Clinical Outcomes of Donor Hepatic Artery to Recipient Replaced Right Hepatic Artery Anastomosis in Living-Donor Liver Transplantation O. Koca,*, F. Yaylakb, B. Saricic, V. Soyerc, and S. Yilmazc a Gastroenterology Surgery, Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey; bDepartment of General Surgery, Dumlupınar University School of Medicine, Kutahya, Turkey; and cDepartment of General Surgery, Faculty of Medicine, Inonu University, Malatya, Turkey
ABSTRACT Objective. The aim of this work was to evaluate the clinical outcomes of donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation. Methods. A retrospective analysis of 12 patients with donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation from January 2012 to July 2014 was performed. Age, sex, clinical diagnosis of the liver disease, ABO mismatch, hepatic artery thrombosis, biliary strictures and leakage, graft loss, and mortality rates were evaluated. Results. Female-to-male ratio was 4:8. Right lobe was transplanted in 11 (91.7%) of the patients. In 1 patient, left lobe was transplanted. In 9 patients, single duct-to-duct biliary anastomosis was performed with cystic duct catheterization. In 2 patients, double ductto-duct biliary anastomosis was performed. In 1 patient, double biliary duct-to-duct anastomosis was performed after ductoplasty to achieve a single ductal orifice. No hepatic artery thrombosis was observed. Biliary complications were observed in 6 patients (50%: biliary leaks in 2 patients, biliary stricture in 3 patients, and both in 1 patient). ABO mismatch was not observed. No graft loss due to hepatic artery thrombosis was observed. Mortality was observed in 2 patients (16.6%). Conclusions. Donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation is somewhat related to biliary complications, but not associated with increased rates of hepatic artery thrombosis.
R
EPLACED RIGHT HEPATIC ARTERY (repRHA) originating from the superior mesenteric artery (SMA) is a common variation of the right hepatic artery (HA). Earlier reports have reported a frequency of 5.8%e13.5% in some series [1e3]. RepRHA is used to achieve blood flow in those recipients with inadequate blood flow with the use of HAs originating from the celiac system. Donor-related HA variations have been reported and discussed previously [4e6]. However, the clinical outcomes of donor HA to recipient repRHA anastomosis in living-donor liver transplantation (LDLT) have not been discussed. In a report by Sutcliffe et al, donor HA to recipient repRHA anastomosis in deceaseddonor liver transplantation (DDLT) was discussed [7].
The aim of the present study was to evaluate the clinical results of the donor HA to recipient repRHA anastomosis in LDLT patients. MATERIALS AND METHODS A retrospective analysis of the LDLT patients with donor HA to recipient repRHA anastomosis from January 2012 to July 2014 was performed. Twelve patients were available for the study. Age, sex,
*Address correspondence to Okay Koc, MD, Gastroenterology Surgery, Gazi Yas¸argil Education and Research Hospital, Diyarbakir, Turkey. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.029
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1478
Transplantation Proceedings, 47, 1478e1481 (2015)
CLINICAL OUTCOMES OF DONOR HEPATIC ARTERY
1479
Table 1. Basic Clinical Features of the Study Cohort (n [ 12) Female-male ratio Age, mean Diagnosis HBV-related chronic liver disease Fulminant liver failure Cryptogenic liver disease Budd-Chiari syndrome Graft type Right lobe LDLT Left lobe LDLT Follow-up, mean (range) Biliary reconstruction type Duct-to-duct single anastomosis Duct-to-duct double-orifice single anastomosis Duct-to-duct double anastomosis
4:8 43.9 y 8 2 1 1 11/12 (91.7%) 1/12 (8.3%) 12 (1e29) mo 9/12 (75%) 1/12 (8.3%) 2/12 (16.6%)
Fig 2. Donor hepatic artery to recipient replaced right hepatic artery anastomosis in a living-donor liver transplant patient, postoperative computerized tomographic angiography.
Abbreviations: HBV, hepatitis B virus; LDLT, living-donor liver transplantation.
clinical diagnosis of the liver disease, ABO mismatch, HA thrombosis, biliary strictures and leakage, graft loss, and mortality rates were evaluated.
