Graft aberrant hepatic arteries in deceased donor liver transplantation: The "one liver, one artery" approach.

In liver transplantation (LT), graft aberrant hepatic arteries (aHAs) frequently require complex arterial reconstructions, potentially increasing the risk of post-operative complications. However, intrahepatic hilar arterial shunts are physiologically present and may allow selective aHA ligation. Thus, we performed a retrospective study from a single-center cohort of 618 deceased donor LTs where a selective reconstruction policy of aHAs was prospectively applied. In the presence of any aHA, the vessel with the largest caliber was first reconstructed. In case of adequate bilobar arterial perfusion assessed on intraparenchymal Doppler ultrasound, the remnant vessel was ligated; otherwise, it was reconstructed. Consequently, outcomes of three patient groups were compared: the "no aHAs" group (n = 499), the "reconstructed aHA" group (n = 25), and the "ligated aHA" group (n = 94). Primary endpoint was rate of biliary complications. Only 38.4% of right aHAs and 3.1% of left aHAs were reconstructed. Rates of biliary complications in the no aHA, reconstructed aHA, and ligated aHA groups were 23.4%, 28%, and 20.2% (p = 0.667), respectively. The prevalence rates of primary non-function (p = 0.534), early allograft dysfunction (p = 0.832), and arterial complications (p = 0.271), as well as patient survival (p = 0.266) were comparable among the three groups. Retransplantation rates were 3.8%, 4%, and 5.3% (p = 0.685), respectively. In conclusion, a selective reconstruction policy of aHAs based on Doppler assessment of bilobar intraparenchymal arterial flow did not increase post-operative morbidity and avoided unnecessary and complex arterial reconstructions.

Successful Transplant of a Liver Graft After Giant Hepatic Artery Aneurysm Resection and Reconstruction.

The shortage of organs has pushed transplant surgeons to accept liver grafts with extended criteria, but severe vascular abnormalities may still discourage the use of otherwise acceptable organs. We report herein the case of a liver graft with a 64-mm aneurysm of the proper hepatic artery extended to the origin of the right and left hepatic branches. The graft was deemed unsuitable for transplant by all other centers in the region. However, liver function tests were normal, and there was no evidence of compromised arterial supply. At back table, we resected the aneurysm and anastomosed the right and left hepatic arteries to a vascular graft obtained from the distal tract of the donor's superior mesenteric artery. After portal reperfusion, we anastomosed the mesenteric graft to the recipient's hepatic artery at the origin of the gastroduodenal artery. The postoperative course and the subsequent 6-month follow-up were uneventful. In conclusion, the presence of a hepatic artery aneurysm should not be an absolute contraindication to the use of a liver graft. The present case emphasizes the possibility to utilize an organ that would have been otherwise discarded.

Graft Hepatic Artery Rupture Due to Carbapenem-Resistant Klebsiella pneumoniae Infection After Liver Transplant.

Carbapenem-resistant Klebsiella pneumoniae infection is a major cause of morbidity and mortality after solid-organ transplant and hematopoietic stem cell transplant. Here, we report a 57-year-old man with hepatitis B virus-related decompensated liver cirrhosis, huge splenic artery aneurysm, and hypersplenism who underwent liver transplant from a deceased brain-dead donor. Recipient sputum surveillance showed carbapenem-resistant Klebsiella pneumoniae when he entered the intensive care unit, and combined tigecycline, meropenem, and fosfomycin were administered. At 1 week posttransplant, the recipient's hepatic artery was eroded by disseminated carbapenem-resistant Klebsiella pneumoniae infection, and the patient developed acute kidney injury. Our experience suggests that colonization of carbapenem-producing organisms may be included during surveillance posttransplant and that the infected graft artery must be removed instead of noninfected vessels.

Segment IV hepatic artery in potential donors for living related liver transplantation: Evaluation with multi-detector CT.

OBJECTIVE: To assess segment IV hepatic arterial anatomy and its variation on multi-detector computed tomography in potential liver donors. METHODS: The retrospective study was conducted at Shifa International Hospital, Islamabad and comprised data of potential liver transplant donors related to the period between January 2012 and June 2017. Computed tomography scans were performed using multi-detector scanners. Images were transferred to work station for postprocessing and were analysed regarding the origination and variation of the arteries by two independent experienced radiologists. RESULTS: Of the 455 patients whose records were evaluated, 299(65.7%) were males and 156(34.3%) were females. Six types of segment IV artery were defined based on their points of origin: left hepatic artery 285(62.6%), right hepatic artery 111(24.4 %), proper hepatic artery 9(1.8 %), common hepatic artery 29(6.4%), gastro duodenal artery 3(0.7 %), and dual 18(4.1 %).313 of total cases (68.8%) had normal anatomy with no variation. Those with aberrant/variant anatomy constituted 142(31.2%) of the total. CONCLUSIONS: Multi-detector computed tomography angiography was found to be a fast, reliable and non-invasive technique that could evaluate normal as well as anatomical variants of segment IV arteries.

