Early Surgical Referral for Penetrating Aortic Ulcer Leads to Improved Outcome and Overall Survival.

BACKGROUND: The natural history of penetrating aortic ulcer (PAU) has been variably described and clear guidelines are lacking. We reviewed our experience with PAUs in a tertiary referral center. METHODS: Imaging reports from January 2010 to December 2017 were retrospectively searched for the diagnosis of "penetrating aortic ulcer." Diagnosis was confirmed by review of imaging studies. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed for associations with need for surgical intervention, aortic complication, and overall survival. RESULTS: One hundred six patients with PAU were identified. Locations included 57 (53.8%) aortic arch, 24 (22.6%) descending thoracic, and 25 (23.5%) abdominal aorta. Dissection was present in 12 (11.4%) and acute rupture in 4 (3.8%) cases. At presentation, 57 (53.8%) patients were symptomatic. Forty-six (43.8%) patients were evaluated by cardiothoracic or vascular surgeons. Thirteen (12.3%) underwent surgical or endovascular repair and 10 (10.4%) had a change in medical management. Long-term follow-up (LTFU) was available in 30 patients for a mean of 36.5 ± 29.2 months. Twenty-one (70%, 21/30) demonstrated disease stability or resolution and 9 (30%, 9/30) worsened with 3 undergoing surgery. No PAU ruptured during follow-up. Patient demographics, presenting symptoms, and PAU morphology did not predict disease progression. Referral to a cardiovascular surgeon at initial presentation was associated with a 40% decreased likelihood of disease progression (P = 0.046) and a 60% survival advantage at LTFU (P = 0.037). CONCLUSIONS: PAU disease progression occurs in 30% of patients at LTFU of 36.5 ± 29.2 months. All patients identified with PAU on diagnostic imaging should be referred for a surgical evaluation and follow-up, as referral to cardiovascular surgeon is associated with improved disease course.

Case series and systematic review of acquired diaphragmatic hernia after liver transplantation.

BACKGROUND: ADH is a rare and potentially fatal complication following LT. In this study, a systematic review was completed to identify risk factors which may contribute to ADH. METHODS: Transplant databases at three LT programs were reviewed. Four pediatric and zero adult cases were identified. Next, a systematic review was completed. Fourteen studies describing 41 patients with ADH were identified. Patient demographics, transplant characteristics, and features of ADH diagnosis were examined. RESULTS: The majority (90.2%) of ADH were in children. In pediatric LT, 95.1% received a segmental allograft. ADH occurred in the right P diaphragm 92.7% of the time, and 87.8% were repaired primarily. Patient demographics, post-transplant complications, and immunosuppression regimens were broad and failed to predict ADH. Most patients presented with either respiratory or gastrointestinal symptoms. There were two pediatric deaths related to undiagnosed ADH. The combined worldwide incidence of ADH in pediatric LT is 1.5% (34/2319 patients). CONCLUSION: ADH is a rare complication post-LT that primarily occurs in pediatric recipients. When diagnosed early, ADH can be repaired primarily with good outcomes.

Improvement in the Outcomes of MELD ≥ 40 Liver Transplantation: An Analysis of 207 Consecutive Transplants in a Highly Competitive DSA.

BACKGROUND: Organ donor shortages continue to persist, especially in regions of the United States where competition is highest and recipients frequently attain a Model for End-Stage Liver Disease (MELD) score of 40 or higher before transplantation. The benefits of Share 35 in highly competitive regions may be underestimated when examining the collective national experience. The purpose of this study was to examine the outcomes of liver transplantation in recipients with a MELD of 40 or higher after implementation of Share 35 in a single center located in region 5. METHODS: The method used in this study was single-center retrospective analysis of 207 liver transplant recipients who achieved MELD score of 40 or higher from April 21, 2002, to May 15, 2015. RESULTS: Multivariable analysis identified implementation of Share 35 as the strongest predictor of graft survival in MELD of 40 or higher liver transplantation. The post-Share 35, 1-year graft survival was 94% compared with 75% pre-Share 35 (P = 0.002). Post-Share 35 recipients waited significantly less time until transplantation (10 vs 16 days, P = 0.015), and fewer were hospitalized for more than 28 days before their transplant (6% vs 18%, P = 0.05). Multivariable analysis identified recipients with diabetes at the time of listing as the strongest predictor of posttransplant patient mortality. CONCLUSIONS: Implementation of the Share 35 allocation policy has a significant effect on outcomes by improving organ access and minimizing candidate waiting times. Recipients achieving a MELD of 40 or higher at our center post-Share 35 had an improved 1-year graft survival. However, nearly 40% remained hospitalized for more than 4 weeks posttransplant, and 20% were discharged to an acute care facility.

Effects of recipient size and allograft type on pediatric liver transplantation for biliary atresia.

The majority of pediatric patients with end-stage liver disease receive a transplant with a whole liver (WL) allograft. However, smaller recipients with biliary atresia (BA) may have improved outcomes with deceased donor partial liver (DDPL) or living donor allografts. This study compares the national outcomes for liver transplantation in BA, with attention to the interaction between liver allograft type and recipient size. From January 2, 2002 to December 30, 2014, 2123 pediatric patients underwent a primary liver transplant for BA. The majority of transplants (53%) were performed with a WL allograft. Utilization of a WL allograft increased from 42% of recipients weighing ≤ 7 kg to 74% of recipients weighing > 14 kg. The 1-, 5-, and 10-year graft survival in recipients weighing ≤7 kg was significantly superior for living donor liver transplantation (LDLT) (91%, 88%, 84%) and DDPL allografts (90%, 84%, 77%) compared with WL allografts (79%, 75%, 74%; P = 0.005). The 1-, 5-, and 10-year graft survival in recipients weighing >14 kg trended toward being inferior in recipients of DDPL allografts (85%, 85%, 71%) compared with WL allografts (96%, 91%, 86%; P = 0.06). Furthermore, the incidence of vascular thrombosis was highest in WL (13%) compared with LDLT (6%) and DDPL (5%) recipients ≤ 7 kg (P = 0.002). Liver retransplantation was also highest in WL (16%) compared with LDLT (9%) and DDPL (9%) recipients ≤ 7 kg (P = 0.02). In conclusion, strong consideration should be given to the use of technical variant allografts in small recipients with BA requiring liver transplantation. Liver Transplantation 23 221-233 2017 AASLD.