RESULTS
In this study donor hepatic artery to recipient repRHA anastomosis in LDLT was performed in 12 patients. Basic clinical features of the study cohort are reviewed in Table 1. Four patients were female (33.3%) and in 8 were male (66.7%). Mean ages were 50 years in female and 37.8 years in male patients. Diagnosis was hepatitis B viruserelated chronic liver disease in 8 (66.7%), acute fulminant liver failure in 2 (16.6%), cryptogenic liver cirrhosis in 1 (8.3%), and Budd-Chiari syndrome in 1 (8.3%) of the patients. Right liver lobe was transplanted in 11 (91.7%) and left liver lobe in 1 (8.3%) of the patients. Donor RHA to recipient replaced right hepatic artery anastomosis in LDLT was performed in 11 (91.7%) of the patients. In 1 patient (8.3%), donor left HA to recipient repRHA anastomosis in LDLT was performed (Figs 1 and 2). Clinical outcomes after LDLT with donor HA to recipient repRHA anastomosis are presented in Table 2. Mean
follow period was 12 (range, 1e29) months. In 9 patients (75%), single duct-to-duct biliary anastomosis was performed with cystic duct catheterization. In 2 patients (16.6%), double duct-to-duct biliary anastomosis was performed. In 1 patient (8.3%), double biliary duct-to-duct anastomosis was performed after ductoplasty to achieve a single ductal orifice. No HA thrombosis was observed. Biliary complications were observed in 6 patients (50%): biliary leakage at anastomotic side in 2 patients (16.6%), biliary stricture at anastomotic side in 3 patients (25%), and biliary stricture after biliary leakage at anastomotic side in 1 patient (8.3%). Biliary leaks were managed with the use of percutaneous drainage, and spontaneous resolution was achieved in 1 patient. The other resulted in mortality. Biliary strictures were managed with the use of percutaneous external-internal biliary drainage catheterizations. No ABO mismatch was observed. No graft loss due to hepatic artery thrombosis (HAT) was observed. Mortality was observed in 2 patients (16.6%): One patient was lost owing to overt hemorrhage on the postoperative 8th day, and 1 patient owing to sepsis due to biliary leakage on the postoperative 13th day. DISCUSSION
Hepatic artery thrombosis rates after liver transplantation have been reported to differ with rates 2%e9% in different series [8,9]. Previously we reported a rate of HAT 6.5% from our liver transplantation center. Blood flow insufficiency, lower diameters of artery, intimal damages near the arterial anastomosis region, arterial reconstruction with vascular grafts, and multiple arterial anastomoses were reported to be related to increased risk of HAT [10e17]. In the present study we did not observe HAT after donor HA Table 2. Clinical Outcomes After LDLT (n [ 12)
Fig 1. Replaced right hepatic artery, preoperative computerized tomographic angiography.
Hepatic artery thrombosis Biliary complications Graft loss Death
None 6/12 (50%) None 2/12 (16.6%)
1480
to recipient repRHA anastomosis in 12 patients with LDLT. This result was achieved with an improved and meticulous surgical technique for arterial anastomosis to minimize intimal injury, patience in perioperative assessment of arterial blood flow, and performance of single arterial anastomosis without reconstruction using vascular graft. Earlier reports have documented different biliary complication rates with a range of 17%e28% [18e20] after liver transplantation. The present authors previously reported a biliary complication rate of 25.8% [10]. The biliary system is fed by the arterial system. Thus, artery-related complications after liver transplantation have a tendency to affect the biliary system. Artery-related biliary complications are well known and named as biliary leakage, strictures, and nonanastomotic strictures. Some risk factors for biliary complications have been reported previously. HAT, HA stenosis, cold ischemia period >12 hours, ABO mismatch, and disturbances of arterial supply to the biliary system during dissection have been reported to be related with biliary complications after liver transplantation [18,19,21]. The type of biliary reconstruction was reported not to be related to biliary complications [19]. In the present study we did not observe HAT or HA stenosis. Cold ischemia period was short owing to the use of living donors. Our dissection and biliary reconstruction techniques were the same in these 12 patients. The high rate of biliary complicationsd50%dwas similar to our earlier results. The biliary complications rate in this study may be due to decreased blood flow as result of other conditions. Relative lower flow rate of SMA is one the causes of decreased arterial blood flow. Thus, one may advocate the need of additional interventions to improve blood flow rates to prevent