AJR 2004; 183:1029-1031
© American Roentgen Ray Society
Rupture of a Stenotic Hepatic Artery After Liver Transplantation: Endovascular Salvage Using a Covered Stent
Dheeraj K. Rajan and
Kenneth W. Sniderman
1Both authors: Division of Vascular and Interventional
Radiology, Department of Medical Imaging, Toronto General Hospital, University
Health Network, University of Toronto, 585 University Ave, NCSB 1C-553.,
Toronto, ON M5G 2N2, Canada.
Received November 15, 2003;
accepted after revision January 20, 2004.
Address correspondence to D. K. Rajan
(dheeraj.rajan{at}uhn.on.ca).
Introduction
Vascular complications after liver transplantation are a major cause of
morbidity and mortality. Hepatic artery thrombosis is the most common vascular
complication, occurring in 3–25% of patients
[1–4].
Hepatic artery stenosis can display a variable presentation similar to that of
hepatic artery thrombosis and has an incidence of 3–13%
[1,
2,
4]. Clinically, hepatic artery
stenosis can have a more insidious course than hepatic artery thrombosis and
present with graft ischemia or infarction, sepsis, cholestasis, biliary leak,
or strictures [2,
5,
6]. Although early
retransplantation is considered the therapy of choice for hepatic artery
thrombosis, percutaneous interventions, including thrombolysis, balloon
angioplasty, or stent placement, are alternative therapeutic options. Hepatic
artery stenosis has been successfully treated with angioplasty and stent
placement
[7–12].
One recognized complication of angioplasty is hepatic artery rupture
[10]. We report a case of
hepatic artery rupture after deployment of a primary uncovered stent that was
successfully treated by placement of a covered vascular stent.
Case Report
A 58-year-old woman underwent cadaveric liver transplantation for cirrhosis
caused by autoimmune hepatitis. One month after the transplantation, a large
pseudoaneurysm developed at the hepatic artery anastomosis as the result of
bile leakage. The transplanted hepatic artery could not be salvaged surgically
and was over-sewn. One month later, the patient underwent retransplantation
with an aortic infrarenal jump graft to the transplanted hepatic artery
constructed from a donor's iliac artery.
After the second transplantation, routine laboratory investigations and
sonographic examinations of the transplant were performed at 3-month
intervals. One year after transplantation, routine sonography showed a focal
abrupt velocity increase, with peak systolic velocities of 450–500
cm/sec, consistent with a focal stenosis of the hepatic artery at the
anastomosis. Distal to the stenosis, the acceleration times within the hilum
of the transplanted liver as well as within the right and left hepatic
arteries decreased to 180–250 cm/sec, with a resistive index ranging
from 0.49 to 0.53. The results of the liver enzyme profile were normal.
The patient was referred for angiographic evaluation 1 month after the
sonographic examination. A hepatic arteriogram obtained by selective
cannulation of the infrarenal jump graft from the aorta showed a focal
concentric stenosis of more than 70% at the graft-to-hepatic-artery
anastomosis (Fig. 1A). Heparin
(2,500 IU) was administered IV, and antispasmodics (10 mg of sublingual
nifedipine and three doses of 100 µg of nitroglycerine injected into the
jump graft) were administered. A 0.035-inch Rosen wire (Cook) was positioned
in the graft proximal to the stenosis, and the diagnostic catheter was
exchanged for a 6-French Abraham sheath (Cook); its tip was placed in the
proximal graft. The wire was removed, and the stenosis was traversed with a
0.014-inch Sparta wire (Guidant). The lesion was then primarily stented with a
18-mm-long Herculink (Guidant) uncovered balloon-expandable stent and was
dilated to a diameter of 6 mm with a high-pressure moderately compliant
angioplasty balloon. The arteriogram obtained after the stent deployment
showed an improved luminal caliber with active hemorrhage from the hepatic
artery in the region of the stent (Fig.
1B). Conservative attempts to stop the extravasation with repeated
prolonged balloon inflation across the area of arterial rupture failed.
Systemic heparinization was not reversed.
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Fig. 1A. —58-year-old woman with stenosis of transplanted hepatic
artery detected on Doppler songraphy. Selective arteriogram of infrarenal jump
graft to hepatic artery reveals concentric stenosis of hepatic artery
anastomosis.
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Fig. 1B. —58-year-old woman with stenosis of transplanted hepatic
artery detected on Doppler songraphy. Selective arteriogram of infrarenal jump
graft obtained after deployment of primary uncovered stent shows improved
luminal caliber and extravasation of contrast medium (arrow),
indicating extravascular hemorrhage.
|
|
The site of bleeding was traversed using a 0.035-inch Tad 2 wire
(Mallinckrodt), and the 6-French Abraham sheath was exchanged for an 8-French
Mullins sheath (Cook), its tip being placed in the proximal graft. A
balloon-expandable stent-graft (polytetrafluoroethylene-covered stent
[4–9 mm diameter, 17 mm long], Jomed) was delivered uncovered to the
site of extravasation, was hand-crimped on a 5-mm diamete x 20-mm length
Pursuit angioplasty balloon (Cook), and was deployed across the site of
bleeding by inflating the angioplasty balloon to a diameter of 5 mm. No
further extravasation was evident (Fig.
