title: Thrombolytic protocol minimizes ischemic-type biliary complications in liver transplantation from donation after circulatory death donors.
abstract: Liver transplantation (LT) with donation after circulatory death (DCD) donors has been associated with a high rate of ischemic-type biliary strictures (ITBSs) and inferior graft survival. To investigate the impact of an intraoperative tissue plasminogen activator (tPA) on outcomes following DCD LT, we conducted a retrospective analysis of DCD LT at the Toronto General Hospital (TGH) and the Ochsner Medical Center (OMC). Between 2009 and 2013, 85 DCD LTs were performed with an intraoperative tPA injection (n = 30 at TGH, n = 55 at OMC), and they were compared with 33 DCD LTs without a tPA. Donor and recipient characteristics were similar in the 2 groups. There was no significant difference in the intraoperative packed red blood cell transfusion requirement (3.2 ± 3.4 versus 3.1 ± 2.3 U, P = 0.74). Overall, biliary strictures occurred less commonly in the tPA-treated group (16.5% versus 33.3%, P = 0.07) with a much lower rate of diffuse intrahepatic strictures (3.5% versus 21.2%, P = 0.005). After 1 and 3 years, the tPA group versus the non-tPA group had superior patient survival (97.6% versus 87.0% and 92.7% versus 79.7%, P = 0.016) and graft survival (96.4% versus 69.7% and 90.2% versus 63.6%, P < 0.001). In conclusion, a tPA injection into the hepatic artery during DCD LT reduces ITBSs and improves graft and patient survival without increasing the risk for bleeding.
authors.affiliation: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada.
authors.forename: John B
authors.initials: JB
authors.lastname: Seal
authors.forename: Humberto
authors.initials: H
authors.lastname: Bohorquez
authors.forename: Trevor
authors.initials: T
authors.lastname: Reichman
authors.forename: Adam
authors.initials: A
authors.lastname: Kressel
authors.forename: Anand
authors.initials: A
authors.lastname: Ghanekar
authors.forename: Ari
authors.initials: A
authors.lastname: Cohen
authors.forename: Ian D
authors.initials: ID
authors.lastname: McGilvray
authors.forename: Mark S
authors.initials: MS
authors.lastname: Cattral
authors.forename: David
authors.initials: D
authors.lastname: Bruce
authors.forename: Paul
authors.initials: P
authors.lastname: Greig
authors.forename: Ian
authors.initials: I
authors.lastname: Carmody
authors.forename: David
authors.initials: D
authors.lastname: Grant
authors.forename: Markus
authors.initials: M
authors.lastname: Selzner
authors.forename: George
authors.initials: G
authors.lastname: Loss
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion; D002423:Cause of Death; D002779:Cholestasis / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D046148:Donor Selection; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006085:Graft Survival; D006499:Hepatic Artery; D006801:Humans; D007269:Injections, Intra-Arterial; D007511:Ischemia / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D055820:New Orleans; D009864:Ontario; D012189:Retrospective Studies; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D014019:Tissue Donors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator