Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases.

INTRODUCTION: Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery-the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery. METHODS: A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency. RESULTS: There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68-0.69) and 1.0m/s (0.88-1.10m/s), respectively. CONCLUSION: Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success.

Use of the Descending Branch of the Lateral Circumflex Femoral Artery as an Arterial Graft in Living Donor Liver Transplant.

BACKGROUND: Reconstructing the hepatic artery in living donor liver transplantation presents the challenges of a short and small donor vessel stump, which is compounded by poor surgical access for microsurgical anastomosis. Arterial interpositional grafts (eg, the radial artery) have been used to overcome these problems. The purpose of this presentation is to describe the use of the descending branch of the lateral circumflex femoral artery (DLCFA) as an alternative when the patient has had an abnormal Allen's test precluding the use of the radial artery or if a Y-graft is needed. METHODS: The DLCFA resides in the septum between the rectus femoris and vastus lateralis muscles. A linear incision made over the proximal third of this septum exposed the avascular plane in which the vessel resides. A graft exceeding 10 cm could be harvested with diameters ranging between ≤2 and 7 mm. There were several muscular branches emanating from the profunda femoris artery system that could be dissected to the required length for a Y-shaped graft. Three cases of living donor liver transplantation using the DLCFA (straight and Y grafts) are described. RESULTS: After DLCFA interpositional grafting, all patients had normal resistive indices on duplex ultrasonography of the intrahepatic arterial system. Follow-up of the 3 patients was between 2 and 6 months. There was no donor site morbidity. CONCLUSIONS: The DLCFA graft was a useful arterial graft for hepatic artery reconstruction. It was easily harvested with minimal donor site morbidity.

Hepatic Artery Reconstruction in Living Donor Liver Transplantation With the Radial Artery Interpositional Graft.

INTRODUCTION: Reconstitution of hepatic artery inflow is essential for a successful liver transplantation. Living donor transplantation presents additional challenges in the form of a short and small donor vessel stump, exacerbating the poor surgical access for microsurgery. Few reports have described the use of the radial artery as an interposition graft in liver transplantation; we present a series of 6 cases and discuss the technical merits of this procedure. METHODS: Retrospective review of consecutive patients undergoing living donor liver transplantation from December 2015 to December 2019 was performed. Demographics, operative details, and postoperative outcomes were reviewed. RESULTS: Twenty-two patients underwent living donor liver transplantation. Radial artery interposition grafting was used in 6 cases, including 1 salvage case for hepatic artery thrombosis. One patient developed hepatic artery stenosis (2 weeks postoperatively) that was conservatively managed. After radial artery grafting, all patients had normal resistive indices on duplex ultrasonography at up to 20 months postoperatively. The mean follow-up was 15.2 months. CONCLUSION: When faced with a significantly short vessel stump or caliber mismatch, radial artery interpositional grafting is a safe and useful technique for reducing tension and overcoming vessel size mismatch in hepatic artery reconstruction.

Impact of Microsurgical Anastomosis of Hepatic Artery on Arterial Complications and Survival Outcomes After Liver Transplantation.

Hepatic artery (HA) complications after liver transplant (LT) can lead to biliary complications, graft failure, and mortality. Although microsurgery has been established to improve anastomotic outcomes, it prolongs surgical time and has not reached widespread adoption at all transplant centers. We investigated the incidences of arterial, biliary complications and outcomes after using microsurgery to anastomose HA during LT. Retrospective cohort of consecutive LT performed from 2006 to 2018 was reviewed for operative details and postoperative outcomes. Cox-regression models were used to investigate the relationship between variables and outcomes. Eighty (62.5%) LTs (Group 1) were performed without and compared with 48 (Group 2) with microsurgical anastomosis of HA. Both groups were comparable in terms of arterial and biliary anastomoses performed. Incidence of early HA thrombosis was similar (6.2% vs 2.1%, P = .28). Group 2 had lower incidence of short- and long-term arterial complications, especially amongst living donor liver transplantations (LDLT) (5.3% vs 35.0%, P = .022). On multivariate analysis, microsurgery was associated with lower risk (hazard ratio [HR] 0.09, 95% confidence interval [CI] 0.01-0.71) of, and LDLT had higher risk (HR 4.23, 95% CI 1.46-12.27) of arterial complications. Biliary complications were associated with LDLT (HR 3.91, 95% CI 1.30-11.71) and dual biliary anastomoses (HR 5.26, 95% CI 1.15-24.08) but not with occurrence of HA complications. Worse patient survival was associated with the occurrence of any HA complication (HR 4.11, 95% CI 1.78-9.48). Hepatic arterial complications can be reduced using microsurgical techniques for the anastomosis, resulting in improved patient survival outcomes after liver transplantation.

Two sequential free flaps for coverage of a total knee implant.

Knee revision arthroplasty following peri-prosthetic joint infections is a formidable challenge. Patients are at a high risk of recurrent infection, and the soft tissue over the revised implant is often of questionable quality. Flap reconstruction has improved the salvage rates of infected arthroplasties, and should be considered in all cases of revision arthroplasty. We present a challenging case requiring staged reconstruction with two free latissimus dorsi flaps after the initial use of a medial gastrocnemius flap.

The Use of Bilayered Fascia Lata With an Interpositional Omental Flap for Autologous Repair of Contaminated Abdominal Fascial Defects.

INTRODUCTION: Contaminated abdominal fascial defects, such as those seen in enterocutaneous fistula, or wound dehiscence with mesh exposure, are a significant source of morbidity and present unique reconstructive challenges. We present our technique of using the fascia lata, augmented with an interpositional omental flap, for complete autologous reconstruction of contaminated fascial defects, and the postoperative results of 3 cases. METHODS: Three patients with contaminated abdominal defects underwent wound debridement/fistula resection and immediate reconstruction with fascia lata and omentum flap. Defect size ranged from 15 × 8 cm (120 cm) to 25 × 12 cm (300 cm). The fascia lata graft was inset using an underlay technique, and the omentum was tunneled through a subcostal slit in the semilunar line to augment the vascularity of the subcutaneous plane and protect the graft. Skin coverage was achieved by undermining and direct closure or local myocutaneous flaps. RESULTS: Three patients underwent abdominal wall reconstruction with our technique. The median follow-up was 12 months. There were no recurrent infections, fistulae, or herniae. All patients experienced full functional recovery with return to independent activities of daily living by 6 months postoperatively. CONCLUSIONS: Since the use of synthetic material is contraindicated in contaminated abdominal fascial defects. We propose that our combination of fascia lata and an interpositional omental flap is a useful technique for the reconstruction of these challenging defects.