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  2. Abstract

The purpose of this study was to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) for treatment of hepatic artery stenosis after living donor liver transplantation. Eighteen patients with hepatic artery stenosis after living donor liver transplantation were included in this study. The success rate and complications of PTA and recurrent stenosis of the hepatic artery were evaluated. Seventeen of 18 patients (94.4%) were successfully treated without complication by a first PTA procedure. Recurrence of hepatic artery stenosis occurred in 6 patients (33.3%). Repeated PTA was performed 12 times for the 6 patients. Two complications occurred as arterial dissection and perforation. As a consequence, the complication rate was 6.7%, involving 2 of 30 procedures in total. In conclusion, PTA is effective for treatment of hepatic artery stenosis after living donor liver transplantation without an increase in the complication rate. Liver Transpl 12:465–469, 2006. © 2006 AASLD.

Liver transplantation is the choice of treatment for patients with liver failure. However, the use of cadaveric liver transplantation is limited due to a lack of cadaveric donors. As a result, living donor liver transplantation (LDLT) has been developed, and the number of such cases is increasing. In LDLT, the hepatic arteries tend to be smaller than those in cadaveric transplantation. Stenosis of the hepatic artery is one of the fatal complications in liver transplantation, and rapid treatment is mandatory to avoid fatal results. Percutaneous transluminal angioplasty (PTA) is one of the treatments used to improve hepatic artery stenosis.1–9 However, most reports are related to PTA after cadaveric liver transplantation.

The purpose of the present study was to evaluate the effectiveness and complications of PTA for hepatic artery stenosis after LDLT.


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From October 1998 to January 2005, 110 patients received LDLT in our institute. Eighteen patients were diagnosed hepatic artery stenosis by hepatic arteriography and then were treated with PTA. This study evaluates these 18 patients. There were 9 males and 9 females, and the patient age ranged from 1 to 59 years (mean, 39.4 years). Four patients were children, while 14 were adults. The diseases of these patients included liver cirrhosis in 8 (7 with hepatitis B and 1 with hepatitis C), fulminant hepatitis in 4, primary biliary cirrhosis in 2, biliary atresia in 2, primary sclerosing cholangitis in 1, and Wilson's disease in 1. The lobes transplanted were the right in 8, the left in 8, and a lateral segment in 2. Arterial anastomosis was performed in an end-to-end fashion by interrupted suture using 8-0 monofilament polypropylene strings. When the diameter of artery was not matched, arterial reconstruction was carried out by using a branch patch. Further, an interposition graft from the radial artery was used to secure enough length for the reconstruction in some cases. Stenosis of the hepatic artery was diagnosed 6-330 days after transplantation (mean, 40.7 days) (Table 1).

Table 1. Summary of Patients
Case no.Age/GenderDiseaseGraftTI after LDLT (days)Balloon DA (mm)First PTA resultFU (days)RECFQ of PTACOMClinical outcome
  1. Abbreviations: TI, time interval; LDLT, living donor liver transplantation; DA, diameter; PTA, percutaneous transluminal angioplasty; FU, follow-up; REC, recurrence; FQ, frequency; COM, complication; LC, liver cirrhosis; (B), with hepatitis B virus infection; (C), with hepatitis C virus infection; WD, Wilson's disease; FH, fulminant hepatitis; BA, biliary atresia; PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; RL, right lobe; LL, left lobe; LA, lateral lobe; S, success; F, failure.

1357/MLC(B)RL164.0S89(+)4perforationdeath, complication occured in 4th PTA
mean39.4  40.73.1 789.7    

With Doppler ultrasound, we evaluated the hepatic arteries and measured the resistive index (maximal systolic velocity−end diastolic velocity/maximal systolic velocity) and the systolic ascending time. The hepatic artery was considered to be stenotic when the resistive index was less than 0.5 and/or the systolic ascending time was greater than 10 milliseconds. If Doppler values were abnormal, the patient was referred to angiography. In our policy, screening Doppler ultrasound was performed by following protocol for early detection of hepatic artery stenosis. Doppler ultrasound was performed twice a day during the first week after transplantation, once a day, during the second week, and once a week after the third week until discharge. If we found any problem in serum liver function test, we did not hesitate to perform Doppler ultrasound as soon as possible.

