Sheiner P A, Varma C V, Guarrera J V, Cooper J, Garatti M, Emre S, Guy S R, Schwartz M E, Miller C M
Department of Surgery, The Mount Sinai Medical Center, New York, New York 10029, USA.
Transplantation. 1997 Nov 15;64(9):1295-9. doi: 10.1097/00007890-199711150-00011.
Hepatic artery thrombosis (HAT) can be a devastating complication of orthotopic liver transplantation (OLT), but early diagnosis may allow successful revascularization and graft salvage.
We reviewed data on 1,026 liver transplants at our institution. For patients in whom HAT was diagnosed within 30 days after OLT, we recorded indications for ultrasonography and liver function tests at diagnosis, management of HAT, and graft and patient survival.
Thirty-two patients (3.1%) developed HAT at 6.8+/-6.6 days (range, 1-29 days) after OLT. Twelve patients (37.5%) were asymptomatic at diagnosis. In 11 of these 12, HAT was diagnosed on routine duplex at 2.0+/-1.55 days after OLT; in the 12th patient, HAT was noted during re-exploration for unrelated bleeding on postoperative day 3. Eleven of 12 patients (91.6%) were revascularized; one patient (8.4%) received no treatment with no sequelae. Of the 11 who were revascularized, 9 (81.8%) had graft salvage and 2 (18.2%) received a second transplant, with one death. Twenty patients (62.5%) were symptomatic. In these 20, HAT was diagnosed at 9.85+/-6.93 days after OLT. Symptoms were: elevated liver function test results (serum glutamic oxaloacetic transaminase: 722+/-1792 U/ml, serum glutamic pyruvic transaminase: 678+/-963 U/ml, and bilirubin: 10.2+/-6.2 mg/dl) in 13 patients (65%); bile leak in 4 patients (20%), and sepsis in 3 (15%). Five of the 20 patients (25%) were revascularized; of these 5, 2 (40%) had graft salvage, 2 (40%) received a second transplant with 1 death, and 1 (20%) died of a liver abscess. Twelve symptomatic patients (60%) had immediate re-OLT; 10/12 are alive, 1 died of sepsis, and 1 died late of unrelated causes. Three symptomatic patients had no treatment; two died of biliary sepsis and one survived. Overall graft salvage was 83.3% in asymptomatic patients and 15% in patients with symptoms (P<0.001). Graft salvage in asymptomatic patients undergoing revascularization was 81.8%, versus 40% in symptomatic patients (P=NS). One-year patient survival was 91.7% in asymptomatic patients and 65% in symptomatic patients (with one late death excluded) (P=NS).
Routine postoperative duplex ultrasonography should be performed early after liver transplantation. We believe that emergent revascularization of hepatic artery thrombosis in asymptomatic patients and retransplantation in symptomatic patients lead to improved graft salvage and patient survival with a relatively low incidence of late biliary complications.
肝动脉血栓形成（HAT）可能是原位肝移植（OLT）的一种灾难性并发症，但早期诊断可能使血管重建成功并挽救移植物。
我们回顾了本机构1026例肝移植的数据。对于OLT术后30天内诊断为HAT的患者，我们记录了诊断时超声检查和肝功能检查的指征、HAT的处理、移植物和患者的存活情况。
32例患者（3.1%）在OLT术后6.8±6.6天（范围1 - 29天）发生HAT。12例患者（37.5%）诊断时无症状。在这12例中的11例中，OLT术后2.0±1.55天通过常规双功超声诊断出HAT；第12例患者在术后第3天因无关出血再次探查时发现HAT。12例患者中的11例（91.6%）进行了血管重建；1例患者（8.4%）未接受治疗且无后遗症。在进行血管重建的11例患者中，9例（81.8%）移植物得以挽救，2例（18.2%）接受了二次移植，其中1例死亡。20例患者（62.5%）有症状。在这20例中，HAT在OLT术后9.85±6.93天被诊断出来。症状包括：13例患者（65%）肝功能检查结果升高（血清谷草转氨酶：722±1792 U/ml，血清谷丙转氨酶：678±963 U/ml，胆红素：10.2±6.2 mg/dl）；4例患者（20%）发生胆漏，3例患者（15%）发生脓毒症。20例患者中的5例（25%）进行了血管重建；在这5例中，2例（40%）移植物得以挽救，2例（40%）接受了二次移植，其中1例死亡，1例（20%）死于肝脓肿。12例有症状的患者（60%）立即接受了再次OLT；12例中的10例存活，1例死于脓毒症，1例后期死于无关原因。3例有症状的患者未接受治疗；2例死于胆源性脓毒症，1例存活。无症状患者的总体移植物挽救率为83.3%，有症状患者为15%（P<0.001）。进行血管重建的无症状患者移植物挽救率为81.8%，有症状患者为40%（P=无显著性差异）。无症状患者1年患者存活率为91.7%，有症状患者（排除1例后期死亡）为65%（P=无显著性差异）。
肝移植术后应尽早进行常规双功超声检查。我们认为，无症状患者肝动脉血栓形成的紧急血管重建和有症状患者的再次移植可提高移植物挽救率和患者存活率，且后期胆并发症发生率相对较低。