biliary complications. SMA blood flow has been evaluated previously. Qamar et al calculated SMA blood flow and reported a rate of 517 19 mL/min [22]. Bradley et al reported a blood flow rate of 1,497 mL/min for HA [23]. Thus, HA blood flow rate is significantly different from SMA blood flow rate. HA blood flow rates are triple SMA blood flow rates. Sutcliffe et al [7] have advocated that a decrease in distribution of arterial blood flow to intestines further decreases the blood flow to the transplanted liver graft and should result in an increased risk for compromised biliary vascular perfusion. In the present series, we performed arterial anastomosis after consideration of the adequacy of repRHA (from SMA) blood flow. Increased biliary complications without artery-related problems were considered to be a result of blood flow rate inadequate to prevent arterial thrombosis though sufficient to supply the needs of biliary system. Another reason or risk factor for increased biliary complications after LDLT is the relative thin biliary ducts of the living-donated liver graft compared with deceased-donated liver grafts. Sutcliffe et al reported biliary complications in 4 of 22 patients (18.4%) with donor HA to recipient repRHA anastomosis in DDLT [7]. Biliary complications were significantly lower than in our series with LDLT patients. However, these controversial results should be considered together with other factors. In their report,
KOC, YAYLAK, SARICI ET AL
Robert et al studied a heterogonous group. Cadaveric liver was split (4 right and 2 right left lateral grafts) in some recipients. Six patients were in pediatric age group. RepRHA was used in 15 patients. Accessory RHA artery was used in 8 patients. Proper HA originating from SMA was used in 4 patients. Thus, with a more homogeneous group such as reported here, our results should be considered to be similar. In addition, some other factors related to type of graft (cadaveric or living donor) may be advocated. However, that issue merits further evaluation. In conclusion, donor HA to recipient repRHA anastomosis in LDLT should be further evaluated for the increased risk of biliary complications, although it is not considered to be related with increased arterial thrombosis. ACKNOWLEDGMENTS The authors thank their patients and all personnel of Inonu University Liver Transplantation Institute.
REFERENCES [1] Varotti G, Gondolesi GE, Goldman J, Wayne M, Florman SS, Schwartz ME, et al. Anatomic variations in right liver living donors. J Am Coll Surg 2004;198:577e82. [2] Yoshida A, Okuda K, Sakai H, Kinoshita H, Aoyagi S. 3D anatomical variations of hepatic vasculature and bile duct for right lateral sector of liver with special reference to transplantation. Kurume Med J 2008;55:43e53. [3] Kishi Y, Imamura H, Sugawara Y, et al. Evaluation of donor vasculobiliary anatomic variations in liver graft procurements. Surgery 2010;147:30e9. [4] Yaprak O, Demirbas T, Duran C, et al. Living donor liver hilar variations: surgical approaches and implications. Hepatobiliary Pancreat Dis Int 2011;10:474e9. [5] Lee KK, Lee SK, Moon IS, Kim DG, Lee MD. Surgical techniques according to anatomic variations in living donor liver transplantation using the right lobe. Transplant Proc 2008;40:2517e20. [6] Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. Surgical management of anatomical variations of the right lobe in living donor liver transplantation. Ann Surg 2000;231:824e31. [7] Sutcliffe RP, Lolis E, Prachalias AA, Srinivasan P, Rela M, Heaton ND. Use of an aberrant right hepatic artery arising from the superior mesenteric artery of the recipient for arterial reconstruction in liver transplantation. Ann Transplant 2010;15:44e8. [8] Proposito D, Loinaz Segurola C, Garcia Garcìa I, et al. [Assessment of risk factors in the incidence of hepatic artery thrombosis in a consecutive series of 687 liver transplantations]. Ann Ital Chir 2001;72:187e205. [9] Abou Ella KA, Al Sebayel MI, Ramirez CB, Rabea HM. Hepatic artery thrombosis after orthotopic liver transplantation. Saudi Med J 2001;22:211e4. [10] Unal B, Gonultas F, Aydin C, Otan E, Kayaalp C, Yilmaz S. Hepatic artery thrombosis-related risk factors after living donor liver transplantation: single-center experience from Turkey. Transplant Proc 2013;45:974e7. [11] Gunsar F, Ronaldo N, Pastacaldi S, et al. Late hepatic artery thrombosis after orthotopic liver transplantation. Liver Transpl 2003;9:605e11. [12] Hidalgo E, Cantarell C, Charco R, et al. Risk factors for late hepatic artery thrombosis in adult liver transplantation. Transplant Proc 1999;31:2416e7. [13] Soliman T, Bodingbauet M, Langer F, et al. The role of complex hepatic artery reconstruction in orthotopic liver transplantation. Liver Transpl 2003;9:970e5.