A 4-6 French sheath was placed through the femoral artery. We carried out selective arteriography of the celiac trunk and made a diagnosis of hepatic artery stenosis. The hepatic artery was considered to be clinically relevant to PTA if the luminal diameter was decreased by more than 50%. A 6-French guiding catheter was placed in the celiac trunk or common hepatic artery, and a micro-guidewire was then advanced distal to the stenosis. For children, after placing a 4-French catheter in the celiac trunk or common hepatic artery, we advanced a micro-guidewire distal to the stenosis, and then removed the 4-French catheter.

Before PTA, heparin (1,000-3,000 units) was injected intravenously and administrated continuously as anticoagulation therapy to keep an activated coagulation time between 150 and 200 seconds until 2 weeks after PTA. PTA was performed with a semicompliant balloon. The balloon size was selected based on the diameter of the hepatic artery distal to the stenosis and ranged from 2.0 to 4.5 mm (mean, 3.1 mm). The balloon was dilated by 4-8 atmosphere for 30 seconds in 1 session. The procedure was performed in 3 sessions of balloon dilatation. If the artery remained stenotic, an additional balloon dilatation was carried out using high atmospheric pressure or a larger balloon. PTA was considered to be successful if the luminal diameter was restored to more than 80 % of the artery diameter.

Next, we evaluated the success rate of PTA, complications, and recurrent stenosis of the hepatic artery.


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Seventeen of 18 patients were successfully treated without complication (Fig. 1). In 1 patient, the hepatic artery was occluded after PTA (Fig. 2), likely due to dissection of the artery. We used the PTA procedure in this patient to compress the intimal flap, utilizing a 3-mm-diameter balloon inflated for 3 minutes. Eventually, the hepatic artery was reopened and the stenosis disappeared. At 17 months after PTA, the patient's course was uneventful.

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Figure 1. A 5-year-old boy suspected of having hepatic artery stenosis 16 days after liver transplantation. (A) Hepatic arteriography shows severe stenosis of the hepatic artery. (B) Hepatic arteriography after PTA shows a disappearance of hepatic artery stenosis. (C) Fifteen days after PTA, hepatic arteriography shows severe stenosis of the hepatic artery at the same site. (D) Hepatic arteriography after repeated PTA shows a disappearance of hepatic artery stenosis.

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Figure 2. A 45-year-old woman was suspected of having hepatic artery stenosis 22 days after liver transplantation. The graft hepatic artery was anastomosed to replace the right hepatic artery. (A) Hepatic arteriography shows severe stenosis of the hepatic artery at the anastomotic site. (B) An abdominal radiograph shows a 3-mm-diameter balloon being used for with PTA. Hepatic arteriography after PTA shows occlusion of the hepatic artery, possibly due to dissection. (D) An abdominal radiograph shows a PTA being reperformed with a 3-mm balloon. (E) Hepatic arteriography after repeated PTA shows a reopening of the hepatic artery. (F) Hepatic arteriography 3 weeks after PTA confirms the continued opening of the hepatic artery.

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Recurrent stenosis of the hepatic artery occurred in 6 of 18 patients (33.3%) (Fig. 1). All 6 were successfully treated with repeated PTA, without complication. In 3 of the 6 patients, restenosis occurred, after which a third PTA was performed without complication. In 2 of these 3 cases, restenosis occurred and a fourth PTA was performed. During the fourth procedure, complications occurred in 1 patient, in which the micro-guidewire perforated the native hepatic arterial wall, causing blood leakage. Balloon dilation was performed twice to close the pinhole using a 4-mm-diameter balloon for 30 minutes and for 15 minutes; eventually, extravasation of the contrast material disappeared. The patient died of sepsis 3 months after the fourth PTA, although graft loss did not occur. In another patient, the fourth PTA was successful, but restenosis occurred. Subsequently, a fifth PTA was performed without complication.

As a consequence, PTA was performed 30 times in 18 patients. Twenty-eight of the 30 procedures (93.3%) were successful. Complications occurred in 2 of 30 procedures (6.7%). Delayed complications did not occur during this follow-up period from 17-2,224 days after PTA (mean, 790 days) (Table 1).


