography and Liver function tests at diagnosis, management of HAT, and graft and patient survival. Results. Thirty-two patients (3.1%) developed HAT at 6.8+/-6.6 days (range, 1-29 days) af ter OLT. Twelve patients (37.5%) were asymptomatic at diagnosis. In II of these 12, HAT was diagnosed on routine duplex at 2.0+/-1.55 days a fter OLT; in the 12th patient, HAT was noted during re-exploration for unrelated bleeding on postoperative day 3. Eleven of 12 patients (91. 6%) were revascularized; one patient (8.4%) received no treatment with no sequelae. Of the II who were revascularized, 9 (81.8%) had graft s alvage and 2 (18.2%) received a second transplant, with one death. Twe nty patients (62.5%) were symptomatic. In these 20, HAT was diagnosed at 9.85+/-6.93 days after OLT. Symptoms were: elevated liver function test results (serum glutamic oxaloacetic transaminase: 722+/-1792 U/ml , serum glutamic pyruvic transaminase: 678+/-963 U/ml, and bilirubin: 10.2+/-6.2 mg/dl) in 13 patients (65%); bile leak in 4 patients (20%), and sepsis in 3 (15%). Five of the 20 patients (25%) were revasculari zed; of these 5, 2 (40%) had graft salvage, 2 (40%) received a second transplant with 1 death, and 1 (20%) died of a Liver abscess. Twelve s ymptomatic patients (60%) had immediate re-OLT; 10/12 are alive, 1 die d of sepsis, and 1 died late of unrelated causes. Three symptomatic pa tients had no treatment; two died of biliary sepsis and one survived. Overall graft salvage was 83.3% in asymptomatic patients and 15% in pa tients with symptoms (P<0.001). Graft salvage in asymptomatic patients undergoing revascularization was 81.8%, versus 40% in symptomatic pat ients (P=NS). One-year patient survival was 91.7% in asymptomatic pati ents and 65% in symptomatic patients (with one late death excluded) (P =NS). Conclusions. Routine postoperative duplex ultrasonography should be performed early after liver transplantation. We believe that emerg ent revascularization of hepatic artery thrombosis in asymptomatic pat ients and retransplantation in symptomatic patients lead to improved g raft salvage and patient survival with a relatively low incidence of l ate biliary complications.