Complete substitution of the left ureter with vermicular appendix during hemicolectomy for cancer in an adult patient.

We demonstrated that a complete left ureteral substitution with appendix is a feasible and safe technique. To our knowledge, this is the first case of a successful complete substitution of the left ureter with vermicular appendix in an adult patient reported in the literature.

Graft vessel wall pathology in a case of hepatic artery pseudo-aneurysm in a liver transplant recipient.

Pseudo-aneurysms (PAs) of the hepatic artery are rare complications of liver transplantation, which are characterized by a high mortality rate. The majority occur within the first 2 months after orthotopic liver transplantation. They become clinically manifest with sudden hypotension, gastrointestinal bleeding, and abnormal liver function test results. Early diagnosis and treatment are essential to prevent life-threatening hemorrhage. Conventional treatment consists of surgical resection and vascular reconstruction, but a feasible treatment option involves an angiographic approach with the positioning of a stent or transarterial coil embolization followed by revascularization. We report a case of posttransplantation hepatic artery PA (HA-PA) with bleeding into the duodenum, diagnosed using abdominal computed tomography (CT). Arterial kinking prevented a covered stent graft from being inserted successfully using X-ray angiography, so the patient underwent emergency surgery in an attempt to exclude the PA and revascularize the organ via an aorto-hepatic bypass with an iliac vascular graft obtained from the donor. The surgical procedure failed due to progressive macroscopic dissection of the HA wall up to the bifurcation. The patient underwent retransplantation but died 25 days later due to multiple-organ failure. Histopathology of the first liver graft confirmed arterial graft dissection and pathological changes in the donor HA wall.

Selective bilirubin removal by plasma treatment with Plasorba BR-350 for early cholestatic graft dysfunction.

Early cholestatic graft dysfunction is a frequent cause of morbidity after orthotopic liver transplantation (OLT). We analyze the role of selective bilirubin plasma absorption (PAP) using Plasorba BR-350 in 4 OLT patients who had experienced early severe cholestatic graft dysfunction within 15 days after transplantation. Patients were treated with 3 consecutive cycles of PAP with Plasorba BR-350. The median amount of plasma treated was 7500 mL. Median treatment duration was 231 minutes. The average plasma bilirubin level was 37 +/- 1 mg/dL before PAP and decreased to 15 +/- 0.2 mg/dL at the end of the third cycle of PAP; 3 of 4 cases had progressive bilirubin normalization after PAP. The average amount of bilirubin removed from the plasma of the patients during each PAP treatment was 143 +/- 24 mg. At the beginning of each cycle of PAP, the Plasorba BR-350 was able to remove >90% of the total plasma bilirubin, a percentage that decreased to 60%, 50%, and 40% after 2 L, 4 L, and 7 L of plasma were treated, respectively. Liver biopsies performed after the third treatment showed reduced cholestasis when compared with the pretreatment biopsy specimen. The preliminary data suggested that PAP selective for bilirubin removal may not only reduce the bilirubin level, but may also improve the histological pattern of the graft in terms of reduced cholestatic signs.

Intraperitoneal Tenckhoff catheter for the treatment of recurrent lymphoceles after kidney transplantation: our early experience.

Lymphoceles may occur as frequently as 16% of the time after kidney transplantation, becoming clinically evident between 18 and 180 days after surgery. The management of lymphoceles is unclear. Percutaneous needle aspiration and external drainage are associated with high recurrence and complications. Surgical intraperitoneal marsupialization of lymphocele is considered the treatment of choice, but requires hospital admission, general anesthesia, and sometimes extensive surgical dissection. We discuss our experience in the treatment of recurrent symptomatic lymphocele intraperitoneally drained using a Tenckhoff catheter in 7 consecutive patients. Clinical manifestations became evident between 26 and 90 days after transplantation. The diagnosis was obtained with abdominal ultrasound in all cases; mean lymphocele diameter was 14 +/- 6 cm. After percutaneous drainage, performed to differentiate urinoma/lymphocele and to rule out infections, the lymphocele recurred within 1 month. Thereafter, we decided to treat recurrent lymphatic collection using a Tenckhoff catheter. The lymphocele was located during the operative procedure using a sterile 3.5-MHz ultrasound probe. With the patient under local anesthesia, we performed 2 vertical 1-cm incisions to the lymphocele and peritoneum, respectively. The Tenckoff catheter was first positioned into the lymphocele and the tunneled inside the peritoneal cavity. One cuff of the Tenckhoff was fixed to the fascia to avoid possible delocalization. The patients were discharged the same day. The catheter was removed 6 months later with no evidence of lymphocele recurrence.

