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CASE REPORT
Graft Retrieval for Liver Transplant in a Donor With Giant Thoracoabdominal Aortic Aneurysm

Liver transplant is a lifesaving treatment option for end-stage liver disease in those with or without hepatocellular carcinoma. Organ shortage is currently the main limitation to liver transplant in many countries worldwide, with fewer donors than patients waiting for transplant. Different solutions have been proposed, including the use of marginal grafts, living donors, and machine perfusion. Potential organs are sometimes discarded due to technical difficulties that may hamper the success of their retrieval and eventual transplant. Here, we present the case of a 69-year-old man with a history of cardiac and pulmonary disease who was considered a potential organ donor after brain death. According to the patient’s history, a computed tomography before acceptance was required. The scan revealed a giant thoracoabdominal aortic aneurysm. The donor had previous cardiac surgery with sternotomy and a talcage of the right pleural space. The 2 renal arteries were also unusable because of spread calcifications and involvement by the aneurism. We decided to cannulate the superior mesenteric vessels. Liver transplant was uneventful, and the recipient had no vascular complications, as shown by Doppler ultrasonography performed on days 1, 3, and 7. Length of hospitalization was 14 days. Organ shortages for transplant seemed to have worsened during the COVID-19 period. Nonetheless, the condition of oncology patients can worsen if surgical treatments are delayed. Rearrangements of resources require adaptations in clinical practice.


Key words : Cirrhosis, Hepatocellular carcinoma, Model for End-Stage Liver Disease

Introduction

Liver transplantation (LT) is a lifesaving treatment option for end-stage liver disease in patients with or without hepatocellular carcinoma. Currently, organ shortages are one of the main limitations to LT in many countries worldwide, with fewer donors than patients on wait lists for transplant. Different solutions have been proposed, including the use of marginal grafts, living donors, and machine perfu­sion. Potential organs are sometimes discarded because of technical difficulties that could hamper the success of organ retrieval and eventual transplant.1 However, centers currently can accept liver grafts from donors with extended criteria. Previous major abdominal and vascular surgery may be one of the reasons to reject the organ. Herein, we report a successful case of liver retrieval from a donor with a giant thoracoabdominal aortic aneurysm.

Case Report

Written informed consent was obtained from the family for publication of this study and any accompanying images. We present the following case in accordance with the CARE reporting checklist.

A 69-year-old man with a history of cardiac and pulmonary disease was considered a potential organ donor after brain death. According to the patient’s history, a computed tomography before acceptance was required. The scan showed a giant thoracoab­dominal aortic aneurysm (Figure 1, A and B). Furthermore, physiological liver perfusion and a left hepatic artery were shown (Figure 1C). We decided to accept the donor for an oncology transplant candidate. Only the liver was acceptable due to chronic kidney failure. The donor had previous cardiac surgery with sternotomy and a talcage of the right pleural space.

After laparotomy, a liver biopsy was performed. The second step was to isolate and loop the iliac veins and arteries. Surprisingly the 2 iliac arteries were involved in the aneurysm. The 2 renal arteries were also unusable because of spread calcifications and involvement by the aneurism. We decided to cannulate the superior mesenteric vessels (Figure 2, A and B). Aortic clamping was a demanding procedure: previous sternotomy and the right pleural talcage were considered contraindications for a second sternotomy. We chose a left thoracotomy incision to safely clamp the aorta. Moreover, considering the aortic aneurysm, this solution was mandatory.

An en bloc procurement was performed with the entire abdominal aorta. During back-table preparation of the graft, a careful dissection was made. The celiac trunk was preserved from the aneurysm, the left hepatic artery was conserved, and no other anomalies were observed (Figure 2C). Liver transplant was uneventful, and the patient had no vascular complications, as shown by Doppler ultrasonography performed on days 1, 3, and 7. Length of hospitalization was 14 days.

Discussion

The increasing number of patients on wait lists and the scarcity of donors have led many transplant centers to accept liver grafts from donors with extended criteria. Donor vascular diseases and abnormalities are still reasons to discard grafts from donors with extended criteria. The hepatic artery anastomosis still represents the Achille’s heel of LT as the arterial inflow influences graft recovery and the viability of the biliary tree. Arterial complications are considered as indications for retransplant. In our case, the biggest challenge was to ensure good perfusion of the liver for retrieval. Generally, perfusion is performed from the iliac artery or directly from the aorta.2 Alternatively, the renal artery could be used in cases of diffuse arterial sclerosis. In our practice, we always perform double arterial and portal perfusion. In addition, before recipient surgery is started, back-table preparation is performed.

Arterial anastomosis is usually performed between the graft and the recipient’s hepatic artery.3 Alternative sites, such as aortohepatic anastomosis with or without conduits, celiac trunk, or splenic artery, are described as safe and effective alternatives.4

Shortages of organs for transplant may have worsened during the COVID-19 period. Nonetheless, the condition of oncology patients may worsen if surgical treatment is delayed. Rearrangements of resources require adaptations in clinical practice.5

Conclusions

A shortage of donors and an increased number of patients on wait lists have obliged us to consider all potential grafts. We suggest the use of mesenteric perfusion in cases of abdominal aneurysms.


References:

  1. De Carlis R, Andorno E, Buscemi V, et al. Successful transplant of a liver graft after giant hepatic artery aneurysm resection and reconstruction. Exp Clin Transplant. 2020;18(4):522-525. doi:10.6002/ect.2019.0028
    CrossRef - PubMed
  2. Benedetti E, Massad MG, Kisthard JA. Aortic cannulation in organ donors with pathology of the infrarenal aorta. J Am Coll Surg. 1997;185(5):488-489.
    CrossRef - PubMed
  3. Guglielmo N, Meniconi RL, Vennarecci G, Ettorre GM. Celiaco-mesenteric trunk: A rare variation that must be known before liver transplant. Dig Liver Dis. 2020;52(3):354. doi:10.1016/j.dld.2019.11.003
    CrossRef - PubMed
  4. Beaurepaire JM, Orlando F, Levi Sandri GB, et al. Comparison of alternative arterial anastomosis site during liver transplantation when the recipient’s hepatic artery is unusable. Hepatobil Surg Nutr. Accepted manuscript. Published online May 13, 2020. doi:10.21037/hbsn-20-10
  5. Berardi G, Colasanti M, Levi Sandri GB, et al. Continuing our work: transplant surgery and surgical oncology in a tertiary referral COVID-19 center. Updates Surg. 2020;72(2):281-289. doi:10.1007/s13304-020-00825-3
    CrossRef - PubMed


DOI : 10.6002/ect.2020.0311


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From the Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for preparation of this work and have no declarations of potential conflicts of interest. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.
Author contributions are as follows: GBLS and GB contributed to conception and design; GME contributed to administrative support; GBLS and NG provided study materials or patients; GBLS and NG collected and assembled the data; GB and GBLS analyzed and interpreted the data; all authors contributed to the writing of this manuscript writing and its final approval.
Corresponding author: Giovanni Battista Levi Sandri, Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circ.ne Gianicolense, 87 00151 Rome, Lazio, Italy
Phone: +39 6 58704816
E-mail: gblevisandri@gmail.com