Zhu Heng-Kai, Zhuang Li, Chen Cheng-Ze, Ye Zhao-Dan, Wang Zhuo-Yi, Zhang Wu, Cao Guo-Hong, Zheng Shu-Sen
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, CAMS, Hangzhou 310003, China; Key Laboratory of Organ Transplantation, Zhejiang Provincial Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou 310003, China.
Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China.
Hepatobiliary Pancreat Dis Int. 2020 Dec;19(6):524-531. doi: 10.1016/j.hbpd.2020.09.014. Epub 2020 Oct 9.
Hepatic artery occlusion (HAO) after liver transplantation (LT) is typically comprised of hepatic artery thrombosis (HAT) and stenosis (HAS), both of which are severe complications that coexist and interdependent. This study aimed to evaluate an integrated endovascular treatment (EVT) strategy for the resolution of early HAO and identify the risk factors associated with early HAO as well as the procedural challenge encountered in the treatment strategy.
Consecutive orthotopic LT recipients (n = 366) who underwent transplantation between June 2017 and December 2018 were retrospectively investigated. EVT was performed using an integrated strategy that involved thrombolytic therapy, shunt artery embolization plus vasodilator therapy, percutaneous transluminal angioplasty, and/or stent placement. Simple EVT was defined as the clinical resolution of HAO by one round of EVT with thrombolytic therapy and/or shunt artery embolization plus vasodilator therapy. Otherwise, it was defined as complex EVT.
Twenty-six patients (median age 52 years) underwent EVT for early HAO that occurred within 30 days post-LT. The median interval from LT to EVT was 7 (6-16) days. Revascularization time (OR = 1.027; 95% CI: 1.005-1.050; P = 0.018) and the need for conduit (OR = 3.558; 95% CI: 1.241-10.203, P = 0.018) were independent predictors for early HAO. HAT was diagnosed in eight patients, and four out of those presented with concomitant HAS. We achieved 100% technical success and recanalization by performing simple EVT in 19 patients (3 HAT+/HAS- and 16 HAT-/HAS+) and by performing complex EVT in seven patients (1 HAT+/HAS-, 4 HAT+/HAS+, and 2 HAT-/HAS+), without major complications. The primary assisted patency rates at 1, 6, and 12 months were all 100%. The cumulative overall survival rates at 1, 6, and 12 months were 88.5%, 88.5%, and 80.8%, respectively. Autologous transfusion < 600 mL (94.74% vs. 42.86%, P = 0.010) and interrupted suture for hepatic artery anastomosis (78.95% vs. 14.29%, P = 0.005) were more prevalent in simple EVT.
The integrated EVT strategy was a feasible approach providing effective resolution with excellent safety for early HAO after LT. Appropriate autologous transfusion and interrupted suture technique helped simplify EVT.
肝移植（LT）后的肝动脉闭塞（HAO）通常包括肝动脉血栓形成（HAT）和狭窄（HAS），这两种都是严重并发症，且相互共存、相互影响。本研究旨在评估一种综合血管内治疗（EVT）策略用于解决早期HAO，并确定与早期HAO相关的危险因素以及该治疗策略中遇到的操作挑战。
回顾性研究2017年6月至2018年12月期间连续接受原位肝移植的受者（n = 366例）。采用综合策略进行EVT，包括溶栓治疗、分流动脉栓塞加血管扩张剂治疗、经皮腔内血管成形术和/或支架置入术。单纯EVT定义为通过一轮包括溶栓治疗和/或分流动脉栓塞加血管扩张剂治疗的EVT使HAO得到临床解决。否则，定义为复杂EVT。
26例患者（中位年龄52岁）因LT后30天内发生的早期HAO接受了EVT。从LT到EVT的中位间隔时间为7（6 - 16）天。再血管化时间（OR = 1.027；95%CI：1.005 - 1.050；P = 0.018）和对导管的需求（OR = 3.558；95%CI：1.241 - 10.203，P = 0.018）是早期HAO的独立预测因素。8例患者被诊断为HAT，其中4例同时伴有HAS。通过对19例患者（3例HAT+/HAS-和16例HAT-/HAS+）进行单纯EVT以及对7例患者（1例HAT+/HAS-、4例HAT+/HAS+和2例HAT-/HAS+）进行复杂EVT，我们实现了100%的技术成功和再通，且无严重并发症。1、6和12个月时的主要辅助通畅率均为100%。1、6和12个月时的累积总生存率分别为88.5%、88.5%和80.8%。自体输血<600 mL（94.74%对42.86%，P = 0.010）和肝动脉吻合采用间断缝合（78.95%对14.29%，P = 0.005）在单纯EVT中更为常见。
综合EVT策略是一种可行的方法，可为LT后早期HAO提供有效的解决办法且安全性良好。适当的自体输血和间断缝合技术有助于简化EVT。
