title: Selective revascularization of hepatic artery thromboses after liver transplantation improves patient and graft survival.
abstract: BACKGROUND
  Hepatic artery thrombosis (HAT) can be a devastating complication of orthotopic liver transplantation (OLT), but early diagnosis may allow successful revascularization and graft salvage.
  
  
  METHODS
  We reviewed data on 1,026 liver transplants at our institution. For patients in whom HAT was diagnosed within 30 days after OLT, we recorded indications for ultrasonography and liver function tests at diagnosis, management of HAT, and graft and patient survival.
  
  
  RESULTS
  Thirty-two patients (3.1%) developed HAT at 6.8+/-6.6 days (range, 1-29 days) after OLT. Twelve patients (37.5%) were asymptomatic at diagnosis. In 11 of these 12, HAT was diagnosed on routine duplex at 2.0+/-1.55 days after OLT; in the 12th patient, HAT was noted during re-exploration for unrelated bleeding on postoperative day 3. Eleven of 12 patients (91.6%) were revascularized; one patient (8.4%) received no treatment with no sequelae. Of the 11 who were revascularized, 9 (81.8%) had graft salvage and 2 (18.2%) received a second transplant, with one death. Twenty patients (62.5%) were symptomatic. In these 20, HAT was diagnosed at 9.85+/-6.93 days after OLT. Symptoms were: elevated liver function test results (serum glutamic oxaloacetic transaminase: 722+/-1792 U/ml, serum glutamic pyruvic transaminase: 678+/-963 U/ml, and bilirubin: 10.2+/-6.2 mg/dl) in 13 patients (65%); bile leak in 4 patients (20%), and sepsis in 3 (15%). Five of the 20 patients (25%) were revascularized; of these 5, 2 (40%) had graft salvage, 2 (40%) received a second transplant with 1 death, and 1 (20%) died of a liver abscess. Twelve symptomatic patients (60%) had immediate re-OLT; 10/12 are alive, 1 died of sepsis, and 1 died late of unrelated causes. Three symptomatic patients had no treatment; two died of biliary sepsis and one survived. Overall graft salvage was 83.3% in asymptomatic patients and 15% in patients with symptoms (P<0.001). Graft salvage in asymptomatic patients undergoing revascularization was 81.8%, versus 40% in symptomatic patients (P=NS). One-year patient survival was 91.7% in asymptomatic patients and 65% in symptomatic patients (with one late death excluded) (P=NS).
  
  
  CONCLUSIONS
  Routine postoperative duplex ultrasonography should be performed early after liver transplantation. We believe that emergent revascularization of hepatic artery thrombosis in asymptomatic patients and retransplantation in symptomatic patients lead to improved graft salvage and patient survival with a relatively low incidence of late biliary complications.
authors.affiliation: Department of Surgery, The Mount Sinai Medical Center, New York, New York 10029, USA. Patricia_Sheiner@smtplink.mssm.edu
authors.forename: P A
authors.initials: PA
authors.lastname: Sheiner
authors.forename: C V
authors.initials: CV
authors.lastname: Varma
authors.forename: J V
authors.initials: JV
authors.lastname: Guarrera
authors.forename: J
authors.initials: J
authors.lastname: Cooper
authors.forename: M
authors.initials: M
authors.lastname: Garatti
authors.forename: S
authors.initials: S
authors.lastname: Emre
authors.forename: S R
authors.initials: SR
authors.lastname: Guy
authors.forename: M E
authors.initials: ME
authors.lastname: Schwartz
authors.forename: C M
authors.initials: CM
authors.lastname: Miller
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D002675:Child, Preschool; D005260:Female; D006085:Graft Survival / Q000502:physiology*; D006499:Hepatic Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007223:Infant; D008099:Liver / Q000098:blood supply / Q000502:physiology; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery*; D014180:Transplantation; D014463:Ultrasonography; D014656:Vascular Surgical Procedures / Q000379:methods