Cagliari, Italy

A liver donor with double hepatic artery aneurysm: a saved graft

Vincenzo Tondolo, Alberto Manzoni and Fausto Zamboni

Cagliari, Italy

The shortage of organs and the increasing median age of deceased donors for orthotopic liver transplantation stimulate transplant centres to accept grafts that otherwise would have been discarded due to severe vascular abnormalities. We encountered a donor with two arterial aneurysms and a left accessory hepatic artery: an arterial aneurysm of the common hepatic artery and a left accessory hepatic artery arising from a second aneurysm of the left gastric artery (Michels type V). A complex reconstruction was created to transplant the liver. Multiple arterial anastomosis was made and the hepatic inflow of the transplanted liver restored. Although the procedure increased the risk of hepatic artery thrombosis, one more organ supposed to be discarded was saved.

liver transplantation;

anastomosis;

anatomy;

hepatic aneurysm;

arterial reconstruction

Introduction

Theshortageoforganshaspushedtransplantsurgeonstoacceptgraftsfromdeceaseddonorsthatotherwisewouldhavebeendiscardedbecauseofseverevascularabnormalities.Theinnovativetechnicalsolutionsmaketheliverstransplantable.[1,2]Wepresentacaseofcomplexarterialabnormalityofthedonordiscoveredatdonorsurgery.Multiplearterialsutureswere necessarytoobtainaneffectivearterialreperfusion.Thecoldischemiatimeandwarmischemiatimewereshort.

Clinical images

A65-year-oldCaucasianwomanwithalcoholiccirrhosis(Child-PughscoreC11,MELDscore25)wasreferredtolivertransplantation.Pre-operativeCTrevealedaMichelstypeVarterialvariation,[3]i.e.aleftaccessoryhepaticarterywasfromtheleftgastricartery.Thedonorwasa69-year-oldmancertifiedtobebrain-deadduetocerebralhemorrhage.Duringthedonorprocedure,aMichelstypeVvariantwasverifiedwithaleftaccessoryhepaticarteryarisingfromananeurysmoftheleftgastricarteryof2.3×2.3cmandasecondaneurysmofthecommonhepaticarteryof2.7×2.5cm(Fig.A).Noothersignificantalterationswerefoundatthesystematicexaminationofthesplenic,mesentericandiliacarteriesofthedonor.Transplantabilityoftheliverwasevaluated.Anen-bloctechniquewasadoptedfortheharvesting.Atthebench-time,asolutionneverdescribedbeforewasadopted.Wecreatedamaincommonarterialtrunkusingfourvascularsutures:thelefthepaticartery(elongation)toatubularsplenicpatch;thesplenicpatchtothegastricstumpofthespleno-gastriccarrefour;thesplenicsideofthecarrefourtotherighthepaticartery;thespleno-gastriccarrefourtoamesentericpatchinordertoobtainagoodarterialstumpfortheanastomosisintherecipient(Fig.B).Totalback-tablelasted125minutes.ThediametersofthearteriesareshowedintheTable.

Fig.Arterialreconstruction.A:Anatomyofthedonor;B:Back-tablereconstruction;C:Arterialreperfusion;D:Contrast-enhancedCT3Dreconstructionat36-monthfollow-up.CHA:commonhepaticartery;RHA:righthepaticartery;LHA:lefthepaticartery;LGA:leftgastricartery;GDA:gastroduodenalartery;SMA:superiormesentericartery;LaHA:leftaccessoryhepaticartery;SA:splenicartery;CT:celiactrunk;S-Gcarrefour:spleno-gastriccarrefour.

Astandardpiggy-backtechniquewasusedforthetransplant:cavalanastomosiswascreatedwithpolypropylene3/0,portalsutureinatermino-terminalfashionwithpolypropylene5/0,thenewcommonarterialtrunk(graft)wassuturedtothecommonhepaticarteryatthegastro-duodenaloriginandtheleftaccessoryhepaticarterytothehomologousbranchoftherecipient(Fig.B).Polypropylene7/0runningsuturewasadoptedforallthearterialanastomosisusingoperativemagnificationloops 3.5×(Fig.C).Thecoldischemiatimewas362minutesandwarmischemiatime45minutes.Arterialanastomosisintherecipientlasted15minutesforthemaincommontrunkand18minutesfortheleftaccessoryhepaticartery.BiliarydrainagewasaccomplishedbyaRouxen-Ycholedochojejunostomywithapolydioxanonesuture.Post-operativecoursewasuneventfulwiththepatientonaspirinsince12thdaypost-operationwhenplateletcountexceeded100×109/Lasstandardmanagementinourcenterinaccordancewiththeliterature.[4]Atthetimeofdischarge,liverfunctionwasgoodwithbilirubin2.7mg/dL,AST/ALT42/71IU/L,andINR1.1.After36monthsoffollow-up,thepatientisingoodconditionswithnormalbiochemistry.Contrast-enhancedCT3Dreconstruction(MDCT-64;GEHEALTHCAREbeforeandaftercontrastinfusionwithMIP3Dreconstruction)showedarterialpatencywithoutanystrictureand/orkinkingofthereconstructedarteries(Fig.D).

