Managing Recipient Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation.

Recipient hepatic artery intimal dissection (HAD) followed by hepatic artery thrombosis (HAT) is a serious complication of liver transplantation. Once this is recognized intraoperatively, the accepted approach is to use an alternative arterial inflow, which may not be possible in all patients. We describe a new classification and technique for the management of HAD during living donor liver transplantation. On the basis of the longitudinal extent of intimal dissection, HAD was classified into 4 types. Management was based on the type of dissection, availability of an adequate length of hepatic artery (HA), and an alternate source of inflow. The dissected HA itself was used for arterial anastomosis in patients with preserved pulsatile flow in the dissected artery and a lack of an alternative source of arterial inflow. The technique of using the dissected artery was based on close approximation of the tunica intima to the media with the first 2 sutures of the arterial anastomosis. Of 47 (2.4%) patients who developed HAD, 22 (46.8%) had a type 2 dissection for whom the other (right or the left) undissected HA was used for the anastomosis, and 20 (42.6%) had major (type 3 or 4) dissection. The dissected artery was used for the anastomosis in 9 (45%) of these patients. Postoperative HAT developed in only 1 of 9 patients. Pre-existing portal vein thrombosis and prior transarterial embolization were found to be major risk factors for the development of HAD. Using the technique described, the dissected artery can be successfully used for a satisfactory HA anastomosis with low thrombosis rates.