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial.

Traditionally, deceased donor liver grafts receive dual perfusion (DP) through the portal vein and the hepatic artery (HA) either in situ or on the back table. HA perfusion is avoided in living donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis (HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of postoperative biliary complications. Consecutive adult patients undergoing living donor liver transplantations were randomized after donor hepatectomy to receive graft perfusion of histidine-tryptophan-ketoglutarate solution either via both the HA and portal vein (DP group, n = 62) or only through the portal vein (standard perfusion [SP] group, n = 62). The primary endpoint was the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included HAT and patient survival. The incidence of biliary stricture was significantly lower in the DP group (6.5% versus 19.4%; odds ratio, 0.29; 95% confidence interval, 0.09-0.95; P = 0.04). There was no significant reduction in the incidence of HAT, bile leak, or hospital stay between the 2 groups. The 3-year mortality and graft survival rates were significantly higher among patients who received DP compared with SP (P = 0.004 and P = 0.003, respectively). On multivariate analysis, nonperfusion of the HA and preceding bile leak were found to be risk factors for the development of biliary stricture (P = 0.04 and P < 0.001, respectively). In conclusion, DP of living donor liver grafts through both the HA and portal vein on the back table may protect against the development of biliary stricture. This could translate to improved patient survival in the short term.

Impact of Extra-anatomical Hepatic Artery Reconstruction During Living Donor Liver Transplantation on Biliary Complications and Graft and Patient Survival.

BACKGROUND: This study was designed to analyze the feasibility of extra-anatomical hepatic artery (HA) reconstruction in living donor liver transplantation (LT). METHODS: Patients who underwent their first living donor LT at our center between January 2008 and December 2017 were reviewed. HA reconstruction was classified as anatomical or extra-anatomical reconstruction (EAR). We compared the background characteristics and posttransplantation outcomes, including complications, biliary complications, graft survival, and overall survival. The potential risk factors for bile leakage were analyzed using multivariable logistic regression, while risk factors for biliary stricture-free survival, graft survival, and overall survival were analyzed using multivariable Cox regression. RESULTS: Among 800 patients, 35 (4.4%) underwent EAR, of whom 7 (7/35, 20.0%) experienced HA complications after the initial anatomical reconstruction and required EAR during reoperation. Patients who underwent EAR (n = 2/35, 5.7%) had a similar rate of HA complications compared with those who underwent anatomical reconstruction (n = 46/772, 5.9%, P = 0.699). EAR was a significant risk factor for bile leakage (odds ratio [OR], 4.167; 95% confidence interval [CI], 1.928-9.006; P < 0.001) along with multiple bile ducts (OR, 1.606; 95% CI, 1.022-2.526; P = 0.040) and hepaticojejunostomy (OR, 4.108; 95% CI, 2.190-7.707; P < 0.001). However, EAR had no statistical relationship to biliary stricture-free survival (hazard ratio [HR], 1.602; 95% CI, 0.982-2.613; P = 0.059), graft survival (HR, 1.745; 95% CI, 0.741-4.109; P = 0.203), or overall survival (HR, 1.405; 95% CI, 0.786-2.513; P = 0.251). HA complications were associated with poor biliary stricture-free survival (HR, 2.060; 95% CI, 1.329-3.193; P = 0.001), graft survival (HR, 5.549; 95% CI, 2.883-10.681; P < 0.001), and overall survival (HR, 1.958; 95% CI, 1.195-3.206; P = 0.008). CONCLUSION: Extra-anatomical HA reconstruction during living donor LT was not a risk factor for biliary stricture, graft failure, or overall survival.

Impact of Donor Risk Index on Risk of Hepatic Artery Thrombosis in Patients After Orthotopic Liver Transplantation.

