Replaced donor right hepatic artery microsurgical reconstruction with interpositioning of the superior mesenteric artery in pediatric deceased donor liver transplantation

doi:10.21203/rs.3.rs-2078931/v1

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Research Article

Replaced donor right hepatic artery microsurgical reconstruction with interpositioning of the superior mesenteric artery in pediatric deceased donor liver transplantation

https://doi.org/10.21203/rs.3.rs-2078931/v1

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Purpose

To present our experience of using the pediatric donor superior mesenteric artery (SMA) as the interpositioning vessel to reconstruct the hepatic artery in pediatric deceased donor liver transplantation.

Methods

Pediatric patients who received pediatric deceased donor livers from December 2019 to June 2021 were enrolled.

Results

A total of 43 pediatric recipients received pediatric deceased donor livers during the study period. Thirty-four (79.1%) pediatric donors had normal hepatic artery anatomy, while nine (20.9%) showed variant anatomies. The SMAs of the pediatric donors were interposed in the latter eight cases. The anastomosis between the donor distal SMA and the donor celiac trunk artery (CTA) was initially performed in the back-table period, after which the other anastomosis between the donor proximal SMA and recipient CHA was performed. Only one case showed HAT occurrence (incidence rate, 2.3%). However, no arterial complications occurred in pediatric recipients with donor grafts that showed the variation of RHA replacement from the SMA and had undergone usage of the donor’s SMA as an interpositioning vessel.

Conclusion

In pediatric deceased donor liver transplantation, the use of SMA as an interpositioning medium can solve the problems related to a tiny caliber and anatomical variations of the donor hepatic artery.

anatomical variation

pediatric deceased donor

arterial plastic

hepatic artery thrombosis

Pediatric liver transplantation is a recognized curative treatment for pediatric patients with end-stage liver disease or some metabolic diseases [1]. However, hepatic artery thrombosis (HAT) remains a life-threatening problem in pediatric recipients, leading to graft loss or even death. The incidence of HAT is generally 8.3% in children, potentially increasing to over 10% in cases with pediatric deceased donors [2], and is significantly higher than that in adults (2.9%) [3–6]. HAT is caused by multiple reasons, but is often related to the surgical procedure. A congenitally tiny caliber of the hepatic artery and fragile artery wall leads to technical difficulty in completing vessel anastomosis [7]. Furthermore, anatomical variations of the hepatic artery in pediatric donors can make the anastomosis procedure more challenging and dramatically increase the risk of HAT, even necessitating discarding of the organ [8].

Variations in the anatomy of the hepatic artery have been reported in approximately 20% of the population [9]. According to Michel’s classification of anatomic variations in the hepatic artery [10], a replaced right hepatic artery (RHA) arising from the superior mesenteric artery (SMA) is one of the most common variations, and is essential for arterial plasticity before graft transplantation. Therefore, we introduce our experience of microsurgical reconstruction using the pediatric donor’s SMA as the interpositioning vessel in patients with donor grafts with the arterial variation of RHA replacement from the SMA, which subsequently showed a good prognosis.

Patient population

Between December 2019 and June 2021, 43 pediatric deceased donor liver transplantations were performed for pediatric recipients at the Liver Transplant Center and Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University. All pediatric grafts were obtained from donation after circulatory death or brain death. This study was approved by the Ethics Committee at the First Affiliated Hospital, College of Medicine, Zhejiang University, China (approval number: 2021-298). The authors were accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Data collection

Data were collected from our data system, including age, sex, primary liver disease, surgical reports, postoperative laboratory parameters, vascular and biliary complications, and donor-related characteristics. The hepatic arterial supply of the donors was graded by Michel classification [10].

Hepatic artery complications

Graft function and blood flow of the liver grafts were monitored by blood routine examination, liver and coagulation function tests, and abdominal ultrasound, which were performed daily during the first postoperative week and then twice a week later. Ultrasonography was used to detect the blood flow of the hepatic artery. When the blood flow signal of the hepatic artery disappeared, contrast-enhanced ultrasound or computed tomography scans were performed to determine whether hepatic artery thrombosis or stenosis occurred.

Patient characteristics

The average age of all pediatric recipients during the study period was 36.6 ± 26.8 months (Table 1). Biliary atresia was the most common primary disease, accounting for 76.7% of the cases. Thirty-four (79.1%) of the 43 pediatric donors showed normal anatomy of the hepatic artery, while the remaining 9 (20.9%) showed variant anatomies. A direct end-to-end anastomosis between the graft common hepatic artery (CHA) and recipient CHA was the most commonly used anastomosis mode. Thus, the variation of the CHA from the SMA did not affect the anastomotic mode of the hepatic artery. The SMAs of the pediatric donors were interposed in eight cases whose donor grafts showed the variation of RHA replacement from the SMA (Table 2). The surgical aspects are summarized in Table 3.

