Objectives: In some cases of liver transplant, standard hepatic artery reconstruction may be difficult or impossible due to inadequate flow of the recipient’s hepatic artery, as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. We compared splenic artery transposition with extra-anatomic jump graft as 2 alternative methods for hepatic artery reconstruction in these situations.
Materials and Methods: We reviewed the files of 2135 liver transplant recipients from March 2011 to February 2016 at the Shiraz Transplant Center. Data of 93 patients with unusual hepatic artery reconstruction were analyzed to assess outcomes, morbidity, mortality, and pre- and posttransplant parameters (both clinical and paraclinical). Patients were divided into 2 groups: 17 with splenic artery transposition (splenic artery group) and 76 with extra-anatomic jump grafts (control group).
Results: There was only 1 occurrence (5.8%) of hepatic artery thrombosis in the splenic artery group causing extra-anatomic jump graft. However, in the control group, there were 4 occurrences (5.2%) of hepatic artery thrombosis, causing 1 revision of anastomosis and 3 retransplant procedures. No deaths due to hepatic artery complications were reported in the 2 groups. Three-year survival rate was 87.5% in the splenic artery group and 68.9% in the control group.
Conclusions: Splenic artery transposition is an acceptable method for hepatic artery reconstruction in deceased-donor liver transplant procedures with no greater rates of complication or morbidity than extra-anatomic jump grafts. Less operation time and better exposure during surgery are advantages of this method.
Key words : Complication, Liver transplantation, Re-transplantation, Revascularization, Splenic artery
Hepatic artery (HA) reconstruction is an important part of deceased-donor liver transplant procedures, which is usually performed by anastomosing the donor and recipient hepatic arteries.1 In some situations, such as with intimal dissection, thrombosis, small hepatic arteries, weak and inadequate HA inflow, and retransplant, extra-anatomic HA reconstruction is essential to restore arterial inflow to the transplanted liver. Most surgeons solve this problem using an extra-anatomic jump graft (EAJG) with an arterial conduit between the aorta and the donor HA. Donor iliac arteries are used for this procedure.2,3 Here, we report an alternative method using arterial transposition of the recipient’s splenic artery for HA reconstruction.
Materials and Methods
Between March 2011 and February 2016, 2135 liver transplant procedures were performed at the Namazi Hospital Shiraz Transplant Center. After reviewing the files of these patients, we identified 93 patients with unusual HA reconstruction: 17 patients with splenic artery transposition (splenic artery group) and 76 patients with EAJG (control group).
All study patients had whole liver grafts, which were taken from deceased donors. In the splenic artery group, 4 patients underwent end-to-side anastomosis and 13 patients underwent end-to-end anastomosis. One patient changed to EAJG because of HA thrombosis 1 day after the transplant procedure. All of the patients in the splenic artery group primarily underwent splenic artery transposition, except for 2 patients. These 2 patients developed HA thrombosis after standard HA anastomosis and were changed to splenic artery transposition at postoperative days 1 and 4.
Extra-anatomic jump graft was created by anastomosing the iliac artery graft (retrieved from brain dead donors) to the anterior aspect of the recipient’s infrarenal aorta, thereby creating an aortic conduit that was then anastomosed to the donor HA. All study patients had been routinely evaluated with Doppler ultrasonography daily for at least 7 days, weekly for the first month after release, and every 3 months during the first posttransplant year and when indicated by the transplant surgeon.
A triple-drug immunosuppression regimen was administered with steroids, tacrolimus, and mycophenolate mofetil. Our analyses included examination of variables such as Model for End-Stage Liver Disease score, pre- and posttransplant laboratory data, demographic data, vascular complications, infections, acute and chronic rejection, biliary complications, graft survival, and patient survival. Data were included for each patient until the end of the study in February 2016.
Continuous variables were compared using Mann-Whitney test. Categorical variables were compared with chi-square test or Fisher exact test. Actuarial survival was estimated by the Kaplan-Meier method with significance testing with the log-rank test. A P value of < .05 was considered statistically significant. All statistical analyses were performed with SPSS software (SPSS: An IBM Company, version 21, IBM Corporation, Armonk, NY, USA).
Between March 2011 and February 2016, we identified 93 of 2135 total patients with unusual HA reconstruction seen at our transplant center. Data were compared between 17 patients (18.3%) with splenic artery transposition versus 76 patients (81.7%) with EAJG. There was no significant difference in age; however, male-to-female ratio was significantly different (P = .031) (Table 1).
