Chapters
Introduction | Arterial Complications After Liver Transplantation
Introduction | Arterial Complications After Liver Transplantation
2017arterialAVIRcategorizedsbvtransplantation
Arterial Occlusive Disease - Definition & Spectrum | Arterial Complications After Liver Transplantation
Arterial Occlusive Disease - Definition & Spectrum | Arterial Complications After Liver Transplantation
2017arterialarteryAVIRdiseasehepaticincludesinstitutionocclusivepediatricprevalencesbvstenosisthrombosistransplantvessels
Arterial Occlusive Disease - Hepatic Artery Stenosis (HAS) | Arterial Complications After Liver Transplantation
Arterial Occlusive Disease - Hepatic Artery Stenosis (HAS) | Arterial Complications After Liver Transplantation
2017anastomosisanastomoticanatomyangiogramaortogramarterialarteryAVIRaxisceliacchapterclampconduitsdependingdiagnosediagnosisdiagnosticdistalfull videografthepaticinfectioninjuryintrahepaticischemialiverprovenproximalrecipientrochestersbvstenosisstricturessurgicalsuturethrombosethrombosedthrombosistransplant
Management of Hepatic Artery Stenosis (HAS) | Arterial Complications After Liver Transplantation
Management of Hepatic Artery Stenosis (HAS) | Arterial Complications After Liver Transplantation
2017angioplastyAVIRchapterfull videohepaticrevascularizationsbvstenosisstenting
Hepatic Artery Angioplasty (HA-PTA) | Arterial Complications After Liver Transplantation
Hepatic Artery Angioplasty (HA-PTA) | Arterial Complications After Liver Transplantation
2017angioplastyangulationAVIRaxillaryballoonsceliaccoaxialexpandableguidewiresinchmesentericnitroplatformradialsbvsheathstentingstentsthrombosisvisceral
Angioplasty | Arterial Complications After Liver Transplantation
Angioplasty | Arterial Complications After Liver Transplantation
2017anastomosisangiogramangioplastyAVIRballoondilatesbvsequentiallysoftstiffwire
Adult Right Split-graft | Living Related | Pre-Angioplasty | Post-Angioplasty | Arterial Complications After Liver Transplantation
Adult Right Split-graft | Living Related | Pre-Angioplasty | Post-Angioplasty | Arterial Complications After Liver Transplantation
2017anastomoticangioplastyarteryAVIRdissectionhepaticmedicationnitrorelievereversesbvspasmsplenicstricturethrombosedthrombosesthrombosisvesselvisceral
Hepatic Artery | Proximal Clamp Injury | Angioplasty | Arterial Complications After Liver Transplantation
Hepatic Artery | Proximal Clamp Injury | Angioplasty | Arterial Complications After Liver Transplantation
2017anastomosisanastomoticangioplastyAVIRclampdissectionhepaticinjurymicrowireproximalsbv
Results Hepatic Artery Angioplasty | Arterial Complications After Liver Transplantation
Results Hepatic Artery Angioplasty | Arterial Complications After Liver Transplantation
2017anastomoticangioplastyanticoagulationantiplateletAVIRcomplicationlesionsmedicationmultiplepatencypercentproblematicrateratesrestenosissbvseriessolitaryspasmstentingstentsstricturessuccessthrombosethrombosesthrombosisunassisted
Doppler ultrasound follow-up | Patency Rates | Restenosis Rates | Hepatic Artery Angioplasty | Arterial Complications After Liver Transplantation
Doppler ultrasound follow-up | Patency Rates | Restenosis Rates | Hepatic Artery Angioplasty | Arterial Complications After Liver Transplantation
2017angioplastyAVIRdopplerhepaticlesionmonthsnormalizeoccurresistiverestenosissbvstenosisstentingstentsultrasound
Lesion | Angulated Anastomosis | Angioplasty | Arterial Complications After Liver Transplantation
Lesion | Angulated Anastomosis | Angioplasty | Arterial Complications After Liver Transplantation
2017anastomosisangioplastyangulatedangulationAVIRmicropatientrecurredsbvspasmstifftortuositywire
Stenting - Hepatic Artery | Arterial Complications After Liver Transplantation
Stenting - Hepatic Artery | Arterial Complications After Liver Transplantation
2017anastomosisangulationarteryAVIRballooncurveexpandablehepaticredundancyrestenosissbvstentstentingstentsstricturethrombosis
Arterial Occlusive Diease - Hepatic Artery Thrombosis (HAT) | Arterial Complications After Liver Transplantation
Arterial Occlusive Diease - Hepatic Artery Thrombosis (HAT) | Arterial Complications After Liver Transplantation
2017arterialAVIRcollateralsdopplerhepatichistoricindicesnormalizedportalresistivesbvvisualization
Causes of Arterial Collaterals in split-grafts | Arterial Complications After Liver Transplantation
Causes of Arterial Collaterals in split-grafts | Arterial Complications After Liver Transplantation
2017adultadultsamericansanastomosisarteryAVIRbridgingcadavericcollateralcollateralsdistancegraftgraftshepaticjapanesesbvshortersplitstumpthrombosedthrombosesthrombosistoleratetoleratedtransplanttransplantedtransplantsunitedversusvessels
