Hepatic Artery Occlusion in Liver
Transplantation: What Counts More,
the Type of Reconstruction or the
Severity of the Recipient’s Disease?
Christian E. Oberkoﬂer,
* Tim Reese,
* Dimitri A. Raptis,
Olivier de Rougemont,
Michelle L. De Oliveira,
and Henrik Petrowsky
Swiss HPB and Transplant Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland;
The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
Although the type of hepatic artery revascularization technique is known to have an impact on patency rates, independent perioper-
ative risk factors on patient outcomes are poorly deﬁned. All consecutive adult patients undergoing cadaveric liver transplantation
(n 5 361) from July 2007 to June 2016 in a single institution were analyzed. Primary outcomes were early (<30 days) hepatic artery
occlusion and primary hepatic artery patency rate. A multivariate model was used to identify independent risk factors for occlusion
and the need of arterial conduit, as well as their impact on graft and patient survival. Arterial revascularization without additional
reconstruction (end-to-end arterial anastomosis [AA]) was performed in 77% (n 5 279), arterial reconstruction (AR) in 15% (n 5
53), and aortohepatic conduit (AHC) in 8% (n 5 29) of patients. AHC had the highest mean intraoperative ﬂow (275 mL/minute;
P 5 0.02) compared with AA (250 mL/minute) and AR (200 mL/minute; P 5 0.02). There were 43 recipients (12%) who had an
occlusive event with successful revascularization in 20 (47%) recipients. One-year primary patency rates of AA, AR, and AHC
were 97%, 88%, and 74%, respectively. Aortic calciﬁcation had an impact on early occlusion. AR (odds ratio [OR], 3.68; 95% con-
ﬁdence interval [CI], 1.26-10.75; P 5 0.02) and AHC (OR, 6.21; 95% CI, 2.02-18.87; P 5 0.001) were independent risk factors
for early occlusion. Dyslipidemia additionally independently contributed to early occlusion (OR, 2.74; 95% CI, 0.96-7.87; P 5
0.06). The 1- and 5-year graft survival rates were 83% and 70% for AA, 75% and 69% for AR, and 59% and 50% for AHC (P 5
0.004), respectively. In conclusion, arterial patency is primarily determined by the type of vascular reconstruction rather than patient
or disease characteristics. The preoperative lipid status is an independent risk factor for early occlusion, whereas overall occlusion is
only based on the performed vascular reconstruction, which is also associated with reduced graft and patient survival.
Liver Transplantation 24 790–802 2018 AASLD.
Received October 12, 2017; accepted February 5, 2018.
Liver transplantation (LT) is the most effective treat-
ment for acute liver failure and end-stage liver dis-
Although LT became a lifesaving procedure for
numerous patients over the past 60 years, it is still asso-
ciated with high morbidity, particularly in the early
Vascular, notably arterial,
complications have a strong impact on graft function,
liver necrosis, or ischemic cholangiopathy.
conditions therefore compromise patient and graft sur-
vival, and they are associated with a high retransplanta-
The incidence of hepatic arterial occlusion ranges
from 4% to 9%
requiring a second liver transplant
in over 50% of patients.
Typically, an end-to-end
anastomosis of the hepatic artery is performed. In
some circumstances, back-table reconstruction of the
artery or the use of an aortohepatic conduit (AHC) is
necessary to provide arterialization of the graft.
These techniques are reported to be associated with
Abbreviations: AA, end-to-end arterial anastomosis; AHC, aortohe-
patic conduit; AR, arterial reconstruction; BAR, balance of risk;
BMI, body mass index; CCI, comprehensive complication index; CI,
conﬁdence interval; CT, computed tomography; DBD, donation after
brain death; DCD, donation after circulatory death; EAD, early
allograft dysfunction; HAT, hepatic artery thrombosis; HCC, hepato-
cellular carcinoma; HDL, high-density lipoprotein; ICU, intensive
care unit; IQR, interquartile range; LDL, low-density lipoprotein;
LT, liver transplantation; MELD, Model for End-Stage Liver
Disease; MRI, magnetic resonance imaging; NAF, normal allograft
function; OR, odds ratio; PNF, primary nonfunction; PTA,
percutaneous transluminal angioplasty; TACE, transarterial chemo-
OBERKOFLER ET AL.