Diagnostic and Therapeutic Management of Hepatic Artery Thrombosis and Stenosis After Orthotopic and Heterotopic Liver Transplantation F. Boyvat, C. Aytekin, A. Firat, A. Harman, H. Karakayalı, and M. Haberal H EPATIC ARTERY thrombosis (HAT) is the most frequent vascular complication after orthotopic liver transplantation (OLT). HAT is associated with a high incidence of mortality and morbidity. In the early postop- erative period, it has a mortality rate of 50%. The reported HAT incidence ranges between 4% and 25% 1 with the incidence of hepatic artery stenosis (HAS) ranging between 4.8% and 11%. 2 Early HAT after liver transplantation produces graft ischemia and extrahepatic biliary tract ne- crosis. If the HAT occurs late, it presents with septicemia, biliary complications, and hepatic bilomas. 3 The urgent repeat transplantation is the method to achieve patient survival after early HAT. There are reports about endovas- cular treatment of HAS and HAT, 4,5 and recently, 2 series discussed metallic stent placement in the hepatic arteries, 6,7 with encouraging results. The purpose of this study was to analyze the effectiveness of thrombolysis, percutaneous transluminal angioplasty (PTA), and stenting of the hepatic arteries in OLT and heterotopic liver transplantation (HLT). PATIENTS AND METHODS Between December 1988 and May 2002, 73 OLT and HLT were performed in our institute. Among them, 24 patients had HLT, with the liver placed into the right subhepatic space. The hepatic artery of the HLT was anastomosed to the right iliac artery either by a PTFE, saphenous vein, or arterial graft. The portal vein was anastomosed to a branch of the superior vein. Doppler ultrasound was performed daily during the hospital stay. Resistive index and systolic ascending time were evaluated for the hepatic arteries. Further diagnostic studies were performed if the resistive index was 0.5 and systolic ascending time 10 msec or both. 8,9 Percutaneous interventions were performed at a median time of 80 days (range, 7–210 days). Arteriography was performed using the right femoral artery access with selective catheterization of the hepatic artery. RESULTS The mean age of the patients was 33.5 years (range, 17– 66 years). Angiography showed that 4 patients had hepatic artery stenosis (3 with HLT and 1 with OLT), 4 patients had hepatic artery occlusion (3 with OLT and 1 with HLT), and 1 patient (HLT), an hepatic artery pseudoaneurysm that had ruptured, to the jejunum. Two patients with stenoses underwent PTA only. However, 3 months later, restenosis developed in 1 patient treated by placement of a coronary stent (NIR-Elite, Boston Scientific-Scimed) (Fig 1). Coro- nary stents also were required in 2 patients with stenoses. Two patients with thromboses underwent initial thrombol- ysis and PTA. One thrombosis case was treated with thrombolytic therapy using urokinase (total dose of 400,000 IU) for 6 hours (Fig 2), and the last patient required a coronary stent, after 1-hour thrombolysis with urokinase (total dose of 150,000 IU). The technical and immediate clinical success was 100%. Although the technical results for hepatic artery occlusions were successful, the long-term results were not satisfactory. In 1 HLT patient with hepatic artery occlusion, follow-up showed reocclusion of the hepatic artery and cholangitic abscesses were developed in 2 weeks. The patient died due to sespsis. The other 2 patients who received thrombolysis developed occlusion of the hepatic arteries in 3 weeks. One died, whereas the second patient underwent retransplanta- tion. The fourth patient’s hepatic artery stayed patent for 3 months. Although the hepatic artery was occluded, collat- erals from the superior mesenteric artery and left gastric artery developed and the patient is doing well. The HLT patient with a stenotic hepatic artery was dilated successfully, but 3 months later, restenosis devel- oped requiring placement of a stent. The artery remained patent with the death of the patient after 1.5 years. The other patient with PTA showed patent hepatic arteries during follow-up. One OLT patient with a coronary stent died due to septic multiple-organ failure at 90 days after stent placement (Fig 3). The hepatic artery was patent until the death of the patient. The other OLT recipient with stent is doing well with a patent hepatic artery. The patient with From the Departments of Radiology and Surgery, Faculty of Medicine, Bas ¸ kent University, Ankara, Turkey. Address reprint requests to Fatih Boyvat, MD Bas ¸ kent Univer- sitesi Tip Faku ¨ ltesi, Radyoloji Bo ¨ lu ¨ mu ¨ , Fevzi C ¸ akamak Cad. 10. Sok. No:45, Bahc ¸ elievler, 06490, Ankara, Turkey. E-mail: boyvat@dialup.ankara.edu.tr © 2003 by Elsevier Inc. All rights reserved. 0041-1345/03/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2003.09.086 Transplantation Proceedings, 35, 2791-2795 (2003) 2791