Split-graft | Collateral Formation | Thrombosis | Arterial Complications After Liver Transplantation
Split-graft | Collateral Formation | Thrombosis | Arterial Complications After Liver Transplantation
2017arterialAVIRcollagencollateralsconnectionsformationhepatichilummichiganrosensbvsplitsurfaceterritoryvenous
Hepatic Artery Thrombosis - How does it Present | Arterial Complications After Liver Transplantation
Hepatic Artery Thrombosis - How does it Present | Arterial Complications After Liver Transplantation
2017abscessesangiogramAVIRbreakdowncomplicationsdopplerfailureischaemiaischemialivernormalprevalenceprogresssbvthrombosestissuetransplanted
Adult Right Lobe Transplant | Normal Doppler | Thrombosis | Angiogram | Arterial Complications After Liver Transplantation
Clot Lysis | Arterial Complications After Liver Transplantation
Clot Lysis | Arterial Complications After Liver Transplantation
2017angiogramangioplastyantennaarterialAVIRbranchesceliacconduitsdefectsFistulahepaticliversbvsplenicstentsuccessfulunderlying
Slow Hepatic Arterial Flow - NOHAH Syndrome | Arterial Complications After Liver Transplantation
Slow Hepatic Arterial Flow - NOHAH Syndrome | Arterial Complications After Liver Transplantation
2017americansanatomicalarterialAVIRcentersdefectdiagnosisflowhematomaidiopathicjapaneseliversbvslowsplenicstealstenosissyndromeunderlying
Splenic Steal Syndrome | Arterial Complications After Liver Transplantation
Splenic Steal Syndrome | Arterial Complications After Liver Transplantation
2017arterialarteryAVIRbloodceliaccirculationdroppingflowhepaticjapaneseliverportalresistanceresistivesbvspleensplenicstealvenous
Treatment - NOHAH Syndrome | Arterial Complications After Liver Transplantation
Treatment - NOHAH Syndrome | Arterial Complications After Liver Transplantation
2017arteryAVIRbreakcoilscyclediagnoseddistallyembolizationembolizesbvspleensplenicstentsurgically
NOHAH | Catheter | Angiogram | Hepatic Artery | Balloon Occlusion Test | Arterial Complications After Liver Transplantation
NOHAH | Catheter | Angiogram | Hepatic Artery | Balloon Occlusion Test | Arterial Complications After Liver Transplantation
2017aetiologyangiogramangioplastyarteryAVIRballooncapturecommitcycledistallydopplerembolizationembolizeflowgastricocclusionportalproximallyreducesbvspleensplenicstentingtheoryvein
Conclusion | Arterial Complications After Liver Transplantation
Conclusion | Arterial Complications After Liver Transplantation
2017arterialAVIRbreakcyclediagnosingembolizehepaticsbv
Hepatic Arterial Injuries | Arterial Complications After Liver Transplantation
Hepatic Arterial Injuries | Arterial Complications After Liver Transplantation
2017aneurysmsarterialAVIRbiopsiesbleedingcommonFistulahepaticinjuriesinjuryocclusiveportalprevalenceprevalentpseudopseudoaneurysmsbvstudiessurvived
Hepatric Arterial | Biopsy | Coaxial | Portal Vein | Arterial Complications After Liver Transplantation
Hepatric Arterial | Biopsy | Coaxial | Portal Vein | Arterial Complications After Liver Transplantation
2017arterialAVIRbiopsycoaxialcoildiagnosisinjuriesmanometrymeasurementportalpressuresbvvein
Arterio-portal fistulae (APF) | Arterial Complications After Liver Transplantation
Arterio-portal fistulae (APF) | Arterial Complications After Liver Transplantation
2017alizeangiogramangiographyarterialascitesaterialAVIRbasicallydetecteddopplerdysfunctionemboliembolizationFistulaflowgrafthemodynamichemodynamicallyimagingliverliversnativephaseportalpulsatilereversalsbvsizessymptomatictheorytransplanttreatveinvenous
Arterial Pseudo-Aneurysms (PsA) | Arterial Complications After Liver Transplantation
Arterial Pseudo-Aneurysms (PsA) | Arterial Complications After Liver Transplantation
2017anastomosisanastomoticAVIRducthepaticintrahepaticleavemycoticraresbvstent
Anastomotic Pseudoaneurysm | Surgical Bypass Extra-Anatomical | Aorto Hepatic Conduit | Arterial Complications After Liver Transplantation
Anastomotic Pseudoaneurysm | Surgical Bypass Extra-Anatomical | Aorto Hepatic Conduit | Arterial Complications After Liver Transplantation
2017anastomoticanatomicarteryAVIRbasicallybypassconduitshepatichiluminfectedpseudoaneurysmsbvstenosissurgicalvein
Pseudoaneurysm | Hepatic Artery | ERCP | Biliary Ducts | Arterial Complications After Liver Transplantation
Pseudoaneurysm | Hepatic Artery | ERCP | Biliary Ducts | Arterial Complications After Liver Transplantation
2017aneurysmsarteryAVIRbarbscolonoscopyercphepaticperineumplasticpseudosbvstents
Treatment | Arterial Complications After Liver Transplantation
Treatment | Arterial Complications After Liver Transplantation
2017alternativesarteryAVIRbypasscoilingembolizationembolizeequivalenceligationperineumsbvstentsurgical
Transcript