Comparison of two techniques of arterial anastomosis during adult cadaveric liver transplantation.

Arterial complications are a major source of morbidity and mortality after orthotopic liver transplantation (OLT). The incidence of hepatic artery thrombosis (HAT) ranges from 1.6% to 8%, with a mortality rate that ranges from 11% to 35%. We have described herein a technique of arterial anastomosis aiming to perform the anastomosis as straight as possible to avoid any kinking, redundancy, or malposition of the artery when the liver is released in its final position. We compared this technique with the traditional technique of arterial anastomosis using an aortic Carrel patch, namely, 198 OLT (group A) with the traditional technique and 117 OLT (group B) with the modified technique. An aorto-hepatic bypass was necessary in 25% of the cases in group A and in 21% of the cases in group B (P = .33). Vascular anomalies were present in 20% of cases in group A and in 27.5% in group B (P = .14). Fourteen cases (7%) of HAT developed in group A versus 0 cases in group B (P = .003). In group B, we experienced 2 (1.7%) late arterial stenoses that were successfully treated using percutaneous transluminal angioplasty. The 14 cases of HAT occurring in group A were successfully managed using immediate surgical revascularization with graft salvage in 6 cases (43%), whereas the remaining 8 cases needed urgent retransplantation. We suggest that a technique of arterial anastomosis aimed at avoiding kinking, redundancy, or malposition of the artery may be a viable option to reduce the risk of HAT after OLT.

Superiority of transplantation versus resection for the treatment of small hepatocellular carcinoma.

The best therapy for hepatocellular carcinoma (HCC) is still debated. Hepatic resection (HR) is the treatment of choice for single HCC in Child A patients, whereas liver transplantation (OLT) is usually reserved for Child B and C patients with multiple nodules. The aim of this study was to compare HR and OLT for HCC within the Milan criteria on an intention-to-treat basis. Forty-eight patients were treated by OLT and 38 by HR. Three- and 5-year patient survival rates were significantly higher (P = .0057) in the OLT group (79% and 74%) than after HR (61% and 26%). The 3- and 5-year disease-free survival rate was better (P = .0005) for OLT (74% and 74%) versus HR (41% and 11%). The probability of HCC recurrences after resection was greater (P = .0002) than after transplantation, achieving 31% and 76% for HR and 2% and 2% for OLT at 3 and 5 years after surgery. The median waiting list time was 118 days; two patients dropped out for HCC progression. We concluded that OLT is superior to HR for small HCC in cirrhotic patients assuming that OLT can be performed within 6 to 10 months after listing to reduce dropouts due to tumor progression.

[Uretero-vescical anastomosis during kidney transplantation. Preliminary results of two surgical techniques]. / L'anastomosi uretero-vescicale nel trapianto di rene. Risultati preliminari di due tecniche a confronto.

AIM: The most frequent urologic complications after renal transplantation involve the uretero-vescical anastomosis (leakage, stenosis, and reflux), with a frequency of 1% to 30% in different series. METHODS: We present our results in a prospective randomized trial performed from October 2004 to September 2005, in a cohort of 36 patients, who underwent renal transplantation from cadaveric donor at our institution. A uretero-vescical anastomosis according to Lich-Gregoir was used in 18 cases (group A), whereas an anastomosis according to Knechtle was performed in other 18 patients (group B), respectively. The groups were comparable for donors and recipients characteristics. The mean donor age was 46.3 years vs 44.9 years, and the mean duration of cold ischemia was 1 086+/-296 min vs 1 100+/-381 min for group A and for group B respectively. The mean recipient age was 47.5 years vs 46.1 for group A and group B, respectively. RESULTS: No differences were evidenced between the two uretero-vescical anastomosis in term of surgical complications, infections or patient and graft survival at one year of follow-up. Stenosis and leakage involved 2 patients for each group respectively. Numbers of infections, days of antibiotic therapy were similar between the two groups. CONCLUSION: Our early experience does not evidence differences between the two types of uretero-vescical anastomosis.

Transient ischemic attack after rizatriptan administration in a liver transplant recipient: a case report.

