Introduction: Development of hepatic artery thrombosis (HAT) after living donor liver transplantation (LDLT) is a severe complication and is associated with an high morbidity and mortality. HAT can result in graft necrosis ang biliary complications due to ischemia of biliary tract.
The aim of our study was to evaluate risk factors for HAT and to assess the impact of management of HAT on the long-term outcomes after LDLT in pediatric patients.
Methods: We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. To assess the impact of HAT on recipients outcome we compared preoperative data, surgical factors, complications and patients and grafts survival in patients with HAT (HAT Group) and without HAT (non-HAT Group). Diagnostic and therapeutic interventions for HAT and its efficacy were also analysed.
Results: 27 patients (6.75%) developed HAT (HAT Group). Median time from LDLT to diagnosis of HAT was 6 days (range 2.5 hours to 116 days). There were no differences in patients characteristics between both groups. Acute liver failure and hepatic artery (HA) anastomosis diameter below 2 mm were significantly more common in HAT Group (p<0.05 and p=0.02026 respectively). Intraoperative HA flow dysfunction on Doppler was significantly higher in HAT Group (p=0.0019). In HAT Group 21 patients (77.8%) underwent urgent surgical revision. Arterial flow was restored in 19 children but HAT recurred in 4 of patients after initial successful surgical revascularization. In 6 patient (22.2%) with HAT surgical revision was not attempted and in 5 of them intrahepatic flow restoration could be noted: in 2 after treatment with intravenous systemic infusion of recombinant tissue plasminogen. Finally permanent HAT was present in 7 out of 400 children (1.75%). All of them underwent liver retransplantation and 3 died. 4 children died with a patent hepatic artery, including 1 with concomitant portal vein thrombosis who underwent retrasplantation. Incidence of biliary stenosis and retransplantation was significantly higher in HAT Group (p=0.00002 and p<0.0001 respectively). Patient 1, 5 and 10 year survival was: in HAT Group 74.1%, 73.9% and 61.5%, in non-HAT Group 93.3%, 89.2% and 85.6% respectively. Graft survival was 66.7%, 63.6% and 46.2% in HAT group, 91.2%, 87.2% and 81.7% in patients without HAT at 1, 5 and 10 years, respectively. Patient and graft survivals were significantly worse in HAT Group (p<0.05).
Conclusions: Patients with HAT have increased risk of biliary stenosis, graft loss and need for retransplantation, especially with irreversible HAT. Early diagnosis and prompt treatment including surgical revascularization may alleviate complications of HAT and improve graft and patient survival.