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TO THE EDITORS:

The development of pseudoaneurysms after liver transplantation is a rare but serious complication. When there is a severe and fixed celiac axis stenosis, the arterial reconstruction in liver transplantation can be performed primarily with a supraceliac aortohepatic jump graft. In those cases, the incidence of pseudoaneurysms on the anastomotic side lies between 3% and 8%.1 In the early postoperative period, they are usually caused by a combination of technical failure and infections (eg, bile leakage).2 The clinical presentation varies from unspecific abdominal pain to fulminant intra-abdominal bleeding.3 Most pseudoaneurysms are identified as incidental findings on cross-sectional imaging or abdominal ultrasound. Patients are at high risk for rupture of the aneurysm and the development of hepatic artery (HA) thrombosis, which may lead to graft failure. Therefore, it is critical that the treatment provides a combination of preservation of the hepatic blood flow and elimination of the rupture risk. In the case of an intra-abdominal infection, it is important to dispel the infection focus. The risk of rupture can be controlled with an endovascular aortic repair (EVAR).4, 5 However, because of the deprivation of arterial perfusion of the liver graft after an EVAR, the risk of graft failure is significant.

We report a case with an incidental finding of a supraceliac aortic pseudoaneurysm after liver transplantation. The patient received a liver transplant for Child-Pugh C alcoholic liver cirrhosis. Because of a subtotal celiac axis stenosis, arterial reconstruction was primarily performed with a supraceliac aortohepatic jump graft. The transplantation and the postoperative course were uneventful, and thus the patient was discharged 3 weeks after surgery. Because of rising inflammation parameters, he was readmitted to the hospital 6 weeks after transplantation. A computed tomography scan showed a 6.5-cm para-aortal pseudoaneurysm (Fig. 1). To achieve the aforementioned therapeutic goal, we opted for a combination of endovascular treatment and open surgery. In order to preserve the arterial blood supply of the liver graft, we decided to transpose the donor's HA to the recipient's gastroduodenal artery (GDA). In addition, an EVAR and a resection of the aneurysm were performed (Fig. 2). The correct placement of the stent graft was documented with angiography. It covered the aneurysmatic side as well as the celiac trunk (CT). The arterial blood flow via the transposed HA was measured intraoperatively at 250 mL/minute with a resistance index of 1.0. The postoperative liver function was normal. Intraoperatively taken cultures were positive for Candida albicans; therefore, long-term antifungal therapy was applied. The postoperative course proceeded without complications. The patient was discharged from the hospital 4 weeks after surgery. Follow-up 1 year after surgery showed sufficient arterial perfusion of the liver and normal liver function.

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Figure 1. Angio-computed tomography scan showing a large pseudoaneurysm on the aortic side of the aortohepatic jump graft anastomosis (axial and sagittal reformation).

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Figure 2. Angio-computed tomography reconstruction of the mesentericohepatic collateral perfusion of the liver graft via the pancreaticoduodenal arcade (coronar reformation, sagittal reformation, schematic chart).

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The treatment options for aortic pseudoaneurysms after liver transplantation are limited and are associated with high morbidity and mortality. Aggressive treatment with an effort to revascularize the graft is always indicated, especially when the pseudoaneurysm occurs in the early posttransplant period.3 The use of alloplastic bypass material is critical because of bacterial or fungal contamination. The rationale for this new revascularization procedure comes from the experience with the modified Appleby operation. In 1953, Appleby6 described the resection of the celiac axis in the context of radical gastrectomy for gastric cancer. In 1976, Nimura et al.7 adopted this operative method for patients with carcinoma of the body and tail of the pancreas and infiltration of the celiac axis.7 The anatomic basis for arterial perfusion of the liver after the occlusion or resection of the CT is the collateral blood circulation from the superior mesenteric artery (SMA) via the pancreaticoduodenal arcade and the GDA.8 To make retrograde arterial perfusion possible in analogy to the Appleby operation, we transposed the donor's HA to the recipient's GDA. The transpancreatic arterial blood flow was measured at 250 mL/minute and was comparable to that of an antegrade-perfused liver graft.9

This hybrid method has proved to be simple and effective, and it should be evaluated for emergency procedures.

REFERENCES

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    Verzaro R, Nishida S, Angelis M, Khan F, Tzakis A. Thoracoabdominal bypass graft with liver retransplantation for the treatment of a pseudoaneurysm of the supraceliac aorta after liver transplantation. Pediatr Transplant 2001; 5: 64-68.
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    Pearce BJ, Baldwin Z, Bassiouny H, Gewertz BL, McKinsey JF. Endovascular solutions to complications of open aortic repair. Vasc Endovascular Surg 2005; 39: 221-228.
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    Kelly DM, Shiba H, Nakagawa S, Irefin S, Eghtesad B, Quintini C, et al. Hepatic blood flow plays an important role in ischemia-reperfusion injury. Liver Transpl 2011; 17: 1448-1456.

Anne Mossdorf M.D.*, Tom Florian Ulmer M.D.*, Sebastian Kalverkamp M.D.*, Ulf Neumann M.D., Prof.*, Christoph Heidenhain M.D.*, * Department of General, Viszeral and Transplantation Surgery, University Hospital Aachen, Aachen, Germany.