title: Endovascular treatment of hepatic artery stenosis after liver transplantation.
abstract: BACKGROUND
  Hepatic artery stenosis (HAS) after orthotopic liver transplantation is a significant risk factor for subsequent hepatic artery thrombosis (HAT). HAT is associated with a 30%-50% risk of liver failure culminating in retransplantation or death. Traditional treatment of hepatic artery complications has been surgical, with hepatic artery revision or retransplantation. Endovascular therapy of HAS, described primarily in the interventional radiology literature, may provide a less-invasive treatment option.
  
  
  METHODS
  This was a retrospective review of all endovascular interventions performed for HAS after orthotopic liver transplantation over a 31-month period (August 2009 to January 2012). Patients with duplex ultrasound imaging evidence of severe main HAS (peak systolic velocity of >400 cm/s, resistive index of <.5) underwent endovascular treatment with either primary stent placement or percutaneous transluminal angioplasty (PTA) alone. Patients were followed with serial ultrasound imaging to assess for treatment success and late restenosis. Reintervention was performed if significant restenosis occurred.
  
  
  RESULTS
  Thirty-five hepatic artery interventions were performed in 23 patients. Over the 31-month study period, 318 orthotopic liver transplantations were performed, yielding a 7.4% (23/318) rate of hepatic artery intervention. Primary technical success was achieved in 97% (34/35) of cases. Initial treatment was with PTA alone (n = 10) or primary stent placement (n = 13). The initial postintervention ultrasound images revealed improvements in hepatic artery peak systolic velocity (267 ± 118 [posttreatment] vs 489.9 ± 155 cm/s [pretreatment]; P < .0001) and main hepatic artery resistive index (0.61 ± 0.08 [posttreatment] vs 0.41 ± 0.07 [pretreatment]; P < .0001). At a mean follow-up of 8.2 ± 1.8 months (range, 0-29), there were 12 reinterventions in 10 patients for recurrent HAS. Thirty-one percent (n = 4/13) of patients undergoing initial stent placement required reintervention (at 236 ± 124 days of follow-up) compared with 60% (n = 6/10) of patients undergoing initial PTA (at 62.5 ± 44 days of follow-up). Primary patency rates (Kaplan-Meier) after primary stent placement were 92%, 85%, and 69% at 1, 3, and 6 months, respectively, compared with 70%, 60%, and 50% after PTA (P = .17). Primary-assisted patency for the entire cohort was 97% at 6 and 12 months. Major complications were one arterial rupture managed endovascularly and one artery dissection that precipitated HAT and required retransplantation. The overall rate of HAT in the entire cohort was 4.3% (1/23).
  
  
  CONCLUSIONS
  Endovascular treatment of HAS can be performed with high technical success, excellent primary-assisted patency, and acceptable morbidity. Initial use of a stent may improve primary patency when compared with PTA. The need for reintervention is common, placing particular importance on aggressive surveillance. Longer follow-up and a larger cohort are needed to confirm these encouraging early results.
authors: Section of Vascular and Endovascular Surgery, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
authors: Blake A
authors: BA
authors: Hamby
authors: Daniel E
authors: DE
authors: Ramirez
authors: George E
authors: GE
authors: Loss
authors: Hernan A
authors: HA
authors: Bazan
authors: Taylor A
authors: TA
authors: Smith
authors: Edward
authors: E
authors: Bluth
authors: W Charles
authors: WC
authors: Sternbergh
mesh_terms: D000293:Adolescent; D000328:Adult; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D001157:Arterial Occlusive Diseases / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D001783:Blood Flow Velocity; D003251:Constriction, Pathologic; D005260:Female; D006499:Hepatic Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012008:Recurrence; D012189:Retrospective Studies; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency; D055815:Young Adult