Hepatic arterioplasty and reconstruction

During the period of organ procurement, the hepatic artery of the donor graft was perfused from the aorta, while the portal vein was perfused with the University of Wisconsin (UW) solution. Finally, the donor livers were preserved in UW. All hepatic arteries of the pediatric grafts were trimmed by experienced surgeons during the back-table procedure. Traction with tension and clipping by clamps were avoided. In addition, the surrounding fibrous tissues of the hepatic artery could be preserved to avoid vascular injury. Besides, the branches should be carefully dissected and ligated to reserve the whole arteries that run from the SMA to the RHA or from the celiac trunk artery (CTA) to the left hepatic artery (LHA) and middle hepatic artery (MHA) (Figure 1).

First, we completed the anastomosis between the donor distal SMA and donor CTA. We usually use the donor distal SMA patch at the junction between the SMA trunk and mesenteric artery branch and the donor CTA patch at the junction between the CTA and aorta to perform patch-to-patch continuous anastomosis. Next, we completed the other anastomosis between the donor proximal SMA and the recipient CHA. With a similar method, we usually use the donor proximal SMA patch at the junction between the SMA trunk and aorta and the recipient CHA patch at the junction between the recipient CHA trunk and recipient gastroduodenal artery (GDA) to perform patch-to-patch continuous anastomosis. If an artery patch could not be acquired, an end-to-end anastomosis with interrupted sutures was applied. All hepatic artery reconstructions were performed with a microsurgical technique using 8-0 or 9-0 prolene sutures according to the diameter of the vessels. Among these eight cases, six were anastomosed in a patch-to-patch continuous manner, while the other two were anastomosed in an end-to-end interrupted manner.

Graft function recovery

The values of alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), and gamma-glutamyl transpeptidase (GGT) can reflect the recovery of graft function as well as the effects of hepatic artery reconstruction. The values of all four parameters decreased from postoperative day (POD) 2 and almost reached the normal level on POD 7 (Figure 2).

Hepatic artery complications

Only one of the 43 pediatric deceased donor liver transplant cases showed HAT within two weeks after the operation, and the incidence (2.3%) was obviously lower than the values recorded in international reports [2, 3, 11]. Interestingly, the eight patients that received donor grafts with the variation of RHA replacement from the SMA and the donor’s SMA as an interpositioning vessel did not show any hepatic artery complications over a follow-up period of at least 2 months. The postoperative three-dimensional CT examination showed good patency of the hepatic artery (Figure 1G).

Hepatic artery variations of the donor liver, especially the replacement of the RHA from the SMA, are commonly encountered in liver transplantation. Many methods of variant artery reconstruction have been reported successively [12–15], and the traditional approach involves anastomosis between the RHA and GDA or splenic artery (Fig. 1H). However, most methods for reconstruction have been described in adults, and the RHA and GDA of pediatric donors (< 4 years old) are very small in caliber. Our study reported the anatomical variation of hepatic artery reconstruction with interpositioning of the donor’s SMA in pediatric deceased donor liver transplantation, and this approach showed good results.

In comparison with the traditional method, this approach yields a bigger anastomosis vessel caliber, and caliber-matched vessels can be chosen to complete both anastomosis. Moreover, this approach only requires trimming of the main branch of the SMA and celiac artery in the back-table period for anastomosis, and could reduce the risk of damaging hepatic artery branches. In addition, the length of the artery is always long and the abdominal cavity is narrow in children, so attention should be paid to anastomosis kinking or stenosis when the abdomen is finally closed.

HAT is one of the most serious complications that influence patient and graft survival in pediatric liver transplantation. Many high-risk factors have been reported to be associated with the occurrence of HAT, including surgical aspects, infection, cold ischemia time, immune rejection, donor age and small graft [2, 16]. The smaller size of the graft and vessels in pediatric patients is the major difference in comparison with adult patients. Despite the development of the microscopic anastomosis technique, protection of artery during trimming and the application of the no-touch principle during anastomosis should also be considered.

Although the number of cases is small and the follow-up period might too short to draw any definite conclusions, we believe that the technique using interpositioning of the donor’s SMA is feasible to solve problems associated with a tiny caliber and anatomical variations of donor hepatic artery reconstruction in pediatric deceased donor liver transplantation. The application of this technique could be expanded to address other complex arterial reconstruction procedures.