board for inviting me here again I I really appreciate it and I'm always happy to to present to present to you guys this is this is actually a long talk I'm going to try to run through run through some slides through

it to make it fit it's about arterial complications in liver transplantation and to start off they're categorized

into occlusive and non-occlusive arterial disease so we're going to start talking about arterial

occlusive disease and that includes hepatic artery stenosis includes hepatic artery kinks which are redundancies in the hepatic artery itself and hepatic artery thrombosis the most common one as far as a complication is usually hepatic artery

thrombosis followed by a hepatic artery hepatic artery stenosis hepatic artery thrombosis incidence and prevalence within a transplant population or post liver transplant populations varies considerably on the

type of transplant so if you're an institution that does a lot of pediatric transplants then you'll have a high hepatic artery thrombosis rate. If you're an institution that does whole grafts on adults mostly then you'll have

a lesser hepatic artery thrombosis rate it all depends on the complexity of the graft whether it's a whole graph or it splits and the size of the vessels the smaller the vessels are more likely they would they would thrombos and we'll

talk about that a little bit a little bit further by starting off with hepatic artery stenosis there are two papers out there one out of Pittsburgh when I was one out of Rochester New York when I was in Rochester New York where they

actually followed up hepatic artery stenosis without treating them without giving them any anticoagulation and its proven that they actually thrombosed with time now what is what what does that have an effect on the liver or not that's

actually that's actually controversial some thoughts is if it narrows down over time does that allows time to kind of create the collaterals and the liver transplant does well and some some people don't

and hence that's the kind of indication of whether you should angioplasty it or not but this it's proven over time about sixty-five percent of them will thrombose within six to twelve within six to twelve months if you don't anticoagulate these patients this is

an example of a stenosis at proximal hepatic artery and to about two and a half months later it basically thrombosed almost complete thrombosis and then later on actually thrombosed completely right at the stenosis. so

hepatic artery stenosis are actually categorize depending depending on the depending on the location there's a surgical and anastomotic right at the anastomosis those are usually technical proximal hepatic artery stenosis that's

basically on the recipient side not on the graft side and is proximal to the arterial anastomosis and then distal hepatic artery stenosis which is distal anastomosis that's the graft side on the liver graft side and

that's sub classified into intrahepatic and extra hepatic distal arterial stenosis hookups in other words the anastomosis there were two anastomosis that actually varies considerably from one place to another and within the same institution you can

get direct aorto hepatic artery conduits and you can get a group of visceral end-to-end anastomosis so to to your to your left is a conduits this is an infrarenal aortal hepatic conduits you can also get rarer

types as a supraceliac to hepatic hepatic conduit. this is very important so if you're doing an angiogram on these patients it is very bad form to do a celiac axis and on this patient for example where where you actually will

diagnose sorry excuse me see this if you actually select that celiac axis you will actually come up with the diagnosis of vericose thrombosis because you don't know your anatomy so it's very bad form to not

