Prevention and treatment of hepatic artery dissection in donors and recipients during liver transplantation
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摘要: 肝动脉重建是肝移植术中关键操作步骤之一,供受者因素及手术操作因素导致术中出现待重建动脉意外形成夹层的情况会打乱手术计划,增加动脉重建难度,明显延长手术时间,增加术后动脉狭窄及血栓的风险,也可能导致急性移植物失功而需要紧急手术干预甚至二次肝移植。探讨如何避免肝移植术中待吻合动脉形成夹层以及待吻合动脉出现夹层后的处理,将有助于预防肝移植术中动脉相关并发症,改善肝移植受者的预后。本文就肝移植术中供受者肝动脉夹层的成因、预防、处理及肝动脉重建方式经验介绍如下。Abstract: Hepatic artery reconstruction is one of the key procedures in liver transplantation. Accidental dissection of the hepatic artery to be reconstructed caused by donor and recipient factors or surgical factors will disrupt the surgical plan, increase the difficulty of arterial reconstruction, significantly prolong the operation time, increase the risk of postoperative arterial stenosis and thrombosis and probably lead to acute allograft failure, which requires emergency surgical interventions or even secondary liver transplantation. Understanding of how to avoid dissection of the artery to be anastomosed during liver transplantation and corresponding treatment will contribute to preventing the incidence of artery-related complications during liver transplantation and improving clinical prognosis of liver transplant recipients. In this article, the causes, prevention and treatment of hepatic artery dissection and hepatic artery reconstruction in donors and recipients during liver transplantation were illustrated.
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图 1 不同血管残端处理方式对动脉夹层的影响
注:A图示结扎线收紧后动脉内膜收缩幅度更大,卷曲成花瓣状,导致多处内外膜分离(红色箭头);B图示剪开结扎线结,纵向剖开动脉,可见动脉内膜结扎线明显切割痕迹(红色箭头),痕迹远端动脉内外膜分离明显;C图示Hem-o-lok夹闭动脉后可见内膜挤出,但无花瓣状及内外膜分离表现(红色箭头);D图示去除Hem-o-lok夹,纵向剖开动脉,可见动脉内膜夹闭处明显切割痕迹(红色箭头),痕迹两侧内膜较为完整。
Figure 1. Influence of different treatment methods for vascular stump on arterial dissection
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[1] AKBULUT S, KUTLUTURK K, YILMAZ S. Hepatic artery reconstruction technique in liver transplantation: experience with 3, 000 cases[J]. Hepatobiliary Surg Nutr, 2021, 10(2): 281-283. DOI: 10.21037/hbsn-21-2. [2] 何博, 王新, 王峰, 等. 肝移植供肝动脉变异与重建方式对术后早期动脉并发症的影响[J]. 临床肝胆病杂志, 2021, 37(8): 1901-1904. DOI: 10.3969/j.issn.1001-5256.2021.08.030.HE B, WANG X, WANG F, et al. Influence of arterial variation and reconstruction of the donor hepatic artery in liver transplantation on early postop-erative arterial complications[J]. J Clin Hepatol, 2021, 37(8): 1901-1904. DOI: 10.3969/j.issn.1001-5256.2021.08.030. [3] AGARWAL S, DEY R, PANDEY Y, et al. Managing recipient hepatic artery intimal dissection during living donor liver transplantation[J]. Liver Transpl, 2020, 26(11): 1422-1429. DOI: 10.1002/lt.25857. [4] LIN TS, VISHNU PRASAD NR, CHEN CL, et al. What happened in 133 consecutive hepatic artery reconstruction in liver transplantation in 1 year?[J]. Hepatobiliary Surg Nutr, 2019, 8(1): 10-18. DOI: 10.21037/hbsn.2018.11.13. [5] LIN TS, CHIANG YC, CHEN CL, et al. Intimal dissection of the hepatic artery following transarterial embolization for hepatocellular carcinoma: an intraoperative problem in adult living donor liver transplantation[J]. Liver Transpl, 2009, 15(11): 1553-1556. DOI: 10.1002/lt.21888. [6] SHIMATA K, SUGAWARA Y, IRIE T, et al. Asymptomatic hepatic artery dissection early after living-donor liver transplantation with simultaneous splenectomy: two case reports[J]. BMC Gastroenterol, 2020, 20(1): 378. DOI: 10.1186/s12876-020-01528-0. [7] LIN TS, LIN CH, KUO PJ, et al. Management of difficult hepatic artery reconstructions to reduce complications through continual technical refinements in living donor liver transplantations[J]. Int J Surg, 2022, 104: 106776. DOI: 10.1016/j.ijsu.2022.106776. [8] ITOH S, YOSHIZUMI T, HARADA N, et al. A no-ligation technique to prevent intraoperative hepatic artery dissection in living-donor liver transplantation[J]. Surg Today, 2021, 51(11): 1877-1880. DOI: 10.1007/s00595-021-02276-8. [9] INCE V, ERSAN V, KARAKAS S, et al. Does preoperative transarterial chemoembolization for hepatocellular carcinoma increase the incidence of hepatic artery thrombosis after living-donor liver transplant?