BACKGROUND: Hepatic artery thrombosis (HAT) is one of the most severe complications after liver transplantation (LT). HAT can lead to early graft loss and retransplantation or death of the recipient. METHODS: This retrospective cohort study was conducted using data from patients treated between January 2008 and December 2013 in the Department of General, Transplant and Liver Surgery at the Medical University of Warsaw. A total of 750 patients underwent LT over this period. RESULTS: HAT occurred in 27 patients (2.1%). The median DRI was 1.414 (IQR 1.103-1.578) points and median donor age was 47 (IQR 33-56) years. The optimal cut-off value of DRI in predicting HAT was ≥1.328 points. The cutoff point was characterized by sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 88.0%, 41.3%, 5.5% and 98.9%, respectively (AUC = 0.605, 95% CI 0.477-0.733). A DRI ≥1.328 was a significant risk factor for HAT (OR = 5.16, 95% confidence interval [CI] 1.529-17.48, P = .008). The optimal cutoff point for donor age was 50 years and was characterized by sensitivity, specificity, PPV, and NPV of 66.7%, 55.8%, 5.3%, and 97.8%, respectively. Donor age ≥50 years (OR = 2.53, 95% CI 1.123-5.714, P = .025) was a significant risk factor for HAT. CONCLUSION: DRI is a clinically relevant factor that allows estimating the risk of HAT after liver transplantation from a deceased donor. To reduce the incidence of this complication, the allocation of organs taken from donors at DRI exceeding 1.328 for recipients without other HAT risk factors should be considered.

Antegrade Arterial and Portal Flushing Versus Portal Flushing Only for Right Lobe Live Donor Liver Transplantation-A Randomized Control Trial.

BACKGROUND: In live donor liver transplantation portal flush only of the graft is done on the bench. There are no data on antegrade arterial flush along with portal flush of the graft. METHODS: Consecutive patients undergoing elective right lobe live donor liver transplantation were block-randomized to receive either portal flush only or both portal and antegrade arterial flush. The primary objectives were safety, rate of early allograft dysfunction (EAD), and impact on vascular and biliary complications. RESULTS: After randomization, there were 40 patients in each group. Both groups had comparable preoperative, intraoperative, and donor variables. There were no adverse events related to arterial flushing. The portal and antegrade arterial flush group had significantly lower postoperative bilirubin on days 7, 14, and 21 (all P < 0.05), EAD (P = 0.005), intensive care unit/high dependency unit (P = 0.01), and hospital stay (P = 0.05). This group also had lower peak aspartate aminotransferase (P = 0.07), alanine aminotransferase (P = 0.06) and lower rates of sepsis (P = 0.08) trending toward statistical significance. Portal and antegrade arterial flush groups had lower ascitic fluid drainage and in-hospital mortality. Arterial and biliary complications were not statistically different in the 2 groups. Multivariate analysis of EAD showed portal with antegrade arterial flush was associated with lower rate (P = 0.007), whereas model for end-stage liver disease Na (P = 0.01) and donor age (P = 0.03) were associated with a higher rate of EAD. CONCLUSIONS: Portal with antegrade arterial flushing of right lobe live liver grafts is safe, significantly decreases postoperative cholestasis, EAD, intensive care unit/high dependency unit, and hospital stay and is associated with lower rates of sepsis, ascitic drainage and inhospital mortality in comparison to portal flush only.

Impact of aberrant left hepatic artery ligation on the outcome of liver transplantation.

The preservation of a graft's aberrant left hepatic artery (LHA) during liver transplantation (LT) ensures optimal vascularization of the left liver but can also be considered a risk factor for hepatic artery thrombosis (HAT). In contrast, ligation of an aberrant LHA may lead to hepatic ischemia with the potential risk of graft dysfunction and biliary complications. The aim of this study was to prospectively analyze the impact on the surgical strategy for LT of 5 tests performed to establish whether an aberrant LHA was an accessory or a replaced artery, thus leading to the design of a decisional algorithm. From August 2005 to December 2016, 395 whole LTs were performed in 376 patients. Five parameters were evaluated to determine whether an aberrant LHA was an accessory or a replaced artery. On the basis of our decision algorithm, an aberrant LHA was ligated during surgery when assessed as accessory and preserved when assessed as replaced. A total of 138 anatomical variants of hepatic arterial vascularization occurred in 120/395 (30.4%) grafts. Overall, the incidence of an aberrant LHA was 63/395 (15.9%). The LHA was ligated in 33 (52.4%) patients and preserved in 30 (47.6%) patients. After a mean follow-up period of 50.9 ± 39.7 months, the incidence of HAT, primary nonfunction, early allograft dysfunction, biliary stricture or leaks, and overall survival was similar in the 2 groups. In conclusion, once shown to be an accessory, an LHA can be safely ligated without clinical consequences on the outcome of LT. Liver Transplantation 24 204-213 2018 AASLD.

