Begin typing your search above and press return to search.
EPUB Before Print

FULL TEXT

CASE REPORT
Maximizing Deceased-Donor Allograft Utilization: Management of a Celiac Artery Aneurysm in a Deceased-Donor Liver

As the scarcity of transplantable organs continues to rise, compounded with an aging donor population, transplant surgeons are increasingly confronted with organ offers from less than ideal donors. The presence of a celiomesenteric aneurysm involving the vascular supply of a donor allograft may predispose to vascular complications in the transplanted liver. We present a 61-year-old brain-dead donor who was discovered to have a celiac artery aneurysm during organ recovery. After gross atherosclerotic or mycotic involvement was ruled out and after careful consideration of the vascular reconstructive options, the donor common hepatic artery was divided distal to the aneurysmal dilatation and anastomosed to the recipient bifurcation of the left and right hepatic artery in an end-to-end beveled anastomosis. The postoperative course was unre-markable, with normal blood flow through the anastomosis and no significant com-plications. The recipient is doing well 6 months after transplant. The presence of a celiomesenteric aneurysm should not discourage the use of an otherwise adequate liver graft. Careful vascular reconstruction is encouraged to increase the rate of marginal graft utilization and minimize vascular complications. Liberal postoperative imaging can enable early detection of vascular com-plication and prompt intervention. Through this case, we demons-trate the remarkable potential of less-than-ideal grafts with acceptable posttransplant outcomes.


Key words : Celiomesenteric aneurysm, Extended criteria donor, Liver transplant

Introduction

Splanchnic artery aneurysms (SAA) are rare vascular pathologic entities involving the celiac artery, superior mesenteric artery, inferior mesenteric artery, and their branches.1-4 Splanchnic artery aneurysms have a reported incidence ranging from 0.1% to 2% and were previously only diagnosed following rupture or during autopsies.1,5 However, with the increased utility of diagnostic and therapeutic abdominal procedures, more vascular anomalies are being incidentally diagnosed, although up to 22% of SAAs still present as clinical emergencies.4-7 Splanchnic artery aneurysms are more common in men; however, when found in women, they are most likely to involve the splenic artery, which is the most common site (60% to 80%) of SAAs in general.2,4,8 Hepatic arteries are the second most common site (20%), followed by the celiac artery and superior mesenteric artery, which make up 4% to 6% of SAAs.1,2,8 Arteriosclerosis is a frequently cited cause of SAAs, especially in older men, although its histopathologic cause has been suggested to be more of a secondary rather than a primary process.2,3,9 The presence of an aneurysm may complicate the arterial anastomosis of the liver transplant, leading to posttransplant vascular complications like hepatic artery thrombosis and hepatic artery stenosis. Careful arterial reconstruction of this vascular anomaly may reduce this risk of vascular complications and improve utilization of a graft that would have been discarded. Herein, we present a case of celiac artery aneurysm (CAA) incidentally found during brain-dead donor liver recovery; the liver was subsequently successfully transplanted after adequate management of the CAA.

Case Report

A 61-year-old African American man with medical history significant for hypertension, hypercho-lesterolemia, chronic renal disease, chronic substance abuse since age 21, and smoking 1 pack per day since 17 years old was found unresponsive in a hypertensive crisis with fixed, dilated pupils. A head computed tomography showed an intracranial hemorrhage, cerebral edema, and subfalcine herniation. He was pronounced brain dead 24 hours after admission, and his family decided to pursue organ donation. A noncontrast abdominal computed tomography scan showed a prominent celiac trunk (Figure 1).

During liver recovery, we identified a CAA 18 mm in diameter, with the common hepatic, splenic, and left gastric arteries originating from the aneurysm (Figure 2). There was no gross evidence of athe-rosclerotic or mycotic degeneration, and the liver graft was deemed appropriate for transplant.

