Soltys Kyle, Lemoine Caroline, Zhang Xingyu, Bhat Rukhmi, Bucuvalas John, Rasmussen Sara, Romero Rene, Batsis Irini, Sayed Blayne, Tunno John, Confair Cassandra, Vargas Sarah, Superina Riccardo, Mazariegos George
Thomas E Starzl Transplant Institute, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Transplant/Pediatric Surgery, Ann & Robert H. Lurie Childrens Hospital of Chicago, Chicago, Illinois, USA.
Pediatr Transplant. 2023 Jun;27(4):e14521. doi: 10.1111/petr.14521. Epub 2023 Apr 4.
Survival after pediatric liver transplantation (PLT) is negatively impacted by thrombotic and hemorrhagic complications. Limited data exists regarding factors associated with these complications and utilization of anticoagulation.
Retrospective review of donor, recipient variables and outcomes from four centers participating in the Starzl Network for Excellence in Pediatric Transplantation.
76 PLT included 39 (51%) technical variant transplants, with mean follow-up 628 ± 193.6 days. Median age/weight at transplant were 59.3 ± 53.8 months and 19.6 ± 17.2 kg. Seven (9.2%) transplants experienced intraoperative hepatic artery thrombosis (iHAT), all successfully corrected. Four HAT recurred postoperatively on POD 1,7,8 and 616. All three portal vein thromboses (PVT) occurred on POD1. Anticoagulation protocols were initiated intraoperatively in 50 and postoperatively in 66 and were active for all thrombotic and hemorrhagic events. Two patients were re-transplanted for HAT. Two patients died without having thrombotic or hemorrhagic complications. iHAT and post-operative HAT were associated with lower hepatic arterial flows. iHAT was associated with donor variant anatomy, reduced allografts and intraoperative blood loss. Intraoperative ultrasound could not predict post-operative HAT nor PVT. Surgeon pre-operative concern regarding the native portal vein correlated with postoperative PVT. Lower hepatic arterial and portal flows, higher estimated blood losses, higher prothrombin time and use of arterial interposition grafts were associated with postoperative hemorrhagic complications.
Thrombotic and hemorrhagic complications after pediatric liver transplant remain rare but significant events. Their occurrence can be predicted with pre-operative assessment of donor and recipient vascular anatomy and direct flow measurement but may not be predicted with ultrasound evaluation nor prevented with anticoagulation.
血栓形成和出血并发症对小儿肝移植（PLT）后的生存产生负面影响。关于与这些并发症相关的因素及抗凝药物使用的数据有限。
对参与小儿移植卓越之星网络的四个中心的供体、受体变量及结果进行回顾性分析。
76例小儿肝移植包括39例（51%）技术变异移植，平均随访时间为628±193.6天。移植时的中位年龄/体重分别为59.3±53.8个月和19.6±17.2千克。7例（9.2%）移植发生术中肝动脉血栓形成（iHAT），均成功纠正。4例肝动脉血栓形成在术后第1、7、8和616天复发。3例门静脉血栓形成（PVT）均发生在术后第1天。50例术中启动抗凝方案，66例术后启动，对所有血栓形成和出血事件均有效。2例患者因肝动脉血栓形成再次移植。2例患者未发生血栓形成或出血并发症而死亡。iHAT和术后肝动脉血栓形成与肝动脉血流较低有关。iHAT与供体变异解剖结构、移植肝体积减小和术中失血有关。术中超声无法预测术后肝动脉血栓形成或门静脉血栓形成。外科医生术前对肝门静脉的担忧与术后门静脉血栓形成相关。肝动脉和门静脉血流较低、估计失血量较高、凝血酶原时间较长以及使用动脉搭桥移植物与术后出血并发症有关。
小儿肝移植后的血栓形成和出血并发症仍然少见但后果严重。通过术前评估供体和受体血管解剖结构及直接血流测量可预测其发生，但超声评估无法预测，抗凝也无法预防。