We report the case of a male liver transplant recipient who developed de novo migraine while on tacrolimus therapy. Considering the inadequate control of pain using nonsteroidal antiinflammatory drugs, rizatriptan benzoate (10 mg orally) was administered (double administration). After both administrations a clinically transient ischemic attack (TIA) occurred. Rizatriptan was discontinued, the patient recovered without sequelae from both episodes of TIA. Remission of migraine occurred after discontinuation of tacrolimus and substitution with cyclosporine. We suggest that the association of rizatriptan and tacrolimus could potentially lead to an excessive risk of cerebral vasospasm and should be used with caution. A change in immunosuppressive therapy (from tacrolimus to cyclosporine or sirolimus) may improve migraine and should be the first choice. Further prospective comparative randomized trials are needed to establish the best therapeutic option in this particular subset of patients.

The role of hepatic biopsy to detect macrovacuolar steatosis during liver procurement.

The ability to predict graft function before transplantation has proven to be a difficult task, especially for macrovacuolar steatosis that is considered a major cause of posttransplant dysfunction. It is well known that macrovacuolar steatosis greater than 25% influences the short- and long-term outcomes of liver transplantation. We retrospectively analyzed frozen sections from 43 donor livers comparing preoperative laboratory/clinical values, and liver ultrasound of a cohort of donors without (group A, n=21) versus with steatosis of 25% to 35% (group B, n=22) upon liver biopsy performed during harvesting. We analyzed the possible correlations between preoperative donor data and the degree of macrovacuolar steatosis. None of the biochemical and clinical parameters were related to the degree of hepatic steatosis. The only difference between the two groups was the echographic pattern, with evidence of 27% fatty liver by ultrasound in group B and 5% in group A (p=.04). The specificity of hepatic ultrasound for macrovacuolar steatosis was 95% and the sensitivity was only 27%, while the positive and negative predictive value were 86% and 55%, respectively. In conclusion, liver biopsy during donor harvesting remains the gold standard to identify macrovacuolar steatosis greater than 25%. Hepatic ultrasound has a role to exclude the presence of steatosis in normal livers due to its high specificity, but it is not useful to make the diagnosis of a fatty liver since it has a low sensitivity and negative predictive value. Thereafter a liver ultrasound positive for hepatic steatosis alone should not be considered a valuable tool to discard an organ from transplantation.

Comparison of clinical and pathological staging and long-term results of liver transplantation for hepatocellular carcinoma in a single transplant center.

Liver transplantation (OLT) is a treatment for hepatocellular carcinoma (HCC) superimposed on cirrhosis provided that the disease meets defined criteria. The aim of the study was to evaluate our experience with respect to clinical and pathological staging and long-term results. From 1996 to 2005, 50 patients underwent OLT for HCC including 43 men (86%) and seven women (14%) of median age 57 years (range 37 to 67). All patients fulfilled the Milan criteria. The HCC diagnosis was based on preoperative imaging and alpha-fetoprotein levels; no tumor biopsy was performed. Upon histological examination of the resected specimens, we discovered 6 (12%) incidentalomas and 8 (16%) cases of no HCC. Finally we had 42 "true" HCC. Twenty-six patients (52%) have been downstaged and 10 (20%) upstaged by preoperative imaging; 15% were pT1, 45% were pT2, 27% pT3, and 13% pT4a. Twenty-six percent of cases exceeded the Milan criteria. One patient (pT4a) with microvascular invasion died of pulmonary metastases at 14 months after transplantation. No HCC recurrences within the liver have been encountered at a median follow-up of 20 months (range 0 to 80 months). Overall the estimated 1-, 3-, and 5-year survival rates were 83%, 77%, and 72%, respectively. One-, 3-, and 5-year estimated survival rates were 87%, 75%, and 75% for pT1, and pT2, and 75%, 67%, and 67% for pT3 and pT4a, respectively (P = .99). Based on our experience OLT for HCC has long-term results comparable to those without HCC despite the presence of a significant number of cases exceeding the Milan criteria upon pathological staging.

De novo malignancies after kidney and liver transplantations: experience on 582 consecutive cases.