The recipient was a 55-year-old man with end-stage liver disease secondary to Laennec cirrhosis. His Modified End-Stage Liver Disease score at the time of transplant was 32 based on a creatinine level of 1.26 mg/dL, a bilirubin level of 17.3 mg/dL, and international normalized ratio of 2.86. The recipient hepatectomy was unremarkable. Venovenous bypass was not used during the hepatectomy. We performed a side-to-side vena caval anastomosis. The liver portal vein was flushed with 750 mL of cold 5% albumin. We performed an end-to-end anastomosis of the portal vein. Once the venous reconstruction was performed, the recipient’s proper hepatic artery was dissected down to the level of the hepatic artery bifurcation to create the anastomosis. The donor’s hepatic artery was divided away from the aneurysmal dilatation to the level of the common hepatic artery. The hepatic artery reconstruction was performed in an end-to-end fashion using a Carrel patch from the recipient’s proper hepatic artery bifurcation to donor’s common hepatic artery.

The recipient had good postoperative recovery. His transplant liver ultrasonography scan showed good flow throughout the liver, and the arterial anastomosis flow was 64 cm/s on postoperative day 1. He was extubated on postoperative day 2. His postoperative course was remarkable for acute blood loss anemia and steroid-induced hyperglycemia, which were adequately managed. The patient was started on oral feeding on postoperative day 3 and began ambulating on the same day. With a pro-gressive improvement in his condition and liver function, he was discharged home on postoperative day 10. Since discharge, the recipient has had 2 episodes of cholestasis-induced pruritus at 7 weeks and 2 months posttransplant, which were managed by endoscopic retrograde cholangiopancreatography with sphincterectomy, dilation, and stent placement. At his last (3 months posttransplant) follow-up visit, his ascites and encephalopathy had completely resolved, and abdominal imaging (Doppler ultraso-nography and computed tomography) showed normal flow through the hepatic artery, hepatic veins, and portal vein. The flow through the arterial anastomosis has demonstrated optimal post-operative flow patterns since transplant.

Discussion

The demand for donor organs far outnumbers available grafts. In the past 10 years, an annual average of 2700 patients in the United States either died waiting for a donor liver or had to be removed from the transplant wait list because they became too sick to undergo liver transplant, accounting for 20% to 26% of all removals from the wait list.10 Thus, it is incumbent on the transplant community to utilize every accessible graft as long as recipient outcomes are not compromised. Surgeons are now increasingly presented with organ offers from traditionally deemed high-risk or extended criteria donors; these include grafts from elderly donors, donors with hepatis B virus or hepatitis C virus infection, and donors with high body mass index.11,12

Despite success shown with liver transplant, vascular complications remain the Achilles heel of the operation. They often occur at the site of anastomosis, with hepatic artery thrombosis (shown in up to 20% of recipients13), hepatic artery stenosis (shown in 11% of recipients14), and other vascular complications associated with high morbidity and mortality. These complications may lead to endothelial necrosis, biliary tree necrosis, or even graft loss, necessitating retransplant.14,15 Vascular variations or anomalies that require reconstruction predispose to technical errors and risk for vascular complications.13,16

The presence of an aneurysm in a donor graft may complicate the vascular reconstruction, distor-ting the arterial supply of the graft. However, a thorough work-up for causes of the aneurysm, with specific attention to infectious sources, should render otherwise discarded grafts adequate for transplant. Our review of literature for CAAs in liver donors yielded only 2 case reports, illustrating the apprehension by transplant surgeons to utilize these grafts, which have the potential to achieve good results.17,18

Conclusions

Herein, we illustrate that a CAA should not dissuade the use of a liver graft if there is no compromise to the integrity of the vessel or vascular reconstruction. It is critical that abnormalities in vessel wall integrity be evaluated in the operating room and infectious sources excluded. We believe that concerns about the risk of vascular com-plications may be addressed by liberal use of ultrasonographic imaging in the immediate posto-perative period to enable early diagnosis of vascular complications and prompt intervention. Flint and associates had a 92% sensitivity in the use of Doppler studies to diagnose hepatic artery thrombosis,19 whereas Langnas and associates had positively diagnosed 91% of patients with hepatic artery thrombosis, 100% of patients with portal vein thrombosis, and 100% of patients with combined hepatic artery thrombosis and portal vein thrombosis using Doppler imaging.15 Thus, our case demons-trates the potential that less-than-ideal liver grafts can possess, which can only be achieved by thorough evaluation of all accessible donor sources.


