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Volume: 17 Issue: 1 February 2019

FULL TEXT

CASE REPORT
Successful Transplant of a Nonagenarian Liver Graft With Fully Replaced Right Hepatic Artery Reconstruction

Organ shortage and increasing donor age in liver transplant are stimulating transplant centers to accept otherwise discarded grafts due to donor age or vascular abnormalities; nevertheless, the use of nonagenarian donor grafts is uncommon because advanced age is associated with a higher risk of ischemic-type biliary lesions and worse long-term graft survival. We herein report the case of a 90-year-old donor with fully replaced right hepatic artery. After back-table vascular assessment, the donor right hepatic artery was anastomosed end-to-end with the gastroduodenal artery with 2 polypropylene 8/0 running sutures. Even if the back-table reconstruction of a replaced right hepatic artery is not associated with an enhanced risk of posttransplant vascular com-plications, vascular abnormalities might discourage the use of otherwise acceptable elderly grafts. The present case underscores that elderly liver grafts should not be discarded per se even in the presence of vascular variants.


Key words : Elderly donors, Extended criteria donors, Liver transplantation, Nonagenarian donors

Introduction

Organ shortage and increasing donor age in liver transplant are stimulating transplant centers to accept otherwise discarded grafts due to donor age or vascular abnormalities. Use of nonagenarian donor grafts is uncommon because advanced age is associated with a higher risk of ischemic-type biliary lesions and worse long-term graft survival.1 Recently, we reported our experience with octogenarian and nonagenarian donors and showed that favorable long-term results can be achieved if proper donor and recipient evaluation are ensured.2,3 Even if a back-table reconstruction of a replaced right hepatic artery is not associated with an enhanced risk of posttransplant vascular complications,4 vascular abnormalities might discourage the use of otherwise acceptable elderly grafts.

Case Report

Recently, a 90-year-old donor after brain death was offered to our center for liver transplant. The donor was a woman with a cerebrovascular accident and a history of arterial hypertension. Her liver function tests were normal (aspartate aminotransferase of 62 IU/L, alanine aminotransferase of 43 IU/L, and bilirubin peak level of 0.96 mg/dL). The recipient was a 62-year-old white woman with stage T2 hepatocellular carcinoma in hepatitis B virus-related cirrhosis. At donor surgery, a replaced right hepatic artery from the superior mesenteric artery was found. An en bloc procurement technique with portal and arterial perfusion was performed. At back-table procedure, the replaced right hepatic artery was anastomosed end-to-end with the gastroduodenal artery with 2 polypropylene 8/0 running sutures (Figure 1, A and B). The transplant procedure was with standard vena cava replacement and simultaneous portal and arterial reperfusion. The donor common hepatic artery was anastomosed with the recipient proper hepatic artery with a polypropylene 7/0 running suture. Cold ischemia time was 530 minutes. The biliary drainage was with an end-to-end bile duct anastomosis on a T tube.

Postoperatively, the patient was administered a triple immunosuppression regimen with delayed introduction of tacrolimus, mycophenolate mofetil, and steroids and use of anti-interleukin 2 monoclonal antibodies. The postoperative period was charac-terized by an episode of acute cellular rejection amenable to steroid boluses. One month thereafter, a Doppler ultrasonography and an abdominal contrast-enhanced computed tomography scan showed patency of the graft hepatic artery (Figure 1, C and D). Figure 1E summarizes the transaminase and bilirubin trends. A 3-month posttransplant T-tube cholan-giography was unremarkable, and the T tube was removed (Figure 1F). At 6 months after transplant, the patient showed good clinical conditions with normal liver function tests.

Discussion

The gap between the growing list of patients waiting for liver transplant and the scarcity of donors has fueled efforts to maximize the available donor pool and to identify novel allocation strategies. The international literature confirms a low rate of vascular complications in liver transplant from elderly donors, when appropriate donor graft evaluation and donor-to-recipient matching are ensured.3 At back table, careful assessment of vessel quality and patency and a low threshold for discarding liver grafts in the presence of occlusive atherosclerosis are crucial for reducing the incidence of vascular complications with older livers.3 In consideration of the prolonged time required for arterial reconstruction at back table, every effort should be made to minimize cold ischemia time, since a time > 12 hours is associated with a 2-fold higher risk of graft failure.5

Conclusions

A small series of nonagenarian liver grafts was recently reported, but there have been no previous reports of ones with vascular reconstruction. The present case underscores that elderly liver grafts should not be discarded per se even in the presence of vascular variants. In the near future, it might be anticipated that, with increasing confidence of using these organs, with novel strategies for assessment of liver graft quality (such as normothermic perfusion machines), and with help from direct antiviral agents for hepatitis C virus, liver graft acceptance criteria might be expanded worldwide, even when an arterial reconstruction is required. The ultimate goal is to reduce wait-list mortality and improve the results of liver transplant.


References:

  1. Cameron AM, Ghobrial RM, Yersiz H, et al. Optimal utilization of donor grafts with extended criteria: a single-center experience in over 1000 liver transplants. Ann Surg. 2006;243(6):748-755.
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  2. Ghinolfi D, Marti J, De Simone P, et al. Use of octogenarian donors for liver transplantation: a survival analysis. Am J Transplant. 2014;14(9):2062-2071.
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  3. Ghinolfi D, De Simone P, Tincani G, Pezzati D, Filipponi F. Beyond the limit: approaching systematic use of nonagenarian donors in liver transplantation. Transplantation. 2016;100(7):e37-38.
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  4. Seket B, Abdelaal A, Gelas T, et al. Back-table reconstruction of the donor replaced right hepatic artery prior to liver transplantation: what is the real impact on arterial complications? Hepatogastroenterology. 2009; 56(91-92):756-762.
    PubMed
  5. Pezzati D, Ghinolfi D, De Simone P, et al. Strategies to optimize the use of marginal donors in liver transplantation. World J Hepatol. 2015;7(26):2636-2647.
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Volume : 17
Issue : 1
Pages : 121 - 123
DOI : 10.6002/ect.2016.0179


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From the 1Hepatobiliary Surgery and Liver Transplantation Unit and the 2Department of Radiology, University of Pisa Medical School Hospital, Pisa, Italy
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare. The authors owe a debt of gratitude to the medical and nursing staff of the Tuscany Transplantation Service Authority (Organizzazione Toscana Trapianti, OTT).
Corresponding author: Davide Ghinolfi, Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa Medical School Hospital, Via Paradisa 2, I-56124, Pisa, Italy
Phone: +39 050 995421
E-mail: d.ghinolfi@ao-pisa.toscana.it