De novo malignancies after transplantation are a growing problem of solid organ transplant recipients, due to longer survival follow-up under chronic immunosuppression. The aim of this study was to analyze a population of 582 consecutive kidney (n = 382) and liver (n = 202) transplant recipients, who survived at least 12 months after transplantation, at a single transplant center for the development of de novo cancers. The incidence of de novo malignancies was 7% after both renal and liver transplantation. The median elapsed time from transplant to the diagnosis of de novo malignancy was 45 months (range 3 to 220) months for kidney and 37 months (range 12 to 101 months) for liver transplants. Skin cancers were the most common within renal recipients, while gastroenteric cancers were more frequently encountered in liver transplants. Oropharyngeal and upper digestive tract tumors were always associated with a history of chronic alcohol consumption in liver recipients. Liver transplant recipients treated for acute rejection had a worse cancer prognosis than patients without rejection 1- and 2-year survivals 83% and 63% versus 36% and 17% (P = .026). The estimated 1- and 2-year survival rates for all types of de novo malignancies were 79% and 66%, including 64% and 51% for solid organ tumors versus 89% and 89% for skin cancers and posttransplant lymphoproliferative disorder (PTLD) (P = .17) in renal transplants and 70% and 42%, including 57% and 28% for solid organ tumors versus 85% and 64% for skin cancers and PTLD (P = .43) in liver transplants respectively.

Splenic Artery Syndrome as a Possible Cause of Late Onset Refractory Ascites After Liver Transplantation: Management With Proximal Splenic Artery Embolization.

BACKGROUND: Portal hyperperfusion (PHP) is a hemodynamic condition which may develop after liver transplantation and cause refractory ascites (RA). The diagnosis is established by exclusion of other causes of increased sinusoidal pressure/resistance such as cellular rejection or toxicity and outflow obstruction. PHP as part of the pathogenesis of the splenic artery syndrome (SAS) can be treated with splenic artery embolization (SAE). METHODS: This is a retrospective study on a cohort of first-time whole-size liver transplant recipients diagnosed with RA due to PHP and treated by proximal SAE (pSAE) at the Liver Transplant Unit of the University Hospital of Udine between 2004 and 2014. RESULTS: For this study, 23 patients were identified (prevalence 8%) and treated. Preliminary clinical workup to diagnose SAS was based on exclusion of other possible causes of RA with graft biopsy, cavogram with hepatic venous pressure measurement, computed tomography scan, and angiography. The pSAE was performed 110 ± 61 days after transplantation, and no procedure-related complications occurred. pSAE resulted in a significant decrease of portal vein velocity (P = .01) and wedge hepatic venous pressure (P = .03). The diameter of the spleen showed a slightly significant reduction (P = .047); no modification of hepatic artery resistive index were encountered (P = .34). Moreover, pSAE determined the resolution of RA in all cases. CONCLUSIONS: pSAE is a safe and effective procedure to modulate the hepatic inflow and thus to treat RA secondary to SAS, with a low incidence of complications and a high rate of clinical response.

Renal transplantation in a patient affected by Mounier-Kuhn syndrome.

Tracheobronchomegaly, also called Mounier-Kuhn syndrome, consists in dilatation of the trachea and major bronchi because of atrophy or absence of their elastic fibers and smooth muscle cells. Standard chest radiography often does not permit diagnosis because only lateral imaging, obtained with X-rays or chest CT scan, shows the true degree of tracheal dilatation. Surgery has no role in tracheomegaly, except for the complications of tracheal stenosis or pneumothorax. The present work reports cadaveric renal transplantation in a 43-year-old woman affected by end-stage renal disease and suffering from congenital tracheobronchomegaly diagnosed during the first decade of life. No surgical or anesthetic problems were encountered during the immediate perioperative period. The patient did not require pulmonary physiotherapy. Antibiotic prophylaxis was given for 10 days. No pulmonary infection developed, and the patient was discharged from the hospital asymptomatic with normal renal function at 25 days after the transplant. Four months later, the patient experienced bronchitis with cough and fever. Antibiotic therapy was performed with totally resolution of symptoms. At 8 months of follow-up after kidney transplantation, the patient is asymptomatic with normal renal function.

Cryopreserved human hepatocytes from cell bank: in vitro function and clinical application.

