J. R. Schroering2, C. A. Kubal1, T. J. Hathaway2, R. S. Mangus1 1Indiana University School Of Medicine,Transplant Division/Department Of Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Indianapolis, IN, USA
Introduction: The arterial anatomy of the liver has significant variability. When a liver graft is procured for transplant, the donor hepatic artery anatomy must be identified and preserved to avoid injury. Reconstruction of the hepatic artery is often required in cases of accessory or replaced vessels. This study reviews a large number of liver transplants and summarizes the arterial anatomy. Clinical outcomes include hepatic artery thrombosis (HAT), early graft loss and long term graft survival.
Methods: All liver transplants at a single center over a 10-year period were reviewed. The arterial anatomy was determined from a combination of the organ procurement record and the liver transplant operative note. Anatomic variants and reconstructions were noted. For this cohort, all accessory/replaced right hepatic arteries were reconstructed to the gastroduodenal artery (GDA) with 7-0 prolene suture on the back table prior to implantation. All accessory/replaced left hepatic arteries were left intact from their origin at the left gastric and hepatic artery when possible, though occasional reconstruction to the GDA with 7-0 prolene suture was performed. Post-operative anticoagulation was not utilized routinely. Antithrombolytic therapy was administered at initial incision in all cases using either aprotinin or epsilon aminocaproic acid. A single Doppler ultrasound (US) was obtained post-operatively in the critical care unit to confirm arterial and venous flow. No other imaging (intraoperative or post-operative) was obtained unless there was an indication.
Results: The records for 1145 patients were extracted. The median recipient age was 57, body mass index 28.4, and MELD 20. Retransplant procedures comprised 4% of the cohort. Hepatic arterial anatomy types include: normal (68%), accessory/replaced left (16%), accessory/replaced right (10%), accessory/replaced right and left (4%), and other variants (2%). There were 222 cases (19%) in which back table arterial reconstruction was required. The overall incidence of HAT was 1%. The highest rate of HAT was in liver grafts with accessory right and left hepatic arteries. The hepatic arterial resistive indices measured on post-operative Doppler US did not differ by hepatic artery anatomy. One-year survival for all grafts was above 90%, but livers with an accessory right hepatic artery (only) had lower survival at 10-years when compared with grafts with normal anatomy (62% versus 75%).
Conclusion: There were 68% of livers with standard anatomy, with the accessory/replaced left (16%) and right (10%) arteries being the next most common variants. All anatomic variants had good 1-year graft survival, though liver grafts with an accessory/replaced right hepatic artery had lowest survival at 10-years.
