Dialysis Interventions and Transplant Interventions

Session: Educational Exhibit Presentations - Station 2: Dialysis Interventions and Transplant Interventions

Transplant Hepatic Artery Stenosis in Liver Donations after Cardiac Death: Diagnosis to Intervention and Outcomes

Monday, March 6, 2023

5:40 PM – 5:45 PM

Location: Phoenix Convention Center, North Ballroom 120ABC, Poster Hall

Abstract Presenter(s)

McKenzie Mosenthal, MD

Diagnostic Radiology Resident Physician
Loyola University Medical Center

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

ST

Surbhi B. Trivedi, MD

Resident Physician
UIC
MB

Marc Borge, MD

Medical Director of Interventional Radiology
Loyola University Medical Center
PC

Penuel Chun, MD

Interventional Radiology Fellow
Loyola University Medical Center
RE

Rami El-Baba, MD

Resident
Loyola University Medical Center
CM

Christopher Molvar, MD

Interventional Radiologist
Loyola University Medical Center

Disclosure(s):

McKenzie Mosenthal, MD: No financial relationships to disclose

Learning Objectives:

Present pictorial examples of cases of hepatic artery stenosis (HAS) after liver transplant (LT).

Discuss propensity for this complication from liver donations after cardiac death (DCD) and potential mechanisms.

Understand the techniques available for treating HAS in this patient population and theoretical efficacy of those interventions in DCD transplants.

Background:

Hepatic artery stenosis is an infrequent but potentially devastating complication of LT, occurring more frequently in the DCD population as compared to donation after brain death (DBD) {1, 2}. The DCD population is likely prone to HAS due to fragility of the vessels after injury to the hepatic artery vasa vasorum with warm ischemia time (WIT){3, 4} . Up to 9% of liver transplants can be complicated by critical HAS, characterized as greater than 50% narrowing of the lumen, a complication which can lead to biliary necrosis and/or graft loss {2}. Hepatic artery stenosis occurring within three months of LT is typically treated with endovascular therapy{5, 6, 8}.

Clinical Findings/Procedure Details:

This single center experience will demonstrate pictorial examples of post-transplant HAS with particular attention to this complication in DCD transplants. Early sonographic findings of HAS include low resistive indices, elevated peak systolic velocity, and tardus parvus waveforms in the distal hepatic artery branches.

For patients with HAS occurring greater than 7 days and less than 3 months after transplant, endovascular therapy is the treatment. Transplant hepatic artery angioplasty is technically challenging due to the tortuosity of the anastomosis. The degree of stenosis and length of the stenotic segment can also complicate interventions {8}.

Warm ischemia time may result in increased risk of HAS in DCD livers as compared to DBD and demonstrates inferior primary patency as compared to DBD counterparts {4}. The mechanism of reduced post treatment efficacy most likely relates to vasa vasorum injury and propensity for spasm and dissection.

Conclusion and/or Teaching Points:

Early onset HAS is a rare complication but carries high associated morbidity and risk of graft loss, particularly in DCD livers {7, 9}. Hepatic artery endovascular angioplasty and stent repair can be effective therapeutic interventions, but technical challenges including tortuous anatomic variant, degree of stenosis, and length of stenotic segment must be considered to avoid complication. These findings may have important implications in future management of DCD transplants such as lower threshold for angiogram in response to lab abnormalities or ultrasound findings.