Le Linda, Terral William, Zea Nicolas, Bazan Hernan A, Smith Taylor A, Loss George E, Bluth Edward, Sternbergh W Charles
Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La.
Department of Surgery, Section of Vascular and Endovascular Surgery, Ochsner Clinic, New Orleans, La.
J Vasc Surg. 2015 Sep;62(3):704-9. doi: 10.1016/j.jvs.2015.04.400. Epub 2015 Jun 6.
Significant hepatic artery stenosis (HAS) after orthotopic liver transplantation (OLT) can lead to thrombosis, with subsequent liver failure in 30% of patients. Although operative intervention or retransplantation has been the traditional solution, endovascular therapy has emerged as a less invasive treatment strategy. Prior smaller studies have been conflicting in the relative efficacy of percutaneous transluminal angioplasty (PTA) vs primary stent placement for HAS.
This was a single-center retrospective review of all endovascular interventions for HAS after OLT during a 54-month period (August 2009-December 2013). Patients with ultrasound imaging with evidence of severe HAS (peak systolic velocity >400-450 cm/s, resistive index <0.5) underwent endovascular treatment with primary stent placement or PTA. Outcomes calculated were technical success, primary and primary assisted patency rates, reinterventions, and complications.
Sixty-two interventions for HAS were performed in 42 patients with a mean follow-up of 19.1 ± 15.2 months. During the study period, 654 OLTs were performed. Of 61 patients diagnosed with HAS, 42 underwent an endovascular intervention. The rate of endovascularly treated HAS was 6.4% (42 of 654). Primary technical success was achieved in 95% (59 of 62) of the interventions. Initial treatment was with PTA alone in 17 or primary stent in 25. Primary patency rates after initial stent placement were 87%, 76.5%, 78%, and 78% at 1, 6, 12, and 24 months, respectively, compared with initial PTA rates of 64.7%, 53.3%, 40%, and 0% (P = .19). There were 20 reinterventions in 14 patients (eight stents, six PTAs). The time to the initial reintervention was 51 days in patients with PTA alone vs 105.8 days for those with an initial stent (P = .16). Overall primary assisted patency was 93% at 24 months. Major complications were one arterial rupture and two hepatic artery dissections. The long-term risk of hepatic artery thrombosis in the entire patient cohort was 3.2%.
HAS after OLT can be treated endovascularly with high technical success and excellent primary assisted patency. This series represents the largest reported cohort of endovascular interventions for HAS to date. Initial use of a stent showed a strong trend toward decreasing the need for reintervention. Avoidance of hepatic artery thrombosis is possible in >95% of patients with endovascular treatment and close follow-up.
原位肝移植（OLT）后发生显著肝动脉狭窄（HAS）可导致血栓形成，30%的患者随后会出现肝衰竭。尽管手术干预或再次移植一直是传统的解决方法，但血管内治疗已成为一种侵入性较小的治疗策略。先前规模较小的研究在经皮腔内血管成形术（PTA）与原发性支架置入术治疗HAS的相对疗效方面存在矛盾。
这是一项对54个月期间（2009年8月至2013年12月）OLT后所有HAS血管内介入治疗的单中心回顾性研究。超声成像显示有严重HAS证据（收缩期峰值流速>400 - 450 cm/s，阻力指数<0.5）的患者接受原发性支架置入或PTA的血管内治疗。计算的结果包括技术成功率、原发性和原发性辅助通畅率、再次干预以及并发症。
42例患者共进行了62次HAS介入治疗，平均随访时间为19.1±15.2个月。研究期间共进行了654例OLT。在61例诊断为HAS的患者中，42例接受了血管内介入治疗。血管内治疗的HAS发生率为6.4%（654例中的42例）。95%（62例中的59例）的介入治疗取得了原发性技术成功。初始治疗单独采用PTA的有17例，采用原发性支架的有25例。初始支架置入后1、6、12和24个月的原发性通畅率分别为87%、76.5%、78%和78%，而初始PTA的通畅率分别为64.7%、53.3%、40%和0%（P = 0.19）。14例患者进行了20次再次干预（8次支架，6次PTA）。单独接受PTA治疗的患者首次再次干预时间为51天，而初始采用支架治疗的患者为105.8天（P = 0.16）。24个月时总体原发性辅助通畅率为93%。主要并发症为1例动脉破裂和2例肝动脉夹层。整个患者队列中肝动脉血栓形成的长期风险为3.2%。
OLT后HAS可通过血管内治疗取得较高的技术成功率和出色的原发性辅助通畅率。本系列代表了迄今为止报道的最大规模的HAS血管内介入治疗队列。初始使用支架显示出明显减少再次干预需求的趋势。通过血管内治疗和密切随访，超过95%的患者可避免肝动脉血栓形成。