ALT, alanine aransaminase; AST, aspartate transaminase; CHA, common hepatic artery; CTA, celiac trunk artery; GDA, gastroduodenal artery; GGT, gamma-glutamyl transpeptidase; HAT, Hepatic artery thrombosis; LHA, left hepatic artery; MHA, middle hepatic artery; POD, postoperative day; RHA, right hepatic artery; SMA, superior mesenteric artery; TBIL, total bilirubin; UW, University of Wisconsin;

Acknowledgments

We thank Yue Wu for her assistance in drawing illustrations.

This work was supported by the National Natural Science Foundation of China (81800707), the National Natural Science Foundation of China (81830089), and the Key Research and Development Project of Zhejiang Province, China (2020C03117).

Conflicts of interest: The authors of this manuscript have no conflicts of interest to disclose.

J. Martinelli, D. Habes, L. Majed, C. Guettier, E. Gonzales, A. Linglart, C. Larue, V. Furlan, D. Pariente, C. Baujard, S. Branchereau, F. Gauthier, E. Jacquemin, O. Bernard (2018) Long-term outcome of liver transplantation in childhood: A study of 20-year survivors, Am J Transplant 18(7) 1680-1689. http://10.1111/ajt.14626.
N. Ma, Z. Song, C. Dong, C. Sun, X. Meng, W. Zhang, K. Wang, B. Wu, S. Li, H. Qin, C. Han, H. Li, W. Gao, Z. Shen (2019) Risk factors of hepatic artery thrombosis in pediatric deceased donor liver transplantation, Pediatr Surg Int 35(8) 853-859. http://10.1007/s00383-019-04500-6.
J. Bekker, S. Ploem, K.P. de Jong (2009) Early hepatic artery thrombosis after liver transplantation: a systematic review of the incidence, outcome and risk factors, Am J Transplant 9(4) 746-57. http://10.1111/j.1600-6143.2008.02541.x.
C.L. Chen, A. Concejero, C.C. Wang, S.H. Wang, C.C. Lin, Y.W. Liu, C.C. Yong, C.H. Yang, T.S. Lin, Y.C. Chiang, B. Jawan, T.L. Huang, Y.F. Cheng, H.L. Eng (2006) Living donor liver transplantation for biliary atresia: a single-center experience with first 100 cases, Am J Transplant 6(11) 2672-9. http://10.1111/j.1600-6143.2006.01528.x.
A. Jain, G. Costa, W. Marsh, P. Fontes, M. Devera, G. Mazariegos, J. Reyes, K. Patel, R. Mohanka, M. Gadomski, J. Fung, A. Marcos (2006) Thrombotic and nonthrombotic hepatic artery complications in adults and children following primary liver transplantation with long-term follow-up in 1000 consecutive patients, Transpl Int 19(1) 27-37. http://10.1111/j.1432-2277.2005.00224.x.
M.A. Silva, P.S. Jambulingam, B.K. Gunson, D. Mayer, J.A. Buckels, D.F. Mirza, S.R. Bramhall (2006) Hepatic artery thrombosis following orthotopic liver transplantation: a 10-year experience from a single centre in the United Kingdom, Liver Transpl 12(1) 146-51. http://10.1002/lt.20566.
Y. Shirouzu, M. Kasahara, D. Morioka, S. Sakamoto, K. Taira, K. Uryuhara, K. Ogawa, Y. Takada, H. Egawa, K. Tanaka (2006) Vascular reconstruction and complications in living donor liver transplantation in infants weighing less than 6 kilograms: the Kyoto experience, Liver Transpl 12(8) 1224-32. http://10.1002/lt.20800.
E. Melada, U. Maggi, G. Rossi, L. Caccamo, S. Gatti, G. Paone, P. Reggiani, E. Brigati, L.R. Fassati (2005) Back-table arterial reconstructions in liver transplantation: single-center experience, Transplant Proc 37(6) 2587-8. http://10.1016/j.transproceed.2005.06.058.
C.B. Winston, N.A. Lee, W.R. Jarnagin, J. Teitcher, R.P. DeMatteo, Y. Fong, L.H. Blumgart (2007) CT angiography for delineation of celiac and superior mesenteric artery variants in patients undergoing hepatobiliary and pancreatic surgery, AJR Am J Roentgenol 189(1) W13-9. http://10.2214/AJR.04.1374.
N.A. Michels (1966) Newer anatomy of the liver and its variant blood supply and collateral circulation, Am J Surg 112(3) 337-47. http://10.1016/0002-9610(66)90201-7.
N. Warnaar, W.G. Polak, K.P. de Jong, M.T. de Boer, H.J. Verkade, E. Sieders, P.M. Peeters, R.J. Porte (2010) Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver transplantation, Liver Transpl 16(7) 847-55. http://10.1002/lt.22063.
M.S. Abouljoud, D.Y. Kim, A. Yoshida, J. Arenas, J. Jerius, L. Malinzak, M. Raoufi, K.A. Brown, D.K. Moonka (2005) Impact of aberrant arterial anatomy and location of anastomosis on technical outcomes after liver transplantation, J Gastrointest Surg 9(5) 672-8. http://10.1016/j.gassur.2005.01.002.
P.T. Cherian, B. Hegab, S.P. Oliff, S.J. Wigmore (2010) The management of an accessory or replaced right hepatic artery during multiorgan retrieval: results of an angiographic study, Liver Transpl 16(6) 742-7. http://10.1002/lt.22075.
F. Di Benedetto, N. Cautero, N. De Ruvo, M. Masetti, R. Montalti, G.E. Gerunda, C. Quintini (2006) A new reconstruction of the accessory donor right hepatic artery with interposition of the SMA in liver transplantation, Surgery 140(5) 835. http://10.1016/j.surg.2006.03.010.
A. Tsaroucha, M. Webb, T. Karatzas, P. Dickson, A. Demirbas, G. Fragulidis, J. Nery, F. Khan, A. Tzakis (1997) Management of allograft-replaced right hepatic arteries in liver transplantation: a review of the University of Miami experience and a preferred method of reconstruction, Transplant Proc 29(7) 2856-8. http://10.1016/s0041-1345(97)00707-0.
X. Chen, L. Wei, Z. Zhu, L. Sun, W. Qu, Z. Zeng (2019) Hepatic artery reconstruction with interposition of donor's right gastroepiploic artery graft in pediatric living donor liver transplantation for metabolic disease, Pediatr Transplant 23(4) e13418. http://10.1111/petr.13418.