CLINICAL OUTCOMES OF DONOR HEPATIC ARTERY [14] Sieders E, Peeters P, ten Vergert EM, et al. Early vascular complications after pediatric liver transplantation. Liver Transpl 2000;6:326e32. [15] Settmacher U, Stange B, Haase R, et al. Arterial complications after liver transplantation. Transpl Int 2000;13:372e8. [16] Stange B, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transpl 2003;9: 612e20. [17] Merion RM, Burtch GD, Ham JM, et al. The hepatic artery in liver transplantation. Transplantation 1989;48:438e43. [18] Gámán G, Gelley F, Doros A, et al. Biliary complications after orthotopic liver transplantation: the Hungarian experience. Transplant Proc 2013;45:3695e7. [19] Bras¸oveanu V, Anghel C, Bacalbas¸a N, et al. Technical aspects of biliary reconstruction correlated with biliary complications
1481 in 46 consecutive right lobe liver transplantations from living donors. Chirurgia (Bucur) 2014;109:15e9. [20] Marubashi S, Kobayashi S, Wada H, et al. Hepatic artery reconstruction in living donor liver transplantation: risk factor analysis of complication and a role of MDCT scan for detecting anastomotic stricture. World J Surg 2013;37:2671e7. [21] Tan JW, Jiang Y, Yao HX, Lu LZ, Zhang SG. Early prevention and treatment of biliary tract complications after orthotopic liver transplantation. Hepatobil Pancreat Dis Int 2003;2:48e53. [22] Qamar MI, Read AE, Skidmore R, Evans JM, Wells PNT. Transcutaneous Doppler ultrasound measurement of superior mesenteric artery blood flow in man. Gut 1986;27:100e5. [23] Bradley SE, Ingelfınger FJ, Bradley GP, Curry JJ. The estimation of hepatic blood flow in man. J Clin Invest 1945;24: 890e7.
ABSTRACT Objective. The aim of this work was to evaluate the clinical outcomes of donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation. Methods. A retrospective analysis of 12 patients with donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation from January 2012 to July 2014 was performed. Age, sex, clinical diagnosis of the liver disease, ABO mismatch, hepatic artery thrombosis, biliary strictures and leakage, graft loss, and mortality rates were evaluated. Results. Female-to-male ratio was 4:8. Right lobe was transplanted in 11 (91.7%) of the patients. In 1 patient, left lobe was transplanted. In 9 patients, single duct-to-duct biliary anastomosis was performed with cystic duct catheterization. In 2 patients, double ductto-duct biliary anastomosis was performed. In 1 patient, double biliary duct-to-duct anastomosis was performed after ductoplasty to achieve a single ductal orifice. No hepatic artery thrombosis was observed. Biliary complications were observed in 6 patients (50%: biliary leaks in 2 patients, biliary stricture in 3 patients, and both in 1 patient). ABO mismatch was not observed. No graft loss due to hepatic artery thrombosis was observed. Mortality was observed in 2 patients (16.6%). Conclusions. Donor hepatic artery to recipient replaced right hepatic artery anastomosis in living-donor liver transplantation is somewhat related to biliary complications, but not associated with increased rates of hepatic artery thrombosis.
R
EPLACED RIGHT HEPATIC ARTERY (repRHA) originating from the superior mesenteric artery (SMA) is a common variation of the right hepatic artery (HA). Earlier reports have reported a frequency of 5.8%e13.5% in some series [1e3]. RepRHA is used to achieve blood flow in those recipients with inadequate blood flow with the use of HAs originating from the celiac system. Donor-related HA variations have been reported and discussed previously [4e6]. However, the clinical outcomes of donor HA to recipient repRHA anastomosis in living-donor liver transplantation (LDLT) have not been discussed. In a report by Sutcliffe et al, donor HA to recipient repRHA anastomosis in deceaseddonor liver transplantation (DDLT) was discussed [7].