UNLABELLED: We Aimed to analyze the in vitro function of isolated and cryopreserved human hepatocytes (CHH) from a cell bank and to define their potential clinical application in a bioartificial liver (BAL) device. METHODS: Over 24 months, 103 not transplantable livers were utilized for human hepatocytes isolation and cryopreservation. Hepatocytes isolated by collagenase were analyzed for yield, viability, diazepam metabolism, and production of human albumin after isolation and cryopreservation in LN(2). RESULTS: The causes for refusal for transplantation were macrosteatosis >60%, ischemic damage due to donor hypotension, and nonviral cirrhosis in 60%, 11%, and 8%, respectively. Cell yields averaged 7 million hepatocytes per gram of liver of mean viability of 80% +/- 13%. The viability of CHH after thawing averaged 50%. Thawed hepatocytes showed diazepam metabolism, and human albumin synthesis comparable to fresh cells. CHH were utilized as the biological component of a BAL for temporary support as three applications of two patients affected by fulminant hepatic failure awaiting urgent transplant. Ten to 13 billion viable CHH were loaded into each BAL. Liver function showed bilirubin and ammonia reduction at the end of each treatment. One patient was successfully bridged to emergency OLTx after one BAL; in the second case there was spontaneous recovery of liver function after two BAL. CONCLUSIONS: Recovery of donor human livers unwanted for transplantation allowed isolation and cryopreservation of viable and functionally active human hepatocytes, which have been banked and successfully used for clinical applications of a BAL device.

Long-term results of in situ split-liver transplantation.

BACKGROUND: Split-liver transplantation (SLT) offers immediate expansion of the cadaver donor pool. The principal beneficiaries have been adult and pediatric recipients with excellent outcomes. This study analyzed a single-center experience of adult to adult in situ SLT in adult recipients. PATIENTS AND METHODS: Fourteen consecutive adult-to-adult in situ SLT have been performed at our institution since 1998. The extended right lobe comprising segment 1 was transplanted in to adult patients, the left lateral segment, for pediatric transplants. RESULTS: Donors of SLT were significantly younger (P = .03) than those of whole liver transplants. Survival rates of patients receiving a split liver were 83%, 73%, and 73% at 1, 3, and 5 years after the transplant respectively and grafts of 73%, 73%, and 73% for SLT and 76%, 70%, and 66% for whole liver transplants (P = .44). The rate of biliary complication after SLT was 21%, which was comparable to that after whole organ transplantation (17%). The incidence of hepatic artery thrombosis and primary nonfunction was not significantly different between split liver and whole organ transplantation performed during the same time period (7% versus 4.6% P = .67 and 7% versus 2.6% P = .32, respectively). CONCLUSION: This limited single-center experience confirmed that both early and long-term results of SLT are comparable to those of traditional whole liver organ transplantation.

Effects of successful renal transplantation on left ventricular mass.

Left ventricular hypertrophy is an independent cardiovascular risk factor in the general population and in patients with chronic renal failure. Relatively little is known about the effects of renal transplantation on left ventricular hypertrophy. The aim of this study was to determine the changes in left ventricular mass after successful renal transplantation and to evaluate the importance of some clinical, laboratory, and echocardiographic variables on the trend to left ventricular hypertrophy. Twenty-three patients with end-stage renal disease were studied by ambulatory blood pressure monitoring and echocardiography before and 2 years following renal transplantation. After 24 months of follow-up, all transplant recipients had adequate renal function (serum creatinine <2 mg/dL). At the end of the study, we observed a significant decrease in left ventricular mass and left ventricular mass index compared to the pretransplantation period. In renal transplant recipients, the prevalence of left ventricular hypertrophy significantly decreased (78% versus 44%, P < .03) after 2 years of follow-up. Systolic 24-hour blood pressure was the only predictor of left ventricular mass and of left ventricular mass index at 2 years after transplantation. In conclusion, successful renal transplantation produces a regression of left ventricular hypertrophy. This beneficial effect depends on a decrease in systolic pressure levels.

A single-center experience of late retransplantation of the liver.

Liver retransplantation is considered to carry a higher risk than primary transplantation. However, there are an increasing number of retransplant candidates, especially owing to late graft failure. The aim of this study was to analyze a single-center experience in late liver retransplantation. The overall rate of primary retransplantation was 11.4% (28 re-OLT out of 245 primary OLT); the 14 (52%) who underwent retransplantation at more than 3 months after the first transplant were analyzed by a medical record review. Causes of primary graft failure leading to retransplantation were chronic hepatic artery thombosis in five cases (36%); recurrent HCV cirrhosis in four cases (29%); chronic rejection in two cases (14%); veno-occlusive disease; hepatic vein thrombosis or idiopathic graft failure in one case each (7%). UNOS status at re-OLT was always 2A, all patients were hospitalized; three were intensive care unit bound. ICU and total hospital stay had been 7 +/- 5 and 28 +/- 16 days, respectively. One- and 2-year patient and graft survivals were 84% and 62% and 67% and 67%, respectively. Death occurred in four patients. Two out of the three recovered in ICU at the time of retransplantation, at a median interval of 15 +/- 9 days after retransplantation. The survival rate after late retransplantation is improving, and this option should be considered to be a efficient way to save lives, especially by defining the optimal timing for retransplantation.

