Author Affiliations: Division of General Surgery and Transplantation, Department of Surgery, Brotzu Hospital, p.le Ricchi, 1-09100, Cagliari, Italy (Tondolo V, Manzoni A and Zamboni F)

Corresponding Author: Vincenzo Tondolo, MD, Divisione di Chirurgia Generale e Trapianti Ospedale Brotzu, p.le Ricchi, 1-09100, Cagliari, Italy (Tel: +39-070-539611; Fax: +39-070-539646; Email: etondolo@hotmail.com)

 

© 2015, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(14)60325-8

Published online October 27, 2014.

 

 

ABSTRACT: 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.

 

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

 

KEY WORDS: liver transplantation; anastomosis; anatomy; hepatic aneurysm; arterial reconstruction

Acknowledgement: The authors thank Mario Costantini for his help in the preparation of figures.

Contributors: TV proposed the study and wrote the first draft. MA collected and analyzed the data of the study. All authors contributed to the design and interpretation of the study and to further drafts. ZF supervised the study and further drafts. TV is the guarantor.

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 this article.

The shortage of organs has pushed transplant surgeons to accept grafts from deceased donors that otherwise would have been discarded because of severe vascular abnormalities. The innovative technical solutions make the livers transplantable.^{[1, 2]} We present a case of complex arterial abnormality of the donor discovered at donor surgery. Multiple arterial sutures were necessary to obtain an effective arterial reperfusion. The cold ischemia time and warm ischemia time were short.

 

A 65-year-old Caucasian woman with alcoholic cirrhosis (Child-Pugh score C11, MELD score 25) was referred to liver transplantation. Pre-operative CT revealed a Michels type V arterial variation,^[3] i.e. a left accessory hepatic artery was from the left gastric artery. The donor was a 69-year-old man certified to be brain-dead due to cerebral hemorrhage. During the donor procedure, a Michels type V variant was verified with a left accessory hepatic artery arising from an aneurysm of the left gastric artery of 2.3×2.3 cm and a second aneurysm of the common hepatic artery of 2.7×2.5 cm (Fig. A). No other significant alterations were found at the systematic examination of the splenic, mesenteric and iliac arteries of the donor. Transplantability of the liver was evaluated. An en-bloc technique was adopted for the harvesting. At the bench-time, a solution never described before was adopted. We created a main common arterial trunk using four vascular sutures: the left hepatic artery (elongation) to a tubular splenic patch; the splenic patch to the gastric stump of the spleno-gastric carrefour; the splenic side of the carrefour to the right hepatic artery; the spleno-gastric carrefour to a mesenteric patch in order to obtain a good arterial stump for the anastomosis in the recipient (Fig. B). Total back-table lasted 125 minutes. The diameters of the arteries are showed in the Table.

 

A standard piggy-back technique was used for the transplant: caval anastomosis was created with polypropylene 3/0, portal suture in a termino-terminal fashion with polypropylene 5/0, the new common arterial trunk (graft) was sutured to the common hepatic artery at the gastro-duodenal origin and the left accessory hepatic artery to the homologous branch of the recipient (Fig. B). Polypropylene 7/0 running suture was adopted for all the arterial anastomosis using operative magnification loops 3.5× (Fig. C). The cold ischemia time was 362 minutes and warm ischemia time 45 minutes. Arterial anastomosis in the recipient lasted 15 minutes for the main common trunk and 18 minutes for the left accessory hepatic artery. Biliary drainage was accomplished by a Roux-en-Y choledochojejunostomy with a polydioxanone suture. Post-operative course was uneventful with the patient on aspirin since 12th day post-operation when platelet count exceeded 100×10⁹/L as standard management in our center in accordance with the literature.^[4] At the time of discharge, liver function was good with bilirubin 2.7 mg/dL, AST/ALT 42/71 IU/L, and INR 1.1. After 36 months of follow-up, the patient is in good conditions with normal biochemistry. Contrast-enhanced CT 3D reconstruction (MDCT-64; GE HEALTHCARE before and after contrast infusion with MIP 3D reconstruction) showed arterial patency without any stricture and/or kinking of the reconstructed arteries (Fig. D).

 

 

The increasing median age of deceased donors and the increasing frequency of manage vascular severe abnormalities nowadays stimulate transplant centers to be ready to manage such vascular variations and problems with success.^{[3, 5]} In the present case, the time of the arterial reconstruction was evaluated carefully in relation to the need to create a single arterial trunk from the left hepatic artery and right hepatic artery and cut downstream of the aneurysm, which were very short and far between themselves. At back-table, with the liver in the up side down position, the suture of small arteries and conduits (Table) as the tubular splenic patch or left hepatic artery and right hepatic artery was easier, faster and precise with an excellent result. We could reperfuse the liver after portal anastomosis and perform arterial reconstruction later. This would have reduced theoretically cold ischemia time, but given the complex reconstruction planned and necessary to save arterial inflow of the graft, the sequence was assessed as unsafe. In our opinion, it was related to the fixed position of the graft in the recipient and the consequent severe discomfort of the operator to perform such multiple sutures, significantly increasing vascular risk. Moreover, we took into account that performing portal reperfusion before the arterial reconstruction in this case could increase very much the risk of warm ischemic damage of bile ducts, where blood supply depends solely on the hepatic artery. We could have chosen to ligate the left accessory hepatic artery without antastomosis with it but, given the large volume of the left hepatic lobe and the large calibre of the left accessory hepatic artery in relation to the left hepatic artery (Fig. C), we estimated that the risk of ischemia of the left liver was too high, especially referring to the left bile duct system.

 

The success of this case implied that in case of severe arterial anatomical alteration of the liver that requires multiple arterial anastomosis to restore hepatic inflow, the graft can be used, giving an increased but acceptable risk of hepatic artery thrombosis. 

 

 

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