The aim of the present study was to evaluate the clinical results of the donor HA to recipient repRHA anastomosis in LDLT patients. MATERIALS AND METHODS A retrospective analysis of the LDLT patients with donor HA to recipient repRHA anastomosis from January 2012 to July 2014 was performed. Twelve patients were available for the study. Age, sex,
*Address correspondence to Okay Koc, MD, Gastroenterology Surgery, Gazi Yas¸argil Education and Research Hospital, Diyarbakir, Turkey. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.029
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1478
Transplantation Proceedings, 47, 1478e1481 (2015)
CLINICAL OUTCOMES OF DONOR HEPATIC ARTERY
1479
Table 1. Basic Clinical Features of the Study Cohort (n [ 12) Female-male ratio Age, mean Diagnosis HBV-related chronic liver disease Fulminant liver failure Cryptogenic liver disease Budd-Chiari syndrome Graft type Right lobe LDLT Left lobe LDLT Follow-up, mean (range) Biliary reconstruction type Duct-to-duct single anastomosis Duct-to-duct double-orifice single anastomosis Duct-to-duct double anastomosis
4:8 43.9 y 8 2 1 1 11/12 (91.7%) 1/12 (8.3%) 12 (1e29) mo 9/12 (75%) 1/12 (8.3%) 2/12 (16.6%)
Fig 2. Donor hepatic artery to recipient replaced right hepatic artery anastomosis in a living-donor liver transplant patient, postoperative computerized tomographic angiography.
Abbreviations: HBV, hepatitis B virus; LDLT, living-donor liver transplantation.
clinical diagnosis of the liver disease, ABO mismatch, HA thrombosis, biliary strictures and leakage, graft loss, and mortality rates were evaluated.
RESULTS
In this study donor hepatic artery to recipient repRHA anastomosis in LDLT was performed in 12 patients. Basic clinical features of the study cohort are reviewed in Table 1. Four patients were female (33.3%) and in 8 were male (66.7%). Mean ages were 50 years in female and 37.8 years in male patients. Diagnosis was hepatitis B viruserelated chronic liver disease in 8 (66.7%), acute fulminant liver failure in 2 (16.6%), cryptogenic liver cirrhosis in 1 (8.3%), and Budd-Chiari syndrome in 1 (8.3%) of the patients. Right liver lobe was transplanted in 11 (91.7%) and left liver lobe in 1 (8.3%) of the patients. Donor RHA to recipient replaced right hepatic artery anastomosis in LDLT was performed in 11 (91.7%) of the patients. In 1 patient (8.3%), donor left HA to recipient repRHA anastomosis in LDLT was performed (Figs 1 and 2). Clinical outcomes after LDLT with donor HA to recipient repRHA anastomosis are presented in Table 2. Mean
follow period was 12 (range, 1e29) months. In 9 patients (75%), single duct-to-duct biliary anastomosis was performed with cystic duct catheterization. In 2 patients (16.6%), double duct-to-duct biliary anastomosis was performed. In 1 patient (8.3%), double biliary duct-to-duct anastomosis was performed after ductoplasty to achieve a single ductal orifice. No HA thrombosis was observed. Biliary complications were observed in 6 patients (50%): biliary leakage at anastomotic side in 2 patients (16.6%), biliary stricture at anastomotic side in 3 patients (25%), and biliary stricture after biliary leakage at anastomotic side in 1 patient (8.3%). Biliary leaks were managed with the use of percutaneous drainage, and spontaneous resolution was achieved in 1 patient. The other resulted in mortality. Biliary strictures were managed with the use of percutaneous external-internal biliary drainage catheterizations. No ABO mismatch was observed. No graft loss due to hepatic artery thrombosis (HAT) was observed. Mortality was observed in 2 patients (16.6%): One patient was lost owing to overt hemorrhage on the postoperative 8th day, and 1 patient owing to sepsis due to biliary leakage on the postoperative 13th day. DISCUSSION
Hepatic artery thrombosis rates after liver transplantation have been reported to differ with rates 2%e9% in different series [8,9]. Previously we reported a rate of HAT 6.5% from our liver transplantation center. Blood flow insufficiency, lower diameters of artery, intimal damages near the arterial anastomosis region, arterial reconstruction with vascular grafts, and multiple arterial anastomoses were reported to be related to increased risk of HAT [10e17]. In the present study we did not observe HAT after donor HA Table 2. Clinical Outcomes After LDLT (n [ 12)
Fig 1. Replaced right hepatic artery, preoperative computerized tomographic angiography.