References:

  1. Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti AA, Pratesi C. Surgical treatment of visceral artery aneurysms: A 25-year experience. J Vasc Surg. 2008;48(2):334-342.
    CrossRef - PubMed
  2. Stanley JC, Thompson NW, Fry WJ. Splanchnic artery aneurysms. Arch Surg. 1970;101(6):689-697.
    CrossRef - PubMed
  3. Pasha SF, Gloviczki P, Stanson AW, Kamath PS. Splanchnic artery aneurysms. Mayo Clin Proc. 2007;82(4):472-479.
    CrossRef - PubMed
  4. Stanley JC, Wakefield TW, Graham LM, Whitehouse WM, Jr., Zelenock GB, Lindenauer SM. Clinical importance and management of splanchnic artery aneurysms. J Vasc Surg. 1986;3(5):836-840.
    CrossRef - PubMed
  5. Carr SC, Mahvi DM, Hoch JR, Archer CW, Turnipseed WD. Visceral artery aneurysm rupture. J Vasc Surg. 2001;33(4):806-811.
    CrossRef - PubMed
  6. Carr SC, Pearce WH, Vogelzang RL, McCarthy WJ, Nemcek AA, Jr., Yao JS. Current management of visceral artery aneurysms. Surgery. 1996;120(4):627-633; discussion 633-624.
    CrossRef - PubMed
  7. Carmeci C, McClenathan J. Visceral artery aneurysms as seen in a community hospital. Am J Surg. 2000;179(6):486-489.
    CrossRef - PubMed
  8. Nosher JL, Chung J, Brevetti LS, Graham AM, Siegel RL. Visceral and renal artery aneurysms: a pictorial essay on endovascular therapy. Radiographics. 2006;26(6):1687-1704; quiz 1687.
    CrossRef - PubMed
  9. Larson PA, Lipchik EO, Adams MB. Development and regression of visceral artery aneurysms following liver transplantation: case report. Cardiovasc Intervent Radiol. 1988;11(2):75-78.
    CrossRef - PubMed
  10. National Data OPTN Web site. Organ Procurement and Transplantable Network; 2017. https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#. Accessed August 15, 2018.

  11. Vodkin I, Kuo A. Extended Criteria Donors in Liver Transplantation. Clin Liver Dis. 2017;21(2):289-301.
    CrossRef - PubMed
  12. Dasari BVM, Schlegel A, Mergental H, Perera M. The use of old donors in liver transplantation. Best Pract Res Clin Gastroenterol. 2017;31(2):211-217.
    CrossRef - PubMed
  13. Esquivel CO, Koneru B, Karrer F, et al. Liver transplantation before 1 year of age. J Pediatr. 1987;110(4):545-548.
    CrossRef - PubMed
  14. Pawlak J, Grodzicki M, Leowska E, et al. Vascular complications after liver transplantation. Transplant Proc. 2003;35(6):2313-2315.
    CrossRef - PubMed
  15. Langnas AN, Marujo W, Stratta RJ, Wood RP, Shaw BW, Jr. Vascular complications after orthotopic liver transplantation. Am J Surg. 1991;161(1):76-82; discussion 82-73.
    CrossRef - PubMed
  16. Karatzas T, Lykaki-Karatzas E, Webb M, et al. Vascular complications, treatment, and outcome following orthotopic liver transplantation. Transplant Proc. 1997;29(7):2853-2855.
    CrossRef - PubMed
  17. di Francesco F, Pagano D, Echeverri G, et al. Selective use of extended criteria deceased liver donors with anatomic variations. Ann Transplant. 2012;17(4):140-143.
    CrossRef - PubMed
  18. Mor E, Emre S, Schwartz ME, Sheiner PA, Miller CM. Aneurysm of the celiac artery in a liver allograft. Transplantation. 1993;56(6):1548-1549.
    CrossRef - PubMed
  19. Flint EW, Sumkin JH, Zajko AB, Bowen A. Duplex sonography of hepatic artery thrombosis after liver transplantation. AJR Am J Roentgenol. 1988;151(3):481-483.
    CrossRef - PubMed


DOI : 10.6002/ect.2019.0023


PDF VIEW [238] KB.

From the 1Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; the 2Hartford Hospital Transplant Program, Hartford, Connecticut, USA; and the 3University of Connecticut School of Medicine, Farmington, Connecticut, USA
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Oleg Slivca, Department of Surgery, Division of Transplantation
Mayo Mail Code 195, 420 Delaware Street SE, Minneapolis, MN 55455, USA
Phone: +1 612 322 3365
E-mail: slivc001@umn.edu