1C). This was an off-label application of the Jomed device and was
used specifically for this case because it was the only covered stent
available at our institution. Sonography performed the next day showed normal
velocities and resistive indices. The patient was discharged with no
anticoagulation medications. Eleven months after stent placement, the patient
underwent an uneventful Whipple procedure for adenocarcinoma in the head of
the pancreas. Thirteen months after deployment of the covered stent, the
patient continues to have a normal hepatic enzyme profile, and routine
sonographic examinations continue to show normal velocities in the hepatic
artery. No further intervention has been required.
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Fig. 1C. —58-year-old woman with stenosis of transplanted hepatic
artery detected on Doppler songraphy. Selective arteriogram of infrarenal jump
graft obtained after deployment of covered stent reveals no further
bleeding.
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Discussion
Transplanted hepatic artery stenosis can lead to arterial thrombosis, graft
ischemia, biliary complications, and eventual graft failure. Critical hepatic
artery stenosis is considered to be a reduction in the diameter of the hepatic
artery by at least 50% [9,
10], although stenosis of more
than 70% was considered significant in two studies
[12,
13]. The interval between
transplantation and the development of hepatic artery stenosis ranges from
days to several months. Surgical intervention with possible retransplantation
is generally required. Percutaneous interventions including fibrinolysis,
angioplasty, and vascular stenting are now accepted as valid alternatives to
surgery.
Multiple studies have reported good results after angioplasty for hepatic
artery stenosis [7,
9,
10]. In the largest published
series to date, Orons et al.
[10] attempted percutaneous
transluminal angioplasty in 21 allografts, with a technical success rate of
81%. These authors also reported that patients who underwent successful
percutaneous transluminal angioplasty had significantly longer allograft
survival than patients in whom percutaneous transluminal angioplasty was
unsuccessful. Potential complications associated with percutaneous
transluminal angioplasty of the hepatic artery include local thrombosis,
dissection, rupture, pseudoaneurysm formation, and distal embolization
[10,
14–16].
When a vessel rupture occurs, conservative measures, including reversal of
anticoagulation and a temporary balloon tamponade, may be attempted. If
significant bleeding continues, deliberate thrombosis of the vessel or
surgical intervention is often required.
Advancements in technology have led to the introduction of vascular stents
with improved materials, radial strength, and flexibility. In patients who
have undergone liver transplantation, vascular stents are now being used
primarily for stenoses and for complications of angioplasty, improvement in
patency, and flow-limiting dissections
[11,
13,
17]. In a study by Denys et
al. [8], coronary stents were
successfully placed as a primary procedure in 13 patients with hepatic artery
stenosis with diameters of 3.5–5.5 mm. After 1 year, a cumulative
primary patency of 53% and a secondary patency of 60% were observed, with four
patients developing intrastent stenosis. In another study, the stents placed
in four patients (two with stenosis, two with thrombosis) remained patent
during the 18- to 25-month follow-up period
[13]. The authors of that
study advocated primary stent placement when technically possible to decrease
the high rate of restenosis they observed after percutaneous transluminal
angioplasty.
In another report, 13 hepatic arteries were stented, with one case of acute
thrombosis (1 day after the stenting). All the other stents in patients who
were alive 1 year after the stenting procedure remained patent
[8]. Comparison of stenting in
similarly sized arteries in other regions of the body is inappropriate because
there are many clinical and biologic factors that may affect outcomes of
patients who have received transplants and those who have not.
For potential rupture of the hepatic artery after angioplasty, available
percutaneous salvage techniques are limited. In the study by Orons et al.
[10], one arterial leak after
percutaneous transluminal angioplasty required surgical repair. The recent
development of lower profile Dacron-(DuPont) and
polytetrafluoroethylene-covered stents means that these devices can now be
successfully placed in more tortuous or smaller vessels than they previously
could. Two covered stents available for use at the time of the procedure were
the Jomed balloon expandable stent-graft and the self-expanding Wallgraft
(Boston Scientific). Both stents were not approved for peripheral arterial
use, and application in this area represented off-label use.
Covered vascular stents now offer an alternative to uncovered stents for
specific complications such as vessel ruptures, fistulous communications, and
ruptured aneurysms [18]. In a
study by Scheinert et al. [19]
of 47 patients treated for catheter-induced injuries of the iliac artery, two
perforations were treated with a self-expanding Dacron-covered stent,
resulting in the exclusion of both perforations. At the median follow-up of 21
months, secondary patency was 100%. In a single case report, a self-expanding
Dacron-covered stent was successfully deployed for external iliac artery
rupture after recanalization and balloon angioplasty for occlusion, with
primary patency found to be retained at 18-month follow-up
[20]. In our patient, covered
stent deployment obviated urgent surgical intervention, and the hepatic
allograft was salvaged with no further intervention required during a 13-month
follow-up.
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Introduction
Case Report