Hepatic artery thrombosis Biliary complications Graft loss Death
None 6/12 (50%) None 2/12 (16.6%)
1480
to recipient repRHA anastomosis in 12 patients with LDLT. This result was achieved with an improved and meticulous surgical technique for arterial anastomosis to minimize intimal injury, patience in perioperative assessment of arterial blood flow, and performance of single arterial anastomosis without reconstruction using vascular graft. Earlier reports have documented different biliary complication rates with a range of 17%e28% [18e20] after liver transplantation. The present authors previously reported a biliary complication rate of 25.8% [10]. The biliary system is fed by the arterial system. Thus, artery-related complications after liver transplantation have a tendency to affect the biliary system. Artery-related biliary complications are well known and named as biliary leakage, strictures, and nonanastomotic strictures. Some risk factors for biliary complications have been reported previously. HAT, HA stenosis, cold ischemia period >12 hours, ABO mismatch, and disturbances of arterial supply to the biliary system during dissection have been reported to be related with biliary complications after liver transplantation [18,19,21]. The type of biliary reconstruction was reported not to be related to biliary complications [19]. In the present study we did not observe HAT or HA stenosis. Cold ischemia period was short owing to the use of living donors. Our dissection and biliary reconstruction techniques were the same in these 12 patients. The high rate of biliary complicationsd50%dwas similar to our earlier results. The biliary complications rate in this study may be due to decreased blood flow as result of other conditions. Relative lower flow rate of SMA is one the causes of decreased arterial blood flow. Thus, one may advocate the need of additional interventions to improve blood flow rates to prevent biliary complications. SMA blood flow has been evaluated previously. Qamar et al calculated SMA blood flow and reported a rate of 517 19 mL/min [22]. Bradley et al reported a blood flow rate of 1,497 mL/min for HA [23]. Thus, HA blood flow rate is significantly different from SMA blood flow rate. HA blood flow rates are triple SMA blood flow rates. Sutcliffe et al [7] have advocated that a decrease in distribution of arterial blood flow to intestines further decreases the blood flow to the transplanted liver graft and should result in an increased risk for compromised biliary vascular perfusion. In the present series, we performed arterial anastomosis after consideration of the adequacy of repRHA (from SMA) blood flow. Increased biliary complications without artery-related problems were considered to be a result of blood flow rate inadequate to prevent arterial thrombosis though sufficient to supply the needs of biliary system. Another reason or risk factor for increased biliary complications after LDLT is the relative thin biliary ducts of the living-donated liver graft compared with deceased-donated liver grafts. Sutcliffe et al reported biliary complications in 4 of 22 patients (18.4%) with donor HA to recipient repRHA anastomosis in DDLT [7]. Biliary complications were significantly lower than in our series with LDLT patients. However, these controversial results should be considered together with other factors. In their report,
KOC, YAYLAK, SARICI ET AL
Robert et al studied a heterogonous group. Cadaveric liver was split (4 right and 2 right left lateral grafts) in some recipients. Six patients were in pediatric age group. RepRHA was used in 15 patients. Accessory RHA artery was used in 8 patients. Proper HA originating from SMA was used in 4 patients. Thus, with a more homogeneous group such as reported here, our results should be considered to be similar. In addition, some other factors related to type of graft (cadaveric or living donor) may be advocated. However, that issue merits further evaluation. In conclusion, donor HA to recipient repRHA anastomosis in LDLT should be further evaluated for the increased risk of biliary complications, although it is not considered to be related with increased arterial thrombosis. ACKNOWLEDGMENTS The authors thank their patients and all personnel of Inonu University Liver Transplantation Institute.