Complications after endovascular treatment of hepatic artery stenosis after liver transplantation.

BACKGROUND: Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis (HAT) and a subsequent 30% to 50% risk of graft loss. Although endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment, the potential risks of these interventions are poorly described. METHODS: A retrospective review of all endovascular interventions for HAS after liver transplantation between August 2009 and March 2016 was performed at a single institution, which has the largest volume of liver transplants in the United States. Severe HAS was identified by routine surveillance duplex ultrasound imaging (peak systolic velocity >400 cm/s, resistive index <0.5, and presence of tardus parvus waveforms). RESULTS: In 1129 liver transplant recipients during the study period, 106 angiograms were performed in 79 patients (6.9%) for severe de novo or recurrent HAS. Interventions were performed in 99 of 106 cases (93.4%) with percutaneous transluminal angioplasty alone (34 of 99) or with stent placement (65 of 99). Immediate technical success was 91%. Major complications occurred in eight of 106 cases (7.5%), consisting of target vessel dissection (5 of 8) and rupture (3 of 8). Successful endovascular treatment was possible in six of the eight patients (75%). Ruptures were treated with the use of a covered coronary balloon-expandable stent graft or balloon tamponade. Dissections were treated with placement of bare-metal or drug-eluting stents. No open surgical intervention was required to manage any of these complications. With a median of follow-up of 22 months, four of eight patients (50%) with a major complication progressed to HAT compared with one of 71 patients (1.4%) undergoing a hepatic intervention without a major complication (P < .001). One patient required retransplantation. Severe vessel tortuosity was present in 75% (6 of 8) of interventions with a major complication compared with 34.6% (34 of 98) in those without (P = .05). In the complication cohort, 37.5% (3 of 8) of the patients had received a second liver transplant before intervention compared with 12.6% (9 of 71) of the patients in the noncomplication cohort (P = .097). CONCLUSIONS: Although endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery and prior retransplantation were associated with a twofold to threefold increased risk of a major complication. Acute vessel injury can be managed successfully using endovascular techniques, but these patients have a significant risk of subsequent HAT and need close surveillance.

Resolution of Hepatic Artery Thrombosis in 2 Pediatric Liver Transplant Patients.

Hepatic artery thrombosis (HAT) is a serious complication after liver transplantation. This is the first report of spontaneous resolution of HAT in pediatric liver transplant patients on low molecular weight heparin therapy. A total of 2 patients, a 26-month-old boy who presented with acute liver failure and required emergent liver transplantation and a 15-year-old boy with ulcerative colitis and autoimmune hepatitis-primary sclerosing cholangitis overlap underwent liver transplantation for progressive cirrhosis; both developed HAT during the postoperative period. They were both treated with low molecular weight heparin. Follow-up imaging for both patients showed resolution of HAT without evidence of collateral flow.

Comparative morphometric analysis of 5 interpositional arterial autograft options for adult living donor liver transplantation.

UNLABELLED: In living donor liver transplantation, the right-sided graft presents thin and short vessels, bringing forward a more difficult anastomosis. In these cases, an interpositional arterial autograft can be used to favor the performance of the arterial anastomosis, making the procedure easier and avoiding surgical complications. OBJECTIVE: We compared the inferior mesenteric artery (IMA), the splenic artery (SA), the inferior epigastric artery (IEA), the descending branch of the lateral circumflex femoral artery (LCFA), and the proper hepatic artery (PHA) as options for interpositional autograft in living donor liver transplantation. METHOD: Segments of at least 3 cm of all 5 arteries were harvested from 16 fresh adult cadavers from both genders through standardized dissection. The analyzed measures were proximal and distal diameter and length. The proximal diameter of the RHA and the distal diameter of the SA, IMA, IEA and the LCFA were compared to the distal diameter of the RHA. The proximal and distal diameters of the SA, IEA and LCFA were compared to study caliber gain of each artery. RESULTS: All arteries except the IMA showed statistical significant difference in relation to the RHA in terms of diameter. Regarding caliber gain, the arteries demonstrated statistical significant difference. All the harvested arteries except PHA were 3 cm in length. CONCLUSION: The IMA demonstrated the best compatibility with the RHA in terms of diameter and showed sufficient length to be employed as interpositional graft. The PHA, the SA, the IEA and the LCFA presented statistically significant different diameters when compared to the RHA. Among these vessels, only the PHA did not show sufficient mean length.