[J]. Exp Clin Transplant, 2017, 15(Suppl 2): 21-24. DOI: 10.6002/ect.TOND16.L7. [10] ANTOCH G, ROELLE G, LADD SC, et al. Selective and sequential transarterial chemoembolization: survival in patients with hepatocellular carcinoma[J]. Eur J Radiol, 2012, 81(9): 2290-2297. DOI: 10.1016/j.ejrad.2011.09.010. [11] 李臻, 叶书文, 谢炳灿, 等. 不同粒径载药微球化学治疗栓塞治疗肝细胞癌的疗效分析[J]. 中华肝脏病杂志, 2022, 30(6): 612-617. DOI: 10.3760/cma.j.cn501113-20210811-00394.LI Z, YE SW, XIE BC, et al. Analysis of curative effects of chemoembolization with drug-loaded microspheres of different particle sizes for the treatment of hepatocellular carcinoma[J]. Chin J Hepatol, 2022, 30(6): 612-617. DOI: 10.3760/cma.j.cn501113-20210811-00394. [12] PANARO F, RAMOS J, GALLIX B, et al. Hepatic artery complications following liver transplantation. does preoperative chemoembolization impact the postoperative course?[J]. Clin Transplant, 2014, 28(5): 598-605. DOI: 10.1111/ctr.12358. [13] MOON JI, CIANCIO G, BURKE GW. Arterial reconstruction with donor iliac vessels during pancreas transplantation: an intraoperative approach to arterial injury or inadequate flow[J]. Clin Transplant, 2005, 19(2): 286-290. DOI: 10.1111/j.1399-0012.2005.00339.x. [14] BEAUREPAIRE JM, ORLANDO F, LEVI SANDRI GB, et al. Comparison of alternative arterial anastomosis site during liver transplantation when the recipient's hepatic artery is unusable[J]. Hepatobiliary Surg Nutr, 2022, 11(1): 1-12. DOI: 10.21037/hbsn-20-10. [15] WANG J, HE Y, ZHAO J, et al. Systematic review and meta-analysis of current evidence in spontaneous isolated celiac and superior mesenteric artery dissection[J]. J Vasc Surg, 2018, 68(4): 1228-1240. DOI: 10.1016/j.jvs.2018.05.014. [16] CAVALCANTE RN, MOTTA-LEAL-FILHO JM, DE FINA B, et al. Systematic literature review on evaluation and management of isolated spontaneous celiac trunk dissection[J]. Ann Vasc Surg, 2016, 34: 274-279. DOI: 10.1016/j.avsg.2015.12.009. [17] MORAMARCO LP, CAPODAGLIO CA, QUARETTI P, et al. Multivessel endovascular therapy for undiagnosed vascular type Ehlers-Danlos syndrome. successful percutaneous transcatheter coil embolization of hepatic artery pseudoaneurysm with stenting of right renal and iliac arteries in emergency setting[J]. BJR Case Rep, 2020, 6(4): 20200025. DOI: 10.1259/bjrcr.20200025. [18] LAXAGUE F, VALINOTI A, RAMALLO D, et al. Intraoperative challenge for vascular reconstruction in orthotopic liver transplantation because of extensive portal thrombosis and intimal dissection of the hepatic artery[J]. ACG Case Rep J, 2020, 7(6): e00390. DOI: 10.14309/crj.0000000000000390. [19] KARATAŞ C, ALIM A, TIRNOVA I, et al. Hepatic artery intimal dissection during living donor liver transplantation: a new modified approach[J]. Transplant Proc, 2023, 55(2): 379-383. DOI: 10.1016/j.transproceed.2023.02.002. [20] DUFFY JP, HONG JC, FARMER DG, et al. Vascular complications of orthotopic liver transplantation: experience in more than 4, 200 patients[J]. J Am Coll Surg, 2009, 208(5): 896905. DOI: 10.1016/j.jamcollsurg.2008.12.032. [21] SITTA R, ROBERTS J, GARDNER J, et al. A novel microsurgical reconstruction technique in a