know your Anatomy before you do your angiogram so always do an aortogram always look at the surgical anatomy to actually go to find out find find this and I've worked with very good techs that I've seen telling physicians you know this is

not the anastomosis that's not a thrombosis you need to do an aortogram you need to instead of doing us using a or a cobra up here use a verte to get into this and actually do a proper a proper angiogram of this so it's very bad form

to do that so you need to know your Anatomy you need to know the anatomy of the graft before you commence on any diagnostic diagnostic angiogram to diagnose whether its hepatic artery stenosis or thromboses this is a typical end to end

hepatic artery to hepatic artery anastomosis and that's the kind of most common one especially in the United States but you can get it off the off the GDA not off the hepatic artery you can get it even off the splenic artery so

you can get it all sorts and also all sorts of ways even off a replaced. so this is an example I didn't draw out but it's actually an example of a replaced hepatic artery and this is an end to end with a replace hepatic artery again

if you go after the celiac you'll diagnose it as thrombose it doesn't exist when it's actually off the SMA so know your Anatomy know your Anatomy very well as far as presentation of stenosis actually depends on the type of the stenosis most

of them present three to four months after the transplant however proximal ones in other words on the recipient side they present earlier and the theory behind that is that that's something to do with the transplant that's that's a

preexisting stenosis that a native liver tolerated and a transplant liver is far more sensitive and susceptible to ischemia is a far less forgiving organ so it actually exposes the narrowing that already pre-existed and

that's why they present they present earlier also when you look at especially institutions that use conduits it's not how I drew it out the first time it's not just one hose it's actually patched

up hoses they're usually venous or arterial ileacs so the more the patching the more the anastomosis so just statistically institutions that use conduits they have more anastomosis so the more likely to have an astomotic

stenosis right it's three times the number on this drawing of the anastomosis. as far as the cause or the etiology of these stenosis surgical anastomosis are usually technical usually a problem with clamping over sewing in

angulation and surgery proximal like I said they're pre-existing problems either arteriosclerotic disease for example arcuate ligament syndrome proximal clamp injury most of these are just diagnosis as anastomotic strictures or distal

clamp injury and then this intrahepatic leave is usually a graft problem usually a graft issue the rejection ischemia or or infection but it's usually an infection and ischaemia problem micro vascular kind of vasa

vasorum ischemia and this is a this is a good example of a proximal clamp injury and an anastomotic stricture and a distal cramp injury so they clamp on both sides and they suture you in the middle they had a suture problem and

they also had a proximal and distal clamp injury so these kind of three tandem strictures there. so a management

of hepatic artery stenosis is just looking at the literature it is on it's now dominantly done with angioplasty sometimes with

stenting but angioplasty. early on it was surgical revascularization but as we got better in IR managing these patients angioplasty has shown to be pretty pretty effective typically use a long

sheath just your typical you know

mesenteric renal visceral angioplasty and stenting usually abraded or reinforced sheath ninety-seven percent it's femoral you can actually try radial as well so sometimes we do switch to a radial or an axillary approach for

celiac angulation guidewires you can use anywhere from a former 0.014 inch platform up to a 0.035 inch platform most people there that do a lot of this will probably use a 0.014 or a 0.018 platform to angioplast and usually usually

coaxial balloons sometimes monorail as well especially on the a14 system adults and balloons usually range between four and six millimeters and when you're using stents also balloon expandable stents usually four to six millimeters as well

on the adult side don't forget to have prednis and always make sure that there's nitro in the room because actually spasm is not is not uncommon so whenever you embarking on an angioplasty on a transplant make sure that you got

heparin in a room TPA is at hand but not necessarily mixed and nitro is mixed and ready at hand because the vessels will spaz and then go into thrombosis very quickly before the even nitro goes in. this is an example of of

an angioplasty and typically in experienced hands we kind of tiptoe across this with a with a 0.014 to 0.018 soft wire with a micro system and then exchange that 0.018 soft wire with a stiffer platform usually a 0.014 kind

of like spartacores for example or a command wire not too stiff but but not too soft too either so spartacores and command whar's not necessarily like a V 14 or v18 those are very very stiff especially in a torture system you lose

you'll lose access and we sequentially dilate you don't have to sequentially dilate but you not uncommonly you will find yourself you know shy you know trying a small size we don't want to rupture the anastomosis try a small size this here

it's a four millimeter balloon repeat the angiogram it looks a lot better and then we followed up with a six millimeter balloon and it looks a lot better afterwards this is an example of a right adults

