Background: Hepatic artery thrombosis (HAT) can result in necrosis of biliary tree and graft loss necessitating re-transplantation. It requires early diagnosis and revascularization to avoid graft loss. The most effective treatment approach is still controversial. The purpose of this study is to review the outcome in the management of HAT after living donor liver transplantation (LDLT) and to clarify the feasibility of the different strategies in the management.
Methods: From May 1996 to August 2017, 827 LDLT using right lobe in adult was done in our center. Our technique of hepatic artery reconstruction is performing an end-to-end anastomosis with interrupted suture under microscope (x10) between the graft artery and the recipient hepatic artery. Diagnosis of HAT was performed using Doppler sonography and CT angiography. Initial treatments of HAT were consisted of surgical treatment or endovascular treatment, and then, re-transplantation was considered according to the graft condition.
Results: In 827 LDLT using right lobe, we experienced 16 (1.9%) cases of HAT within one month after transplantation. Seven cases (43.8%) occurred within first week (early HAT), 9 cases (56.2%) occurred between first week and a month (late HAT). The incidence of graft failure was high in early HAT (42.9%), and the frequency of biliary complication was high in late HAT (77.8%). On the treatment of HAT, reoperation was mainly performed in early HAT and endovascular treatment was performed in late HAT.  5 patients (31.3%) underwent re-anastomosis using initial artery (n=3), opposite hepatic artery (n=1) and transposition of gastroepiploic artery (n=1). The endovascular treatment (thrombolysis and/or stent) was performed initially in 11 patients (68.7%). The success rate of hepatic artery recanalization was 100% (5/5) after reoperation, and the success rate of endovascular procedure was 45.5% (5/11). Of the patients whose procedure failed, 4 patients underwent neovascularization during observation, and in 3 of them, serum bilirubin was stable and did not require liver transplantation. Five patients underwent graft failure and three of them underwent re-LT. The mortality was observed in 3 patients (18.8%) included one patient in the surgical group and 2 patients in the endovascular treatment group. Causes of death were sepsis with graft failure (n=2) and asphyxia due to aspiration (n=1).
Conclusion: Early diagnosis and aggressive treatment in HAT is necessary to avoid graft loss and the choice of therapy depends on a variety of factors, including the timing of complications, the graft function, and the availability of organs for re-transplantation. Early HAT needs to be prepared for graft failure, and late HAT requires treatment for biliary complications.