Liver computed tomography with low tube voltage and model-based iterative reconstruction algorithm for hepatic vessel evaluation in living liver donor candidates.

OBJECTIVE: The objective of this study was to investigate the image quality and diagnostic performance of model-based iterative reconstruction (MBIR) for hepatic vessel evaluation on low-tube-voltage (100 kilovolt [peak]) liver computed tomography (CT) for living donors. METHODS: Fifty-one liver donor candidates (low-kilovolt group) underwent low-tube-voltage CT, which was reconstructed using filtered back projection, adaptive statistical iterative reconstruction, and MBIR. Additional 51 donor candidates who underwent 120-kilovolt (peak) CT using FBP were selected as matching control (standard group). The volume CT dose index, image noise, contrast-to-noise ratios, diagnostic accuracy, and confidence of hepatic vasculatures were evaluated. RESULTS: Significant dose reduction was obtained with low-tube-voltage CT. The MBIR images of the low-kilovolt group showed significantly lower image noise and higher contrast-to-noise ratios than did the other image sets (P < 0.001). Regarding diagnostic accuracy and confidence of hepatic vessel anatomic variations with surgical correlation, the MBIR images provided results equivalent to those of other images (P > 0.05). CONCLUSIONS: Low-tube-voltage liver CT using MBIR may increase image quality and preserve diagnostic performance of hepatic vessel evaluation at reduced radiation dose.

Effect of sex on biomechanical properties of the proper hepatic artery in pigs and humans for liver xenotransplant.

OBJECTIVES: This study investigated the relation between biomechanical properties of the proper hepatic artery and sex in pigs and humans to provide the theoretical basis for selecting suitable donor in pig-to-human liver xenotransplant. MATERIALS AND METHODS: The proper hepatic arteries of 32 Chinese Hubei white pigs (8 males, 8 females, 8 castrated males, and 8 ovariectomized females) and 10 deceased donors (5 human men, 5 human women) were obtained. The pressure-diameter relations of the proper hepatic arteries were measured on biomechanical test equipment to calculate the incremental elastic modulus (Einc), pressure-strain elastic modulus (Ep), volume elastic modulus (Ev), and compliance. Each sample was sliced into 5-µm frozen sections and stained with hematoxylin-eosin. RESULTS: There were significant differences in Einc (F=10.24; P = .001), Ep (F=3.75; P = .001), and Ev (F=3.41; P = .002) of the proper hepatic arteries of female, male, and gonadectomized pigs; females had the lowest elastic modulus and the gonadectomized group had the highest (P < .01). There was a significant difference in compliance of the porcine proper hepatic arteries between the sexes, highest in the female group and lowest in the gonadectomized group (P < .01). No difference in the elastic modulus and compliance of the proper hepatic artery between the male pig and the human man. There was no difference between the female pig and the human woman. CONCLUSIONS: There were differences in the biomechanical properties of the proper hepatic arteries of the female, male, and gonadectomized pigs. The biomechanical properties of the human men/women proper hepatic artery match those of the porcine male/female hepatic artery. The correlation between sex and biomechanical properties of the proper hepatic artery in pigs could imply that a pig of the same sex should be chosen for pig-to-human liver xenotransplant.

Split ex situ e in situ: técnica y resultados / No disponible

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Techniques of flushing and reperfusion for liver transplantation.

BACKGROUND: Various techniques of flushing and reperfusion have been advocated to improve outcomes after liver transplantation. There is considerable uncertainty as to which method is superior. OBJECTIVES: To compare the benefits and harms of different methods of flushing and reperfusion during liver implantation in the transplant recipients. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2011. SELECTION CRITERIA: We included all randomised clinical trials that were performed to compare different techniques of flushing and reperfusion during liver transplantation. DATA COLLECTION AND ANALYSIS: Two authors independently identified the trials and extracted the data. We analysed the data with both the fixed-effect model and the random-effects model using RevMan analysis. For each outcome we calculated the hazard ratio (HR), risk ratio (RR), rate ratio, mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on available case analysis. MAIN RESULTS: We included six trials involving 418 patients for this review. The sample size in the trials varied from 30 to 131 patients. Only one trial involving 131 patients was of low risk of bias for mortality. This trial was at high risk of bias for other outcomes. Four trials excluded patients who underwent liver transplantation for acute liver failure. All the trials included livers obtained from cadaveric donors. The remaining five trials were of high risk of bias for all outcomes. Liver transplantation was performed by the conventional method (caval replacement) in two trials and piggy-back method (caval preservation) in one trial. The method of liver transplantation was not available in the remaining three trials. The comparisons performed included an initial hepatic artery flush versus initial portal vein flush; blood venting via inferior vena cava in addition to venting of storage fluid versus no blood venting; initial hepatic artery reperfusion versus initial portal vein reperfusion; simultaneous hepatic artery and portal vein reperfusion versus initial portal vein reperfusion; and retrograde inferior vena cava reperfusion versus simultaneous hepatic artery and portal vein reperfusion. Only one or two trials could be included under each comparison. There was no significant difference in mortality, graft survival, or severe morbidity rates in any of the comparisons. Quality of life was not reported in any of the trials. AUTHORS' CONCLUSIONS: There is currently no evidence to support or refute the use of any specific technique of flushing or reperfusion during liver transplantation. Due to the paucity of data, absence of evidence should not be confused with evidence of absence of any differences. Further well designed trials with low risk of systematic error and low risk of random errors are necessary.

