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nnovative Technique to Reconstruct Two Branches of the Rightepatic Artery in Living Donor Liver Transplantation

.-C. Lee, L.-B. Jeng, P.-C. Li, H.-R. Yang, C.-W. Lu, T.-H. Chen, H.-T. Cheng, S.C.-N. Chang,.-S. Lin, K.-S. Poon, Y.-F. Chen, and Y.-J. Ho

ABSTRACT

Hepatic arterial thrombosis is a critical complication in living donor liver transplantation(LDLT). Two separate branches of the right hepatic artery (RHA) are sometimesobserved and addressed by anastomosis of the larger branch first, then checking backflowfrom the smaller branch. If not good, the smaller branch must be reconstructed. We usedthe cystic artery as a conduit for the reconstruction. Meticulous dissection was performedto identify all branches of the hepatic artery in the donor operation. The length of cysticartery preserved was as long as possible. The cystic arterial stump was anastomosed to thestump of the posterior branch the of RHA under microscopic guidance on the back table.Patency was checked through the stump of the anterior branch of the RHA. With thistechnique, only one orifice, the stump of right anterior hepatic artery, was used for hepaticartery reconstruction. We have performed this technique in two patients. Both had goodarterial flow after living donor liver transplantation. This innovative technique is easy andsafe, and requires only one anastomosis, which, in theory, decreases the adds of developing

hepatic arterial thrombosis.

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EPATIC ARTERIAL thrombosis (HAT) is a criticalcomplication that occurs in living donor liver trans-

lantation (LDLT).1,2 Anomalies of the hepatic artery areess common on the right side; however, in some cases,here are two separate branches of the right hepatic arteryRHA). For this anomaly, various techniques have beeneported for reconstruction of the RHA. Most series favornastomosis of the larger branch first, then checking theackflow from the smaller branch. If not good, the smallerranch must be reconstructed. Technically, it is difficult toeconstruct the smaller branch in the operative field. Wesed the cystic artery as a conduit to perform the recon-truction.

ETHODS

eticulous dissection was performed to identify all branches of theepatic artery in the donor operation. The length of the cysticrtery preserved was as long as possible while performing theholecystectomy and intraoperative cholangiography. The rightobe of the liver was harvested in the usual manner, with particularttention to not injure any arterial branches. The cystic arterialtump was anastomosed to the stump of the posterior branch of theHA under the microscopic guidance on the back table (Fig 1).atency was checked through the stump of the anterior branch of

he RHA. With this technique, only one orifice, the stump of the s

2008 Published by Elsevier Inc. 60 Park Avenue South, New York, NY 10010-1710

ransplantation Proceedings, 40, 2525–2526 (2008)

ight anterior hepatic artery, was used for hepatic artery recon-truction (Fig 2).

ESULTS

e have performed this technique in two patients. Bothatients have good arterial flow as proved at Dopplerltrasonography. Their graft functions are well maintainedt 10 and 15 months, respectively, after LDLT.

ISCUSSION

epatic arterial thrombosis is one of the most seriousomplications after liver transplantation.1–2 The incidenceay be higher in the setting of LDLT because the arteries

From the Department of Surgery (C.-C.L., L.-B.J., P.-C.L.,.-R.Y., C.-W.L., T.-H.C., H.-T.C.), Division of Plastic and Re-onstructive Surgery (S.C.-N.C., M.-S.L.), Department of Anes-hesiology Pain Service and Critical Care Medicine (K.-S.P.), andepartment of Radiology (Y.-F.C., Y.-J.H.), China Medical Uni-ersity and China Medical University Hospital, Taichung, Taiwan,hina.Address reprints requests to Dr Long-Bin Jeng, Department of

urgery, China Medical University and China Medical Universityospital, 2 Yu-Der Road, Taichung, 404 Taiwain, China. E-mail:

urgery@www.cmuh.org.tw

0041-1345/08/$–see front matterdoi:10.1016/j.transproceed.2008.07.025

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2526 LEE, JENG, LI ET AL

re thinner, shorter, and sometimes multiple,2 and thenastomoses must be performed in a limited surgical field.echnical refinements, in particular, the introduction oficrosurgery techniques, have decreased the incidence ofAT.3

Reconstruction of all anomalous hepatic arteries wastrongly advocated to prevent HAT. In LDLT, this is notlways necessary.4 Ikegami et al4 suggested reconstruction ofhe thickest of several arteries with ligation of the others ifulsatile backflow bleeding as confirmed from their cut ends.The incidence of multiple orifices in a right lobe graft

aries among reports,5,6 hence, the different strategies toerform arterial reconstructions for multiple orifices. Mar-os et al5 prefer to use an interposition Y graft to reduce thencidence of HAT. Kishi et al6 advocated a single arterialnastomosis without interposition in all 72 patients of theirith right lobe grafts; none of them developed HAT.In our experience, four of 39 patients undergoing right

obe LDLT had two RHA branches. In two of theseatients, the size of both the anterior and the posteriorranches was similar. In addition, the cystic artery branchedrom the anterior RHA was also of comparable size. Theength of cystic artery harvested was as long as possible. Thetump of the cystic artery was anastomosed to the dividednd of the posterior branch of the RHA. The procedure was

ig 1. Two branches of the hepatic artery, that is, the rightosterior hepatic artery (1) and the right anterior hepatic artery

2). A length of cystic artery (3) was dissected and anastomosedo the stump of the posterior branch of the right hepatic artery.he stump of the anterior branch of the right hepatic artery was

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Tsed for anastomosis to the right hepatic artery of the recipient.

ompleted under microscopic guidance on the back table.atency was easily confirmed. Therefore, only one orifice,

he stump of the anterior branch, was used for anastomosisith the recipient RHA.This innovative technique the adequate size and branch-

ng course of the cystic artery. If both conditions areresent, the cystic artery can be used as a conduit to connecthe branches and to enable a single arterial anastomosis.

e recommend meticulous dissection, especially in cases inhich the pretransplantation images demonstrate two RHAranches. If the cystic artery is in good condition, it can besed, as in our two patients.In conclusion, this innovative technique is easy and safe

ecause the anastomosis is completed on the back table. Itnables only one anastomosis to be performed in theimited surgical field, which, in theory, decreases the inci-ence of HAT.

EFERENCES

1. Broelsch CE, Whitington PF, Emond JC, et al: Liver trans-lantation in children from living related donors. Ann Surg 214:28, 19912. Sakamoto Y, Takayama T, Nakatsuka T, et al: Advantage in

sing living donors with aberrant hepatic artery for partial liverraft arterialization. Transplantation 74:518, 2002

3. Mori K, Nagata I, Yamagata S, et al: The introduction oficrovascular surgery to hepatic artery reconstruction in living-

onor liver transplantation: its surgical advantages compared withonventional procedures. Transplantation 54:263, 1992

4. Ikegami T, Kawasaki S, Matsunami H, et al: Should allepatic arterial branches be reconstructed in living-related liverransplantation? Surgery 119:431, 1996

5. Marcos A, Killackey M, Orloff MS, et al: Hepatic arterialeconstruction in 95 adult right lobe living donor liver transplants:volution of anastomotic technique. Liver Transpl 9:570, 2003

6. Kishi Y, Sugawara Y, Kaneko J, et al: Hepatic arterial

ig 2. Patient 2. The length and diameter of the cystic arteryarrow) were suitable for anastomosis to the right posteriorepatic artery (asterisk).

natomy for right liver procurement from living donors. Liver

ranspl 10:129, 2004