182 LIVER Οriginal Paper Hepato-Gastroenterology 2012; 59:182-186 doi 10.5754/hge10453 © H.G.E. Update Medical Publishing S.A., Athens Key Words: Liver transplantation; Living donor; Vascular complications. Abbreviations: Living Donor Liver Transplantation (LDLT); Hepatic Artery Thrombosis (HAT); Chronic Hepatocellular Liver Diseases (CHD); Hepatocellular Carcinoma (HCC); Fulminant Hepatic Failure (FHF); Body Mass Index (BMI); Auxiliary Partial Orthotopic Liver transplantation (APOLT); Graft Recipient Body Weight Ratio (GRWR); Inferior Mesenteric Vein (IMV); External Iliac Vein (EIV); Polydioxanone Sutures (PDS); Hepatic Vein Thrombosis (HVT); Portal Vein Thrombosis (PVT); Portal Vein Stenosis (PVS); Hepatic Vein Stenosis (HVS); Intensive Care Unit (ICU). ABSTRACT Background/Aims: Vascular complications after liv- er transplantation remain a major source of morbidi- ty and mortality for recipients especially those receiv- ing LDLT owing to the complex vascular reconstruc- tion. Methodology: During the period from May 1999 to May 2004, 518 LDLT were performed in the Depart- ment of Liver Transplantation and Immunology, Kyo- to University Hospital, Japan. Results: The recipients were 261 males and 257 females. Pediatric cases were 230. The indications were cholestatic diseases in 42.5%, chronic hepatocellular diseases (CHD) in 13.3%, HCC in 18.5%, other tumors in 2.7% and others in 23%. Small- for-size grafts in 4.8%, accepted size grafts in 16.0%, op- timum size grafts in 74.5% and large-for-size grafts in 4.6%. Vascular complications occurred during hospital stay in 6.4%, within 3 months from discharge in 2.5% and after 3 months from discharge in 6.0%. The suc- cess rate of the management of HAT was 83.3%, portal vein complications was 97.6% and hepatic vein compli- cations was 84.6%. Conclusions: Careful preoperative evaluation and the proper intraoperative techniques in vascular reconstruction prevent vascular complica- tions. Intraoperative microsurgical technique for hepat- ic artery reconstruction decreases hepatic artery com- plications. Routine post transplant Doppler examina- tion should be performed at least twice a day for the first week after the operation. Immediate surgical in- tervention is required for acute vascular complications, whereas late complications may be treated by balloon angioplasty and endoluminal stent to avoid late compli- cations and even mortality. INTRODUCTION Liver transplantation is an increasingly common cu- rative therapeutic solution for patients with acute and end-stage liver disease. Graft ischemia after liver trans- plantation is associated with a high incidence of mor- bidity and mortality. Vascular complications are of great importance after liver transplantation. The most com- mon vascular complication is hepatic artery thrombo- sis occurring in 2-12% of transplants (1). Hepatic artery stenosis is the second most common vascular complica- tion after liver transplantation occurring in 5% or less of transplants (2). Hepatic artery thrombosis (HAT) re- mains a devastating complication in clinical liver trans- plantation, leading to hepatic necrosis, bile leakage and septic insult with high mortality of around 50% (1,3,4). Portal vein thrombosis was reported to be 2.5%-6% in left sided living donor lining transplantation (LDLT) and it is unusual event in adult to adult LDLT (5,6). Hepatic artery reconstruction under high magnification was in- troduced in Kyoto with the seventh case. This allowed successful hepatic artery reconstruction in the case of diminutive or multiple arteries. This technique reduced the incidence of HAT to 1.5-2% (7). METHODOLOGY During the period from 24 th of May 1999 to 23 rd of May 2004, 518 LDLTs were performed in the Depart- ment of Liver Transplantation and Immunology, Kyoto University Hospital. Recipient characteristics The recipient gender was 261 males (50.4%) and 257 females (49.6%). Pediatric cases (<18 years old) were 230 (44.4%) and adult cases (≥18 years old) were 288 (55.6%). The median age was 25 years (range 0.7-69). The median body weight was 48.3kg, (range 2.78-108). The preoperative performance status of the recipients was at home in 241 cases (46.5%), hospitalized in 220 cases (42.5%) and intensive care unit (ICU) in 57 cases (11%). Child-Pugh classification was Child A in 57 cas- es (11%), Child B in 222 cases (42.9%) and Child C in 239 cases (46.1%). ABO blood type compatibility was identical in 348 cases (67.2%), compatible in 104 cas- es (20.1%) and incompatible in 66 cases (12.7%). The indications for LDLT were cholestatic liver diseases in 220/518 cases (42.5%), chronic hepatocellular liver diseases (CHD) in 69/518 cases (13.3%), hepatocellu- lar carcinoma (HCC) with or without liver cirrhosis in 96/518 cases (18.5%), other tumors in 14/518 cases (2.7%), fulminant hepatic failure (FHF) in 59/518 cases (11.4%), metabolic liver diseases and genetic liver dis- eases in 21/518 cases (4.1%), vascular causes in 2/518 cases (0.4%) and graft failure and re-transplantation in 37/518 cases (7.1%). Donor characteristics The number of donors was 519 (one recipient re- ceived a dual graft from his twin daughters). The donors were 258 males (49.7%) and 261 females (50.3%). The Management of Vascular Complications after Living Donor Liver Transplantation Ayman Zaki Azzam 1 and Koichi Tanaka 2 1 Department of General Surgery, Alexandria University, Alexandria, Egypt 2 Institute of Biochemical Research and Innovation, Kobe, Japan Corresponding author: Dr. Ayman Zaki Azzam, Liver Transplant Surgeon, King Faisal Specialist Hospital and Research Center, MBC: 72, P.O.Box 3354, Riyadh, 11211, Saudi Arabia; Tel.: +96 61464-7272 (Ext 39474), Fax: +96 61442-4817; E-mail: aazzam70@yahoo.com