Hepatic artery graft in pediatric liver transplantation: single-center experience with 58 cases.

INTRODUCTION: The use of arterial grafts (AG) in pediatric orthotopic liver transplantation (OLT) is an alternative in cases of poor hepatic arterial inflow, small or anomalous recipient hepatic arteries, and retransplantations (re-OLT) due to hepatic artery thrombosis (HAT). AG have been crucial to the success of the procedure among younger children. Herein we have reported our experience with AG. METHODS: We retrospectively reviewed data from June 1989 to June 2010 among OLT in which we used AG, analyzing indications, short-term complications, and long-term outcomes. RESULTS: Among 437 pediatric OLT, 58 children required an AG. A common iliac artery interposition graft was used in 57 cases and a donor carotid artery in 1 case. In 38 children the graft was used primarily, including 94% (36/38) in which it was due to poor hepatic arterial inflow. Ductopenia syndromes (n = 14), biliary atresia (BA; n = 11), and fulminant hepatitis (n = 8) were the main preoperative diagnoses among these children. Their mean weight was 18.4 kg and mean age was 68 months. At the mean follow-up of 27 months, multiple-organ failure and primary graft nonfunction (PNF) were the short-term causes of death in 9 children (26.5%). Among the remaining 29 patients, 2 (6,8%) developed early graft thrombosis requiring re-OLT; 5 (17%) developed biliary complications, and 1 (3.4%) had asymptomatic arterial stenosis. In 20 children, a graft was used during retransplantation. The main indication was HAT (75%). BA (n = 15), ductopenia syndromes (n = 2), and primary sclerosing cholangitis (n = 2) were the main diagnoses. Their mean weight was 16.7 kg and age was 65 months. At a mean follow-up of 53 months, 7 children died due to multiple-organ failure or PNF. Among the remaining 13 patients, 3 developed biliary complications and 1 had arterial stenosis. No thrombosis was observed. CONCLUSION: The data suggested that use of an AG is useful alternative in pediatric OLT. The technique is safe with a low risk of thrombosis.

Hypoperfusion of segment 4 in right in situ split-liver transplantation.

To expand the donor pool, split-liver transplantation has been implemented in recent years. In the classic technique, the arterial axis with the artery for segment 4 (S4) coming from the left hepatic artery (HA) is included with the right graft. To give a surgical advantage to pediatric recipients in our center, the left HA, the common HA, and the celiac trunk are generally retained with the left liver. Thus the artery for S4 is sacrificed. We compared the outcomes of S4 in 290 whole grafts (WG; group A) with 28 right in situ split-liver grafts (SSLG; group B), which were transplanted over the past 10 years (January 1999-December 2009). The rates of major biliary and of hemorrhagic complications were similar. In most of cases (16/24, 66%) S4, on computerized tomographic scan appeared to show signs of hypoperfusion, sometimes with a peripheral aspect of hyperperfusion in the arterial phase. S1 showed signs of hypoperfusion in only 2 cases. A biliary collection near the resection line present in 8 cases was treated in 6 of them with percutaneous drainage and in 2 with laparotomy. These complications did not influence graft or patient survival. Graft survivals at 1, 5, and 10 years for WG and SSLG were not different among the groups: 85%, 74%, and 66% vs 89%, 79%, and 63%, respectively (P = .8). Although our technique cannot be considered to be anatomically correct, the ischemia of S4 did not influence the outcome. The rate of retransplantations for hepatic artery thrombosis was 17.9% in RSSG and 3.4% in WG (P = .001), which was probably due at least in part to the insertion of interposition grafts.