Quality-of-life assessment before and after liver transplantation.

BACKGROUND: Quality-of-life (QoL) assessment includes health status, disability, psychological wellness, and social performance. We sought to evaluate the effect of liver transplantation (OLT) on the QoL of patients awaiting the procedure and its variations up to 8 years afterwards. METHODS: LEIPAD-perceived QoL and BSI-psychological distress tests were used. Patients were divided in four groups (waiting list patients, 1 to 2 years after LT, 3 to 4 years after LT, 5 to 8 years after LT). Patients were also evaluated for type and severity of liver disease. RESULTS: We evaluated 126 patients, 71% male, 29% female, median age 60.7 years (range 40 to 76 years), median follow-up 4 years (range 1 to 8). The patients on the waiting list scored worse both in global stress index (GSI) and total LEIPAD scores than transplanted patients. Upon univariate linear regression analysis, the only dimension associated with time groups was LEIPAD--physical functioning, showing a progressive improvement of perceived physical status with time from transplant. Severity of liver disease showed a protective effect, probably reflecting a better control of stressful events from patients transplanted at advanced stages of liver disease. Protective effects were found for male sex, retired, cohabitant patients, and the degree of education. Housewife and widow patients showed negative associations with BSI and LEIPAD dimensions. No independent predictors of QoL were found in this study. CONCLUSIONS: OLT improves most, but not all, QoL and psychological distress domains.

De Novo Solid Tumors After Kidney Transplantation: Is It Time for a Patient-Tailored Risk Assessment? Experience From a Single Center.

BACKGROUND: Progress in immunosuppressive therapy and perioperative techniques has improved the survivals of both grafts and patients. The patient, however, is exposed to the risks of aging and side effects of immunosuppression. De novo tumors are the 2nd cause of death in the organ transplant population. The aim of this study was to evaluate whether the current accepted guidelines for the pre-transplantation study and the post-transplantation follow-up have been effective, in our kidney transplant population, regarding early detection and treatment, improving prognosis, and reducing mortality of some curable neoplastic diseases. METHODS: We considered de novo tumors in kidney transplant patients from 1995 to 2010 (n = 636) excluding hematologic and nonmelanoma skin tumors from our study. RESULTS: There were 64 de novo tumors in 59 patients out of 636 kidney transplant patients; 29.68% were urogenital cancer, 26.56% gastrointestinal cancer, 12.5% melanoma, 6.25% lung cancer, 6.25% biliopancreatic cancer, 4.68% visceral Kaposi sarcoma, 4.68% breast cancer, 4.68% thyroid cancer, 1 pleural mesothelioma, 1 meningioma, 1 merkeloma. Twenty patients died because of cancer. Ten patients had a late de novo tumor diagnosis, when the stage of tumor was advanced and not suitable for curative treatment. CONCLUSIONS: Because of the increased neoplastic risk, we consider it mandatory to carry out a meticulous screening and to implement pre-transplantation study concerning this increased neoplastic risk population to detect a subgroup of patients presenting the highest risk to improve their outcome.

Right lobe living related graft loss due to intrahepatic multiple arterio-portal fistulas.

We report a case of a 38-year-old Caucasian female with ileal carcinoid and bilobar hepatic metastases. After resection of the primary tumor, octreotide therapy was prescribed. Carcinoid histology was positive for chromogranin A and sinaptophsine and negative for MIB1. At 1-year, a follow-up computed tomography scan, Octreoscan, and PET scan were negative for extrahepatic involvement. The patient underwent right lobe living related liver transplantation donated by her sister. Acute hepatic artery thrombosis was successfully revascularized 24 hours after transplantation. Extrahepatic biliary ischemia was treated by a bilio-digestive anastomosis. Eight months later, ascites and clinical and serologic signs of liver failure developed; a liver biopsy revealed fibrosis. Spiral computed tomography scan and hepatic angiography showed multiple intrahepatic arterio-portal fistulas resulting in arterialization and inversion of the portal flow in the absence of graft outflow obstruction.