right split graft such as a living related transplant so there is no left hepatic artery and an anastomotic stricture that we that we angioplastied this is actually after the angioplasty looks pretty good but in

between this is what you had we have dilated with a five millimeter balloon and this is typical. lots of spasm everywhere use some nitro to actually and I'm going to repeat that again the spasm everywhere and use some

nitro to to to relieve the spasm and this kind of post angioplasty and post nitro if there is significant spasm where the hepatic artery truncates you actually don't know what it is it could be spasm it could be a dissection and it

could be thrombosis and it could be all three and so you're you're you're just it's going to be a guess of using TPA it's usually if it's in a bad situation you're actually using TPA you're asking you nitro and you

angioplasty you're just trying to open up this vessel it's quite a quite a stressful situation where you actually don't know what you're dealing with they all look truncated you don't know if its a dissection thromboses or spasming you just

hoping for the best and and using whatever you can to to open this up the problem with this with TPA and nitro any medication on a vessel that's really spastic in the visceral this is not a lower extremity. lower extremities they're

end arteries they have nowhere to go except the foot. here if you inject nitro or Hep or TPA you'll actually go into the splenic artery or just diverge to the spinal artery because the other side of spasms the artery that's really in need

the spastic or thrombosed doesn't get the medication so it's not that effective you have to be really up close and personal to the spasm to actually relieve the spasm with nitro or at reverse or you know reverse the thrombosis

with TPA. this is another example the one

I showed you earlier with the replaced hepatic artery and this is kind of a magnified up view of it and I'll show you the anatomy here this is a proximal clamp injury this is not anastomotic

it's not anastomotic because that's actually the size mismatch you actually pick up on on the where the anastomosis usually is the easy ways of size mismatch. okay so this is actually a proximal clamp injury we cross it again with a with a

micro catheter a microwire put a wire in and basically angioplasty it with a balloon to relieve it you will find that there's a focal non flow limiting dissection which is fine that usually would remodel that's

kind of your pre and post your pre and post images right there. when it comes to

the results overall it's about eighty percent success rates and about a ten twelve percent complication rate. so there's a pretty high complication rate

it also depends on the lesion selection so the best ones are solitary lesions are anastomotic multiple lesions or problematic distal lesions are problematic and most importantly lesions that are associated with kinks are problematic

your wire will dig into the kink you'll cause dissection spasm on thrombosis down that rabbit hole which we talked about you know with with thromboses the section and spasm but overall the success rate is around eighty percent

those institutions or series that boast a hundred percent success rate those are very selective you know they've selected out these lesions very carefully making them sing solitary anastomotic strictures only. Patency

rates ranges about fifty to sixty five percent unassisted that means without any more angioplasty with assisted multiple angioplasty's reaches up about eighty percent at 12 to 24 12- 24 months when it comes to stents it's

very similar results angioplasty versus stenting believe it or not the patency is almost almost the same especially the primary unassisted patency the restenosis rate is about thirty percent the thrombosis

rate is a little lower in the series because with stents we give anti-platelet medication and sometimes even anticoagulation most of the series with angioplasty they don't give anything afterwards but with with stents

antiplatelet medication and anticoagulation actually helps out with the with the patency rates remember that if you if you don't treat these lesions sixty-five percent of them will thrombose so compared these these thrombosis rate

at six to twelve months of seventy percent eighty percent which is not treating it at all sixty-five percent

restenosis rates of hepatic artery stenosis after angioplasty notice that

afterwards it's actually stable most of the recurrences occur one and a half to six months after the lesion after the lesion has been angioplastied after after that usually restenosis will not occur when you actually place stents on this

it's actually the same restenosis rate the only difference is that the the graph shift is towards the right in other words it's the same restenosis rate on the long run it just takes a longer time to re-stenose based on

this we usually get a doppler ultrasound after the angioplasty or stenting within 48 hours and then at one month at three months six months and then as clinically indicated so that's your protocol after an angioplasty or

stenting with following up with doppler ultrasound and about sixty-five percent of patients will either normalize or improve their Doppler parameters usually relying on a resistive index of about 0.5 or fifty percent the same 0.5 is