REFERENCES [1] Varotti G, Gondolesi GE, Goldman J, Wayne M, Florman SS, Schwartz ME, et al. Anatomic variations in right liver living donors. J Am Coll Surg 2004;198:577e82. [2] Yoshida A, Okuda K, Sakai H, Kinoshita H, Aoyagi S. 3D anatomical variations of hepatic vasculature and bile duct for right lateral sector of liver with special reference to transplantation. Kurume Med J 2008;55:43e53. [3] Kishi Y, Imamura H, Sugawara Y, et al. Evaluation of donor vasculobiliary anatomic variations in liver graft procurements. Surgery 2010;147:30e9. [4] Yaprak O, Demirbas T, Duran C, et al. Living donor liver hilar variations: surgical approaches and implications. Hepatobiliary Pancreat Dis Int 2011;10:474e9. [5] Lee KK, Lee SK, Moon IS, Kim DG, Lee MD. Surgical techniques according to anatomic variations in living donor liver transplantation using the right lobe. Transplant Proc 2008;40:2517e20. [6] Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP. Surgical management of anatomical variations of the right lobe in living donor liver transplantation. Ann Surg 2000;231:824e31. [7] Sutcliffe RP, Lolis E, Prachalias AA, Srinivasan P, Rela M, Heaton ND. Use of an aberrant right hepatic artery arising from the superior mesenteric artery of the recipient for arterial reconstruction in liver transplantation. Ann Transplant 2010;15:44e8. [8] Proposito D, Loinaz Segurola C, Garcia Garcìa I, et al. [Assessment of risk factors in the incidence of hepatic artery thrombosis in a consecutive series of 687 liver transplantations]. Ann Ital Chir 2001;72:187e205. [9] Abou Ella KA, Al Sebayel MI, Ramirez CB, Rabea HM. Hepatic artery thrombosis after orthotopic liver transplantation. Saudi Med J 2001;22:211e4. [10] Unal B, Gonultas F, Aydin C, Otan E, Kayaalp C, Yilmaz S. Hepatic artery thrombosis-related risk factors after living donor liver transplantation: single-center experience from Turkey. Transplant Proc 2013;45:974e7. [11] Gunsar F, Ronaldo N, Pastacaldi S, et al. Late hepatic artery thrombosis after orthotopic liver transplantation. Liver Transpl 2003;9:605e11. [12] Hidalgo E, Cantarell C, Charco R, et al. Risk factors for late hepatic artery thrombosis in adult liver transplantation. Transplant Proc 1999;31:2416e7. [13] Soliman T, Bodingbauet M, Langer F, et al. The role of complex hepatic artery reconstruction in orthotopic liver transplantation. Liver Transpl 2003;9:970e5.
CLINICAL OUTCOMES OF DONOR HEPATIC ARTERY [14] Sieders E, Peeters P, ten Vergert EM, et al. Early vascular complications after pediatric liver transplantation. Liver Transpl 2000;6:326e32. [15] Settmacher U, Stange B, Haase R, et al. Arterial complications after liver transplantation. Transpl Int 2000;13:372e8. [16] Stange B, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transpl 2003;9: 612e20. [17] Merion RM, Burtch GD, Ham JM, et al. The hepatic artery in liver transplantation. Transplantation 1989;48:438e43. [18] Gámán G, Gelley F, Doros A, et al. Biliary complications after orthotopic liver transplantation: the Hungarian experience. Transplant Proc 2013;45:3695e7. [19] Bras¸oveanu V, Anghel C, Bacalbas¸a N, et al. Technical aspects of biliary reconstruction correlated with biliary complications
1481 in 46 consecutive right lobe liver transplantations from living donors. Chirurgia (Bucur) 2014;109:15e9. [20] Marubashi S, Kobayashi S, Wada H, et al. Hepatic artery reconstruction in living donor liver transplantation: risk factor analysis of complication and a role of MDCT scan for detecting anastomotic stricture. World J Surg 2013;37:2671e7. [21] Tan JW, Jiang Y, Yao HX, Lu LZ, Zhang SG. Early prevention and treatment of biliary tract complications after orthotopic liver transplantation. Hepatobil Pancreat Dis Int 2003;2:48e53. [22] Qamar MI, Read AE, Skidmore R, Evans JM, Wells PNT. Transcutaneous Doppler ultrasound measurement of superior mesenteric artery blood flow in man. Gut 1986;27:100e5. [23] Bradley SE, Ingelfınger FJ, Bradley GP, Curry JJ. The estimation of hepatic blood flow in man. J Clin Invest 1945;24: 890e7.