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Many explanations have been suggested for hepatic artery stenosis after liver transplantation, including ischemia of the anastomotic site, diagonal anastomosis, torsion and angulation by a bagged anastomotic vessel, small vascular diameter, external compression, problems with the operative procedure, rejection, reactive edema, thrombus, endoluminal hyperplasia, and fibrosis.2–5, 10–11 However, it is difficult to clearly specify the cause, and a variety of issues may related to stenosis.4 The frequency of hepatic artery stenosis after liver transplantation has previously been reported to be 2-13%.1–2, 10–15 Stenosis has been found to occur at the anastomotic site in 70% of cases4 and within 3 months after transplantation.1–2, 4–5, 10, 15–16

Stenosis of the hepatic artery causes thrombosis because the hepatic arterial flow is static, resulting in hepatic necrosis.1, 6, 11, 15 Ischemia of the bile duct is also caused by hepatic artery stenosis, as the bile duct is fed primarily by the hepatic artery. Bile duct ischemia may develop in association with a complication of the biliary system such as cholangitis, bile duct stricture, biloma, hepatic abscess, and bile duct necrosis.4, 6, 8, 10–11, 14, 17 Acute hepatic necrosis and complications of the biliary system greatly influence the survival rate of a graft. Hepatic artery stenosis therefore requires immediate treatment.

Although hepatic artery stenosis after liver transplantation is conventionally treated by either surgical repair or retransplantation, interventional procedures have been recently been reported.1–9, 11 Most of these procedures use PTA or stent placement after cadaveric liver transplantation. PTA after LDLT has been reported only rarely,4–5, 8 so the results remain unclear.

In LDLT, the grafted branch is the right or left hepatic artery. On the other hand, in cadaveric liver transplantation, the grafted branch is the proper hepatic artery. Therefore, the diameter of the anastomotic branch in LDLT tends to be smaller than that in cadaveric liver transplantation. In cadaveric liver transplantation, the previously reported balloon diameter for PTA has been indicated to be 3-6 mm.2, 7, 11, 18 In our series, the balloon diameter was 2-4.5 mm. The high restenosis rate in our series (33.3%) may be attributed to the smaller balloon diameter. Nevertheless, repeated PTA was effective without increasing the complication rate.

Complications related to angioplasty of the grafted hepatic artery occur in 5-10% of cases,6 a rate similar to ours (6.7%). Complications include dissection, thrombosis, distal embolism, rupture, and pseudoaneurysm.11, 18–19 There have been 2 reports of delayed complication in which pseudoaneurysms occurred 1 day and 14 months after PTA. It is therefore suggested that long-term follow-up is necessary after PTA. It has also been reported that complications of PTA tend to occur more frequently in children than in adults.8 In the earliest time period after transplantation, PTA was considered to have a potentially high risk for complication; however, there was no evidence for what time period is safe. In our results, 6 of 18 patients (33%) were treated with PTA within 2 weeks after transplantation without complications, even though the earliest case was 6 days after transplantation. We believe that PTA should be performed more than one week after transplantation.

Another option for treatment of hepatic artery stenosis is intra-arterial placement of a stent.9, 11–12, 17, 20 Stent placement may prevent recurrent stenosis or dissection of the artery after PTA.11 As previously reported, the stent diameter is generally 3.5-5.5 mm,9, 11, 17 which is larger than our balloon diameter. It is therefore uncertain whether stent placement would be as effective for the prevention of hepatic artery stenosis in LDLT as it is in cadaveric liver transplantation.

Another concern is the tortuosity of the hepatic artery. A living donor graft increases in volume compared to a cadaveric liver graft. The difference in the graft volume may intensify the tortuosity of the grafted hepatic artery. The smaller graft artery and the larger graft volume could explain why it is difficult to treat hepatic artery stenosis by PTA in LDLT. It is also unclear whether a stent can be placed at the appropriate position. Therefore, stent placement should be limited for only the case in which a large and straight vessel is available. Nevertheless, we believe that stent placement may be used in the treatment of hepatic artery stenosis in LDLT in the future.

In conclusion, PTA is effective for the treatment of hepatic artery stenosis in LDLT and of recurrent hepatic artery stenosis, without significantly increasing the complication rate.


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  2. Abstract
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