Splenic artery was more frequently used in female recipients (13/17 patients; 76.5%); however, in the control group, the splenic artery was used more in men (41/76 patients; 53.9%). Mean pretransplant Model for End-Stage Liver Disease score was 20.88 (range, 13-35) in the splenic artery group and 20.59 (range, 4-40) in the control group. Cause of liver transplant was not significantly different between the 2 groups (Table 1). As shown in Table 1, the need for arterial anastomosis conversion was mostly seen in patients with autoimmune-based diseases, resulting from the effects of corticosteroids on the vasculature of the liver. Most of the arteries had a thin wall and were fragile and developed “flapping,” with dissection leading to anastomosis diversion to splenic artery or EAJP.4,5 There were 11 vascular complications: 3 in the splenic artery group (17.6%) and 8 in the control group (10.5%). Bile duct complications were seen in 13 patients, rejection in 21, infection in 10, graft failure in 11, and retransplant in 9 patients. In addition, 23 patients died during our study. However, we found no significant differences between groups in any of these results (Table 2). The 5-year graft and patient survival rates after liver transplant using splenic artery for reconstruction of the HA was good (82% and 88%) compared with the control group (60% and 69%), although no significant differences were found with log-rank test (P = .924 and .329) (Tables 3 and 4 and Figures 1 and 2). Regarding other variables examined, we found no significant differences between most of the laboratory data, both before and after transplant. These laboratory results included complete blood count, liver function tests, serum electrolytes, and coagulation tests. However, significant differences between groups were shown with pretransplant white blood cell count (P = .009), pretransplant potassium level (P = .025), posttransplant hemoglobin level (P = .021), and posttransplant albumin level (P = .002). We detected no differences in platelet counts in patients who had splenic artery transposition compared with the control group; however, we observed rapid normalization of platelet counts after end-to-end anastomosis with splenic artery. In the control group, vascular complication and infection were prognostic factors for decreased survival in log-rank test (P < .001). In the splenic artery group, complications had no adverse effects on survival.
Our study shows that liver transplant using splenic artery transposition has long-term results similar to those with standard liver transplant procedures.6,7 In comparison with other techniques,8-10 such as the extra-anatomic aortohepatic conduit technique, results were better at our center, although not statistically different. This study is important because the Namazi Transplant Center in Shiraz (Iran) was the most crowded transplant center of the world during our study period, and we can now present our results to other centers. New considerations, even under work pressures, can improve our skills and results for better future outcomes. We found that splenic artery transposition is an acceptable method that can be used safely for deceased-donor liver transplant procedures with no negative effects on long-term graft and patient survival rates7,11 and with less postoperative problems such as vascular, biliary, and infectious complications. This method, compared with the EAJG technique, had no worse results. Its shorter operation time and better exposure during surgery were advantages of this method. In the EAJG method, we needed a conduit (iliac artery of deceased donor); however, organ shortages in most centers are a limiting factor, as well as the possibility that older donor age would make this conduit atherosclerotic and unusable. Furthermore, dissection of the abdominal aorta can promote bleeding, lymph leakage, and intimal dissection, especially in older recipients.10,12,13 Therefore, arterial transposition of the splenic artery with no need for conduit seems to be a more approachable method. We recommend this type of arterial anastomosis as an excellent method, especially in patients with splenomegaly due to their larger splenic artery.14-16 In addition, this method can result in earlier normalization of platelet counts.1,17,18
When complications arise with arterial anastomosis during liver transplant procedures, we can use many methods, depending on the surgeon’s skills and trends of the transplant center. We recommend splenic artery transposition because of its better exposure and results and less bleeding and operation time. This method is suggested as a preference before other methods of arterial reconstruction.
Volume : 15
Issue : 1
Pages : 204 - 207
DOI : 10.6002/ect.mesot2016.P82
From the 1Department of Organ Transplantation, Namazi Hospital, Shiraz, Iran;
and the 2Organ Procurement Unit, Namazi Hospital, Shiraz, Iran
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare. This article was extracted from Pirooz Samidoost’s fellowship thesis on liver transplant surgery. The authors thank Shiraz University of Medical Sciences, Shiraz, Iran, and also the Center for Development of Clinical Research of Namazi Hospital and Dr. Nasrin Shokrpour for editorial assistance.
Corresponding author: Pirooz Samidoost, Department of Organ Transplantation, Namazi Hospital, 7193711351, Shiraz, I.R. Iran
Phone: +98 911 383 0520
Table 1. Demographic Data
Table 2. Complications
Table 3. Graft Survival
Table 4. Patient Survival
Figure 1. Graft Survival for Patients Who Received Liver Transplant With Splenic Artery Transposition Versus Patients Who Received Extra-Anatomic Jump Grafts
Figure 2. Patient survival for Patients Who Received Liver Transplant With Splenic Artery Transposition Versus Patients Who Received Extra-Anatomic Jump Grafts