Dear Editor:

Anatomic variations of the hepatic artery have been approached with various reconstruction techniques to ensure complication-free arterial anastomosis during liver transplant.¹ When faced with donor hepatic arterial anatomic variations, the surgeon should use the technique best suited for the situation so that the hepatic allograft can be adequately arterialized. We describe a novel technique of arterial reconstruction for a rare right hepatic arterial anomaly during a deceased-donor liver transplant.

A whole liver allograft, recovered from a 40-year-old male donor who died of brain hemorrhage, showed a replaced right hepatic artery arising directly from the aorta. The recipient, a 54-year-old male patient with hepatitis C, had a Model for End-Stage Liver Disease score of 18. Because of diameter discrepancies, the replaced right hepatic artery was considered unsuitable for anastomosis to the gastroduodenal donor arterial stumps. In addition, bringing the replaced right hepatic artery to the splenic artery would result in a kinking that would affect blood flow. So that a single anastomosis could be performed in the recipient, the donor celiac trunk and the replaced right hepatic artery were anastomosed using a foldover technique at the back table. In the recipient, the inflow was established by anastomosis between the recipient common hepatic artery and the donor splenic artery (Figure 1). The postoperative recovery of the patient was unremarkable, with normal Doppler results. The patient was discharged 18 days after the surgical procedure.

For successful arterialization of a liver allograft, complex procedures such as 2 arterial anstomoses² or ligation of the accessory artery 1 week before transplant from a living donor³ have been described. However, a successful arterial anastomosis is more likely with a simple and single anastomosis.¹ Complications of arterial anastomosis, such as thrombosis, can be lethal due to hepatic necrosis, biliary complications, or sepsis. The given anatomy, arterial wall disease, and diameters should be assessed to choose the appropriate reconstruction technique because of the known association between vasculobiliary complications and reconstruction techniques.⁴

Hepatic arterial anatomy is highly variable, with only 12% to 49% of patients described as having a so-called normal anatomy in anatomic and radiologic studies.⁵ It is not uncommon for anatomic variations to be reported that cannot be classified conventionally. Replaced right hepatic artery arising directly from the aorta has not been classified and occurs in approximately 1% of patients.⁵ In deceased-donor liver transplants, only the origin of the aberrant artery affects the planning for reconstruction, as in our case. To our knowledge, this is the first description of such an arterial reconstruction technique for this anatomic variation.

In conclusion, careful consideration should be given to variations in the anatomy of a donor’s hepatic artery so that the best reconstruction technique can be selected to avoid the potential complications of arterial anastomosis. As described here, when a replaced right hepatic artery originates from the aorta, the reconstruction can be made by anastomosis with the celiac trunk, with inflow reestablished through the splenic artery.

References:

1. Lerut JP, Gordon RD, Tzakis AG, Stieber AC, Iwatsuki S, Starzl TE. The hepatic artery in orthotopic liver transplantation. Helv Chir Acta. 1988;55(3):367-378.
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2. Panaro F, Chauvat J, Carabalona JP, et al. Double arterial anastomosis in liver transplantation: is two better than one? J Gastrointest Surg. 2013;17(8):1512-1515.
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3. Douard R, Ettorre GM, Sommacale D, et al. A two-step strategy for enlargement of left arterial branch in a living related liver graft with dual arterial supply. Transplantation. 2002;73(6):993-994.
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4. Mabrouk Mourad M, Liossis C, Kumar S, et al. Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques. Liver Transpl. 2015;21(1):63-71.
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5. Koops A, Wojciechowski B, Broering DC, Adam G, Krupski-Berdien G. Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. Surg Radiol Anat. 2004;26(3):239-244.
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