Heng-Ki Zhu , Guo-Hong Co , Shu-Sen Zheng , ?

a Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China

b Department of Radiology, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China

The Author Reply:

We thank Dr. Gastaca et al. for the interest toward our article and the thoughtful comments. We are willing to further discuss the topic of endovascular treatment (EVT) after liver transplantation (LT). Congratulation to their successful experience of EVT. As Dr. Gastaca emphasized, most of the transplant centers,even important centers, are hesitant to perform EVT early after LT [1–3] . Their team demonstrated successful experience of EVT treating hepatic artery thrombosis and stenosis during very early period with high patency rates and absence of major complications [4] . We strongly agree with Dr. Gastaca’s attitude and admire the novel approach.

EVT has become the standard procedure that is preferred over surgical revision or re-transplantation in our center. Our study also showed that the median interval from LT to EVT was 7 days, and most of the procedures started in the first two weeks [5] . We have several opinions toward EVT in early period. From the perspective of the broad graft ischemic spectrum, the therapeutic goal is to relieve occlusion and improve hepatic perfusion regardless of any recanalization procedures used. Thus, nicorandil was introduced to prompt vasodilation and restore graft perfusion. And interrupted suture of hepatic artery anastomosis might play an important role in simplifying EVT.

In addition, the differences between the choices of procedures in the two practices may be the result of differences in the definition of occlusion. Hepatic artery narrowing > 50% or > 70%were defined as EVT indication in two studies, respectively. We set < 30% residual stenosis as recanalization criteria, which was consistent with Dr. Gastaca’s article.

Stenting and angioplasty within the first week after LT must be performed by expert radiologists with the support of expert surgeons. Low volume transplant centers may adopt the integrated EVT strategy to reduce the risk of arterial complications. Therefore,we thank Dr. Gastaca et al. again for their interest in our study and for advocating early EVT to avoid unnecessary and more challenging surgical approaches. We look forward to their further research with a larger cohort and more detailed technique introduction.

Acknowledgments

None.

CRediT authorship contribution statement

Heng-Kai Zhu: Conceptualization, Writing - original draft. Guo-Hong Cao: Writing - review & editing. Shu-Sen Zheng: Conceptualization, Supervision, Writing - review & editing.

Funding

None.

Ethical approval

Not needed.

Competing interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.