living-related liver donor hepatic artery dissection using the native hepatic artery[J]. Am J Transplant, 2022, 22(10): 2467-2469. DOI: 10.1111/ajt.17103. [22] OKAZAKI M, ASATO H, TAKUSHIMA A, et al. Hepatic artery reconstruction with double-needle microsuture in living-donor liver transplantation[J]. Liver Transpl, 2006, 12(1): 46-50. DOI: 10.1002/lt.20550. [23] ANILIR E, ORAL A, ATASOY A, et al. A single-center's early surgical outcomes of living donor liver transplantation[J]. Transplant Proc, 2023, DOI: 10.1016/j.transproceed.2023.03.028[Epubaheadofprint]. [24] 李欣澄, 黄帆, 王国斌, 等. 肝动脉重建技术对肝移植预后的影响[J]. 器官移植, 2023, 14(1): 128-134. DOI: 10.3969/j.issn.1674-7445.2023.01.017.LI XC, HUANG F, WANG GB, et al. Effect of hepatic artery reconstruction techniques on prognosis of liver transplantation[J]. Organ Transplant, 2023, 14(1): 128-134. DOI: 10.3969/j.issn.1674-7445.2023.01.017. [25] 夏强, 沙朦. 活体肝移植的进展与展望[J]. 中华消化外科杂志, 2022, 21(1): 39-42. DOI: 10.3760/cma.j.cn115610-20211205-00622.XIA Q, SHA M. Progress and prospect of living donor liver transplantation[J]. Chin J Dig Surg, 2022, 21(1): 39-42. DOI: 10.3760/cma.j.cn115610-20211205-00622. [26] TAN BK, FONG HC, TAN EK, et al. Strategies for a successful hepatic artery anastomosis in liver transplantation: a review of 51 cases[J]. Ann Acad Med Singap, 2021, 50(9): 679-685. DOI: 10.47102/annals-acadmedsg.2020635. [27] LIPINSKA JA, WANG J, CAREY JN, et al. Long-term suitability of left gastric artery inflow for arterial perfusion of living donor right lobe grafts[J]. Case Rep Transplant, 2022: 9421648. DOI: 10.1155/2022/9421648. [28] ALIM A, ERDOGAN Y, DAYANGAC M, et al. Normal primary graft function despite early hepatic artery thrombosis after living-donor liver transplant[J]. Exp Clin Transplant, 2022, 20(3): 293-298. DOI: 10.6002/ect.2017.0363. [29] YILMAZ S, AKBULUT S, USTA S, et al. Distal gastroduodenal arterial inflow as a salvage strategy for extensive intraoperative arterial dissectıon in living donor liver transplantation[J]. Liver Transpl, 2022, 28(2): 334-335. DOI: 10.1002/lt.26304. [30] BHATTI ABH, AHMAD H, ZIA HH, et al. Distal gastroduodenal arterial inflow as a salvage strategy for extensive intraoperative arterial dissection in living donor liver transplantation[J]. Liver Transpl, 2021, 27(10): 1507-1508. DOI: 10.1002/lt.26039. [31] CHERUKURU R, KRISHNA P, SHETTY G, et al. Distal gastroduodenal arterial inflow as a salvage strategy for extensive intraoperative arterial dissection in living donor liver transplantation[J]. Liver Transpl, 2021, 27(8): 1207-1211. DOI: 10.1002/lt.25982. [32] ULLAH K, DOGAR AW, SHAMS-UD-DIN, et al. Splenic artery transposition for hepatic arterial supply in living donor liver transplantation[J]. Pak J Med Sci, 2023, 39(1): 154-160. DOI: 10.12669/pjms.39.1.6351. [33] YILMAZ S, KUTLUTURK K, USTA S, et al. Techniques of hepatic arterial reconstruction in liver transplantation[J]. Langenbecks Arch Surg, 2022, 407(7): 2607-2618. DOI: 10.1007/s00423-022-02659-6. [34] 叶征辉, 赵红川, 耿小平, 等. 同种异体原位肝移植的复杂肝动脉重建经验总结[J]. 器官移植, 2019, 10(5): 589-593, 611. DOI: 10.3969/j.issn.1674-7445.2019.05.020.YE ZH, ZHAO HC, GENG XP, et al. Experience summary of complex hepatic artery reconstruction in orthotopic liver transplantation[J]. Organ Transplant, 2019, 10(5): 589-593, 611. DOI: 10.3969/j.issn.1674-7445.2019.05.020. [35] JWA EK, KIM JD, CHOI DL. Comparison of hepatic artery reconstruction using surgical loupe and operating microscope during living donor liver transplantation focusing on the beginner's point[J]. Ann Hepatobiliary Pancreat Surg, 2019, 23(2): 122-127. DOI: 10.14701/ahbps.2019.23.2.122.