50% that's depending on the lingo that

at you this case is actually from UVA and we basically told the surgeons we don't want it we don't want to treat this if the anastomosis angulated is

right at right at right at an angle there we don't want to do this this is a high-risk case we will actually cause spasm or dissection and they insisted that they do it which we're fine with we just need to

make sure that they have been they're insisting on it and then and know and know that the risks you know it's a game we play so know that it's a high-risk case and we actually angioplastied this patient and actually did this patient

did very well angioplast same way micro catheter across put a stiffer wire once your cross with a micro caster and then and then angioplasty it and it looked good patient recurred multiple times but we and we angioplastied them again began

and they they did very they did very well just to clip through the images here just to show you and your planning that whole area sometimes you don't know exactly where it is notice that spasm see that corrugation their typical and

that's kind of your final final image and the spasm will will go down a lot after you take that stiff wire out and always remember not too stiff level of a wire especially with tortuosity and angulation you'll lose access you will

cause a lot of spasm too. patient recurred as its recurrence a lot better from the original recurred within within about a month and a half two months and we angioplastied the patient again. talked

about stenting. this is the third time here

look that's a third restenosis so talked about stenting stenting is not is not good this is a stricture right at the right at the anastomosis so the problem with stenting on the turn is that when you put the stent in it propagates so he

deploys stent like that and a vessel that's really floating the angulation redundancy actually propagates around us and then you jail the stance and then you then you then you're in a lot of trouble okay because you can't get

around and get into the stents anymore so you have to be very careful in putting any any stents in a sharp turn in a hepatic artery if you're forced to do that the best thing is to put a self-expanding stent and to buttress the

artery itself and then put a balloon expandable inside of it just to to take that curve and try to straighten out that curve instead of putting a short balloon expandable standard just jails and the redundancy just

basically curls around the stent like i drew it out initially hepatic artery thrombosis usually seen

either non visualization of the Patrick auditory or very low resistive indices sometimes you do have normalized

resistive indices in the settings of pedagogue from Bose and I'll show you that and that's because of that's because other collaterals and always remember in Doppler these are sensitivities and specificities so most

institutions use 0.5 as as the as the bench to actually call something something's actually going wrong with this but it's not specific there are a lot of reasons to that Nazi resistive index and hepatic artery can happen

including snows east on boses and arterial portal fish camps on Melissa's rejection but I said that's a historic that's a historic matter for years the

United Stettin transplants countries of the world with the United States and

Japan the Japanese transplanted in one way the Americans transplanted another way japanese for cultural reasons transplant and living related transplants they did not transplant cadaveric Americans transplanted

cadaveric whole grafts okay so for years the Japanese did it one way the Americans it another way the so the US experience the only time the US did split grafts were on kids because they're small graphs more people or

levels so we actually split their graphs and so for the years in the United States we found that there was hepatic artery thrombosis and kids it was a lot more common in kids but at the same time kids tolerated hepatic artery thrombosis

a lot more than adults that was the going going theme more likely to have pathetic cards from boses but also more likely to tolerate it than an adult okay and we put that on well their kids they tolerate a lot their their bodies bounce

back they swarm collab so this is that this is an adult versus kid thing when we started in the u.s. transplanting split graphs on adults we found the same thing a high thromboses rates but tolerated but tolerated

hepatic guards from boces just as well as kids so this is not a child versus adults compare problem this is a split graft versus whole graft problem okay so we found that by trial and error so but graphs are more likely to thrombosed and

but more likely to have tolerate thrombosis because of collateral formation while bowl grafts whether adults or kids actually are less likely from bos because they have bigger vessels and more intact vessels and less

complex anatomy and reconstruction of the artery and but they are more they are less likely to form collaterals and are more likely to not tolerate a category 2 imposes and here are the theories why to your left is a whole

graph to your right as a split graft on adults shall we say the stump of the whole graph is actually a lot longer the anastomosis is a good distance away from from the transplant the stump on its split graphs a lot shorter shorter

distance easier collateral bridging longer distance more difficult collateral bridging so you actually get a lot of immense momentum sorry get a lot of momentum up here and a lot of mesentery a lot of five roses in this

area that actually that actually helps them so it's a short bridge it actually gets penetrating collaterals here instead of this long distance it's a lot a lot difficult to form to form

split graft this is the this is something that you actually find collaterals there again on the omentum this is not Michigan upside down this is actually just from this is just from from boces 5 Rosen and

and basically collagen formation at the hilum where all these and AXA Moses and surgical connections are made whether its ability connection or arterial and venous connections and that five roses and scoring actually is a good medium

for collaterals in a split graph it's a larger territory there's actually a cut surface with a lot of collaterals as you can penetrate through the cut surface and that's another reason why split graphs do a lot better they promote they

