Bhangui Prashant, Salloum Chady, Lim Chetana, Andreani Paola, Ariche Arie, Adam René, Castaing Denis, Kerba Tech, Azoulay Daniel
Department of Surgery, Medanta Institute of Liver Transplantation and Regenerative Medicine, Delhi, India.
HPB (Oxford). 2014 Aug;16(8):723-38. doi: 10.1111/hpb.12200. Epub 2013 Dec 12.
Portal vein arterialization (PVA) has been used as a salvage inflow technique when hepatic artery (HA) reconstruction is deemed impossible in liver transplantation (LT) or hepatopancreatobiliary (HPB) surgery. Outcomes and the management of possible complications have not been well described.
The present study analysed outcomes in 16 patients who underwent PVA during the period from February 2005 to January 2011 for HA thrombosis post-LT (n = 7) or after liver resection (n = 1), during curative resection for locally advanced HPB cancers (requiring HA interruption) (n = 7) and for HA resection without reconstruction (n = 1). In addition, a literature review was conducted.
Nine patients were women. The median age of the patients was 58 years (range: 30-72 years). Recovery of intrahepatic arterial signals and PVA shunt patency were documented using Doppler ultrasound until the last follow-up (or until shunt thrombosis in some cases). Of five postoperative deaths, two occurred as a result of haemorrhagic shock, one as a result of liver ischaemia and one as a result of sepsis. The fifth patient died at home of unknown cause. Three patients (19%) had major bleeding related to portal hypertension (PHT). Of these, two underwent re-exploration and one underwent successful shunt embolization to control the bleeding. Four patients (25%) had early shunt thrombosis, two of whom underwent a second PVA. After a median follow-up of 13 months (range: 1-60 months), 10 patients (63%) remained alive with normal liver function and one submitted to retransplantation.
Portal vein arterialization results in acceptable rates of survival in relation to spontaneous outcomes in patients with completely de-arterialized livers. The management of complications (especially PHT) after the procedure is challenging. Portal vein arterialization may represent a salvage option or a bridge to liver retransplantation and thus may make curative resection in locally advanced HPB cancers with vascular involvement feasible.
当肝移植（LT）或肝胰胆（HPB）手术中肝动脉（HA）重建被认为不可能时，门静脉动脉化（PVA）已被用作一种挽救性流入技术。其结果及可能并发症的处理尚未得到充分描述。
本研究分析了2005年2月至2011年1月期间16例行PVA患者的结局，这些患者因LT后HA血栓形成（n = 7）、肝切除术后（n = 1）、局部晚期HPB癌根治性切除（需要HA阻断）（n = 7）以及HA切除未重建（n = 1）而接受PVA。此外，还进行了文献综述。
9例患者为女性。患者的中位年龄为58岁（范围：30 - 72岁）。使用多普勒超声记录肝内动脉信号恢复及PVA分流通畅情况直至最后一次随访（或在某些情况下直至分流血栓形成）。5例术后死亡患者中，2例死于失血性休克，1例死于肝缺血，1例死于败血症。第5例患者在家中不明原因死亡。3例患者（19%）发生与门静脉高压（PHT）相关的大出血。其中，2例接受了再次探查，1例成功进行了分流栓塞以控制出血。4例患者（25%）出现早期分流血栓形成，其中2例接受了第二次PVA。中位随访13个月（范围：1 - 60个月）后，10例患者（63%）存活且肝功能正常，1例接受了再次移植。
对于完全去动脉化肝脏的患者，门静脉动脉化的生存率与自然转归相比是可以接受的。该手术后并发症（尤其是PHT）的处理具有挑战性。门静脉动脉化可能是一种挽救性选择或肝再次移植的桥梁，从而使局部晚期伴血管受累的HPB癌的根治性切除成为可能。