Table 1 General characteristics of pediatric recipients

Variables	Value
Age (month)	36.6 ± 26.8
Sex (male/female)	17/26
Etiology of liver disease
Biliary atresia	33 (76.7%)
OTCD	2 (4.7%)
MSUD	2 (4.7%)
Alagille syndrome	4 (9.3%)
FH	2 (4.7%)
Classification of the hepatic artery in donor
RHA and LHA from the CHA	34 (79.1%)
Replaced RHA from SMA	8 (18.6%)
CHA from SMA	1 (2.3%)
OTCD, ornithine transcarbamylase deficiency; MSUD, maple syrup urine disease; FH, familial hypercholesterolemia; RHA, right hepatic artery; LHA, left hepatic artery; CHA, common hepatic artery; SMA, superior mesenteric artery.

Table 2 Donor characteristics

Cases	Age (mo)	Weight (kg)	Gender	Graft weight (g)	Donor type	ICU stay (d)
Patient 1	26	12.0	Female	385	DBD	4
Patient 2	23	11.0	Male	427	DBD	7
Patient 3	42	14.5	Female	680	DCD	4
Patient 4	19	11.5	Female	383	DCD	3
Patient 5	31	13.5	Male	416	DCD	2
Patient 6	28	12.4	Female	414	DBD	16
Patient 7	39	18.0	Male	480	DBD	3
Patient 8	42	14.8	Male	370	DCD	1
ICU, intensive care unit.

Table 3 Surgical aspects

Cases	GRWR (%)	Cold ischemia time (h)	Total operation time (min)	Anhepatic phase (min)	Artery anastomosis time (min)	ICU stay (d)	Follow-up time (mo)	Hepatic artery complication
Patient 1	5.9	10.2	430	36	18	6	18	No
Patient 2	5.7	10.9	268	38	17	8	13	No
Patient 3	3.8	6.6	385	46	30	4	10	No
Patient 4	6.2	4.3	408	48	26	5	8	No
Patient 5	6.1	7.9	283	48	26	11	7	No
Patient 6	4.1	6.3	378	45	25	4	6	No
Patient 7	5.2	9.7	285	53	32	2	5	No
Patient 8	5.5	3.5	304	40	35	5	3	No
GRWR, graft-to-recipient weight ratio; ICU, intensive care unit.

No competing interests reported.

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You are reading this latest preprint version

Replaced donor right hepatic artery microsurgical reconstruction with interpositioning of the superior mesenteric artery in pediatric deceased donor liver transplantation

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Abstract

Purpose

Methods

Results

Conclusion

Figures

Introduction

Patients And Methods

Results

Discussion

Abbreviations

Declarations

References

Tables

Additional Declarations

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