have a nice large area territory for collateral formation so they do very well in this is the cut this is from boses cut service in the HGC collaterals going through the cut service from a fennec branch and reconstituting the

hepatic artery in traumatically hepatic

historically traditionally they say it presents with equal in equal prevalence either as Foreman on liver failure death or retrans plantation or billary

complications or some fever due to micro abscesses however over over over all the moat the one that's prevalence is billary why because the formula to Patek failure either dies or gets three transplanted so you start from zero and

the abscesses either progress the full monty patek failure and die or get we transplanted starting from zero or they progress into the liver disease so as a population it is very complications as how they is the most prevalent thing

with a category with a pedagogy thromboses always remember i touched up on this a little earlier is that in the setting of normal quote unquote doctor doctor old sound but this tissue breakdown or blurry complications get an

angiogram and not a Doppler even if the Doppler is normal because sometimes it's a Patek orissa noses on thrombosis with a reconstituted artery so you do a Doppler it looks normal but there's actually ski Mia ischemia and so this

actually increases the sensitivity and specificity and this is what surgeons actually do they'll do a Doppler it looks normal but delivers acting funny there's ischaemia this tissue breakdown their

ability complications let's get an angiogram and that's what that's

a of a right an adult's right lobe transplant with a with a normal dollar but this tissue breakdown by loma xin

prank may get an angiogram and this is actually the same patient and you see this complete thromboses it's actually a conduit so did an angiogram notice at the bottom it looks like it's from bos but it's actually from the cilia catch

you go down doing it doing it in your oh grandma this actually is from Bose that's where the conduit is frantic artery shows reconstituted reconstitution of the interpreter corey through through collateral so remember

even normal doppler but in the presence of a liver that is acting up tissue breakdown berry complications that look ischemic check with an angiogram and not a Doppler Doppler has its pitfalls

lomas PTC complications that a drainage and this is the patient actually had a narrowing and we angioplasty impatient

we're not very good at this okay only only really when you force it on us

especially on conduits would we actually do this very rarely are we successful with visas usually would be successful with an aortal hepatic conduits and not an antenna or convert why for the same reason I talk to you about the TPA and

the Nitro if you're going to put the TPA in the celiac axis a usual just divert into the splenic but if it's a conduits it's just like a leg it's an end artery there's nowhere except the liver there's no alternative so we can actually like

these and that's why we're more successful with a direct a order of hepatic conduit hose that ends in the liver there's nope no side branch where the our medication goes preferentially somewhere else and so that's those are

the ones where somewhat successful with and if one of the first things that you should do is actually go through the clock get into the liver and do an angiogram and see if their branches if you see branches are

open that's usually a good sign that means you have you have good outflow you have them from bos into the small vessels so once you're through there that's usually a good sign your lice overnights you can and you jes and like

in any man-made human-made conduits you have to look for underlying arterial defects there are any underlying ordeal arterial defects just like a fistula declawed you have to angioplasty be an Eskimo ZZZ ZZZ narrowings older patient

will come back again with thrombosis to the angioplasty and stent any underlying narrowings so somewhat somewhat successful with those in very very selective cases but not terribly excited

splenic steal syndrome I mean splenic steal syndrome is actually quite a complicated diagnosis usually diagnosis of exclusion some people actually don't believe in it some people believe in it again historically for years the

Japanese and the Americans did not believe in it okay the Germans built their career on it okay for some reason Germans and their cousins whether the twists of the Austrians they built their careers on it the Americans and Japanese

under called it they did not they did not believe in it now the world is becoming a smaller place there are more and more American centers that are actually starting to believe in it a little bit more but not the expense of

of what was the Germans talk talk about it's a traditional name is splenic steal syndrome based on that is the spleen is large and it steals blood from the form of the transplants so it's basically slow arterial flow but slow arterial

flow that is caused by a lot of things it could be an anatomical defect stenosis from boces or kinks or it's a patent think so noah syndrome it basically includes anything that causes slow flow in a category without an

underlying without an underlying anatomical defect and there's a lot of reasons some of it is arterial feel some of it is rejection idiopathic some of it is compartment syndrome a large sub capsular hematoma that's

actually putting a sub capture liver hematoma that's actually putting pressure on the liver kind of like a page kidney and compressing the liver would actually reduce flow in a paddock rd so there are many many reasons some

of them are idiopathic this is kind of

an example of an extreme case where in where the portal venous phase actually catches up with the hepatic artery angiogram you know goes to the spleen and back and the portal vein is running

