Fujiki Masato, Hashimoto Koji, Palaios Emmanouil, Quintini Cristiano, Aucejo Federico N, Uso Teresa Diago, Eghtesad Bijan, Miller Charles M
Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.
Surgery. 2017 Nov;162(5):1101-1111. doi: 10.1016/j.surg.2017.07.012. Epub 2017 Aug 30.
Hepatic artery thrombosis after liver transplantation is a devastating complication associated with ischemic cholangiopathy that can occur even after successful revascularization. This study explores long-term outcomes after hepatic artery thrombosis in adult liver transplantation recipients, focusing on the probability, risk factors, and resolution of ischemic cholangiopathy.
A retrospective chart review of 1,783 consecutive adult liver transplantations performed between 1995 and 2014 identified 44 cases of hepatic artery thrombosis (2.6%); 10 patients underwent immediate retransplantation, and 34 patients received nontransplant treatments, involving revascularization (n = 19) or expectant nonrevascularization management (n = 15).
The 1-year graft survival after nontransplant treatment was favorable (82%); however, 16 of the 34 patients who received a nontransplant treatment developed ischemic cholangiopathy and required long-term biliary intervention. A Cox regression model showed that increased serum transaminase and bilirubin levels at the time of hepatic artery thrombosis diagnosis, but not nonrevascularization treatment versus revascularization, were risk factors for the development of ischemic cholangiopathy. Ischemic cholangiopathy in revascularized grafts was less extensive with a greater likelihood of resolution within 5-years than that in nonrevascularized grafts (100% vs 17%). Most liver abscesses without signs of liver failure also were reversible. Salvage retransplantation after a nontransplant treatment was performed in 8 patients with a 1-year survival rate equivalent to immediate retransplantation (88% vs 80%).
Selective nontransplant treatments for hepatic artery thrombosis resulted in favorable graft survival. Biliary intervention can resolve liver abscess and ischemic cholangiopathy that developed in revascularized grafts in the long-term; salvage retransplantation should be considered for ischemic cholangiopathy in nonrevascularized grafts because of a poor chance of resolution.
肝移植术后肝动脉血栓形成是一种毁灭性并发症，与缺血性胆管病相关，即使在成功进行血管重建后也可能发生。本研究探讨成年肝移植受者肝动脉血栓形成后的长期结局，重点关注缺血性胆管病的发生概率、危险因素及缓解情况。
对1995年至2014年间连续进行的1783例成年肝移植病例进行回顾性病历审查，确定44例肝动脉血栓形成病例（2.6%）；10例患者立即接受再次移植，34例患者接受非移植治疗，包括血管重建（n = 19）或非血管重建的期待性治疗（n = 15）。
非移植治疗后的1年移植物存活率良好（82%）；然而，34例接受非移植治疗的患者中有16例发生缺血性胆管病，需要长期胆道干预。Cox回归模型显示，肝动脉血栓形成诊断时血清转氨酶和胆红素水平升高是缺血性胆管病发生的危险因素，而非非血管重建治疗与血管重建治疗。血管重建移植物中的缺血性胆管病范围较小，5年内缓解的可能性大于非血管重建移植物（100%对17%）。大多数无肝衰竭迹象的肝脓肿也可逆转。8例患者在非移植治疗后进行了挽救性再次移植，1年生存率与立即再次移植相当（88%对80%）。
肝动脉血栓形成的选择性非移植治疗可带来良好的移植物存活率。胆道干预可长期解决血管重建移植物中发生的肝脓肿和缺血性胆管病；对于非血管重建移植物中的缺血性胆管病，由于缓解机会渺茫，应考虑进行挽救性再次移植。