Discussion

Theincreasingmedianageofdeceaseddonorsandtheincreasingfrequencyofmanagevascularsevereabnormalitiesnowadaysstimulatetransplantcenterstobereadytomanagesuchvascularvariationsandproblemswithsuccess.[3,5]Inthepresentcase,thetimeofthearterialreconstructionwasevaluatedcarefullyinrelationtotheneedtocreateasinglearterialtrunkfromthelefthepaticarteryandrighthepaticarteryandcutdownstreamoftheaneurysm,whichwereveryshortandfarbetweenthemselves.Atback-table,withtheliverintheupsidedownposition,thesutureofsmallarteriesandconduits(Table)asthetubularsplenicpatchorlefthepaticarteryandrighthepaticarterywaseasier,fasterandprecisewithanexcellentresult.Wecouldreperfusetheliverafterportalanastomosisandperformarterialreconstructionlater.Thiswouldhavereducedtheoreticallycoldischemiatime,butgiventhecomplexreconstructionplannedandnecessarytosavearterialinflowofthegraft,thesequencewasassessedasunsafe.Inouropinion,itwasrelatedtothefixedpositionofthegraftintherecipientandtheconsequentseverediscomfortoftheoperatortoperformsuchmultiplesutures,significantlyincreasingvascularrisk.Moreover,wetookintoaccountthatperformingportalreperfusionbeforethearterialreconstructioninthiscasecouldincreaseverymuchtheriskofwarmischemicdamageofbileducts,wherebloodsupplydependssolelyonthehepaticartery.Wecouldhavechosentoligatetheleftaccessoryhepaticarterywithoutantastomosiswithitbut,giventhelargevolumeofthelefthepaticlobeandthelargecalibreoftheleftaccessoryhepaticarteryinrelationtothelefthepaticartery(Fig.C),weestimatedthattheriskofischemiaoftheleftliverwastoohigh,especiallyreferringtotheleftbileductsystem.

Table.Diametersofarteries

Thesuccessofthiscaseimpliedthatincaseofseverearterialanatomicalalterationoftheliverthatrequiresmultiplearterialanastomosistorestorehepaticinflow,thegraftcanbeused,givinganincreasedbutacceptableriskofhepaticarterythrombosis.

Acknowledgement:TheauthorsthankMarioCostantiniforhishelpinthepreparationoffigures.

Contributors:TVproposedthestudyandwrotethefirstdraft.MAcollectedandanalyzedthedataofthestudy.Allauthorscontributedtothedesignandinterpretationofthestudyandtofurtherdrafts.ZFsupervisedthestudyandfurtherdrafts.TVistheguarantor.

Funding:None.

Ethical approval:Notneeded.

Competing interest:Nobenefitsinanyformhavebeenreceivedorwillbereceivedfromacommercialpartyrelateddirectlyorindirectlytothisarticle.

1BekkerJ,PloemS,deJongKP.Earlyhepaticarterythrombosisafterlivertransplantation:asystematicreviewoftheincidence,outcomeandriskfactors.AmJTransplant2009;9:746-757.

2diFrancescoF,PaganoD,EcheverriG,DeMartinoM,SpadaM,GridelliBG,etal.Selectiveuseofextendedcriteriadeceasedliverdonorswithanatomicvariations.AnnTransplant 2012;17:140-143.

3MichelsNA.Neweranatomyoftheliveranditsvariantbloodsupplyandcollateralcirculation.AmJSurg1966;112:337-347.

4ShayR,TaberD,PilchN,MeadowsH,TischerS,McGillicuddyJ,etal.Earlyaspirintherapymayreducehepaticarterythrombosisinlivertransplantation.TransplantProc2013;45:330-334.

5MartinsPN.Livergraftvascularvariantwith3extra-hepaticarteries.HepatobiliaryPancreatDisInt2010;9:319-320.

Received April 5, 2014

Accepted after revision July 14, 2014

Ifamanemptieshispurseintohishead,nomancantakeitawayfromhim,aninvestmentinknowledgealwayspaysthebestinterest.

—Benjamin Franklin

(Hepatobiliary Pancreat Dis Int 2015;14:443-445)

AuthorAffiliations:DivisionofGeneralSurgeryandTransplantation,DepartmentofSurgery,BrotzuHospital,p.leRicchi,1-09100,Cagliari,Italy(TondoloV,ManzoniAandZamboniF)

VincenzoTondolo,MD,DivisionediChirurgiaGeneraleeTrapiantiOspedaleBrotzu,p.leRicchi,1-09100,Cagliari,Italy(Tel:+39-070-539611;Fax:+39-070-539646;Email:etondolo@hotmail.com)

?2015,HepatobiliaryPancreatDisInt.Allrightsreserved.

10.1016/S1499-3872(14)60325-8

PublishedonlineOctober27,2014.