parallel to the parallel to the back door and that's very very slow flow differential diagnosis for that would be an arterial portal fistula right because you'll see both the portal vein and an order next one of how do you

differentiate that with a fistula the order or the contrast actually goes all the way to the spleen and back so that's not that's not a fistula this is just portal venous phase angiogram and you still see the artery on a category in

the portal venous phase of the of the answer I'm very very slow flow in a paddock artery so one of the theories of this is like I said as the spleen is very large it steals blood from the from the liver you can also get GTA steel

that's a GD a artery that's open is very large that's a rare type that steals blood also from from the from the liver and those those are basically bicycle types and the treatment for that is splenic artery embolization sometimes

they stink grafts narrowed stent grafts and the in this planet Kadri however

than that it is not just pure steel and that's why we're kind of gravitating away from using the term splenic steal

syndrome and again it goes back to history and against a small world the Germans talked about splenic seal the screen is stealing blood from the liver the Japanese we're talking about there's too much flow in the portal vein and

they were actually talking about the same thing and I'll show you what's going on here celiac axis gives you at Baddeck artery gives you a splenic artery to the spleen but the spleen then dumps the blood into

the portal circulation the portal circulation goes back to the paddock artery okay in this in the case of too much portal flow hyperdynamic portal flow the hepatic artery actually slows down in a reflex response by what's

called the habber hepatic artery buffer responses which is a somewhat symbiotic system so in other words you increase the portal flow the Atlantic artery responds by dropping its by dropping its flow so this is a lot more complicated

than just simply stealing if you have too much flow going into the liver you basically will get a response by slowing down there by recorder II the Japanese we're talking about about about this the Germans were talking about stealing and

it's actually both okay and it could be a bit of both it could be it could be a combination of both and we still haven't figured that out so let me give you another layer of complexity to this in actuality this is a closed circuit it is

a balance on the arterial side of the house between the resistive index of the spleen and the resistive index of the liver if the liver the spleen is very large in stealing blood and the liver is diseased then blood will flow

preferentially to the spleen and that's a splenic steal phenomenon okay but it's two things at the same time things that would actually increase the resistance in the spleen in the liver and decrease the resistance of the Saline will tilt

it towards the spleen so it's a balance on two things on the arterial side of the house on the portal or venous side

of the house it's also a balance it is a balance of how much portal flow is going into the liver but it's also how healthy

that liver is so you can have normal portal flow that's not increased but the liver is crappy so it's normal it's it's relatively high flow for a liver that's disease and that's what japanese with talking is called small

precise syndrome in other words the liver is the graph is new and it's small for the size of the patients of the recipients undersized graft basically

into one which is called Noah syndrome

there's a lot a lot of moving parts it's a lot more complicated than just simply the spleen stealing blood from the erratic artery just food for thought on that one be it may or what I've just told you is academic the treatment is to

break the cycle it's a closed system so whatever the causes are the treatment is the same you break the cycle and the easiest place to break the cycle is the splenic artery and you amble I is approximately okay and we embolize it

with plugs coils and in in good diet well diagnosed cases is actually not easy to embolize the splenic artery you can put a coil and it literally will fly through distally to the spleen because the flow is very very high so try to put

a plug in and then some coils to follow up lines you can also put a stent in like an hour glass that's actually narrow it down or choke it alternatively surgically they will actually ligate it they'll let you go and ligate it or put

a ring the Germans have a rubber ring kind of like to put it on they actually do it prophylactically and up to twenty-five percent of cases in the US it's diagnosed in less than one percent of cases in Germany they diagnose it

twenty twenty-five percent of cases among that's what I'm telling you it's a big it's a big big thing if it's a GD a seal that's easy that means that's just the GDA embolization with coils this is

an example where we actually testing

things out trying to figure things out we actually put two captures a balloon occlusion capture and a diagnostic capture this is the angiogram here with slow flow in the paddock artery see that and then we actually do it balloon

occlusion test okay with the cancer adjacent to it and this is what you see so there's a test balloon occlusion before we commit to angioplasty and stenting with the doppler all sounds as well just to take a look at it

and so once it looks this is all research once it looks normal the portal vein actually slows down which is another intention is to slow down the portal vein we actually commit with putting quills and and plugs in this

kind of your posts your post results notice that the spleen is alive and well because it's actually reconstituted distally with a very large left gastric left gastric artery and that's why we embolize proximally we do not embolize

this lee we do not embolize particles this is not hyper spun ism for us to do particle embolization this is what you need is to impede flow you don't want to kill the spleen you don't want to reduce the spleen you all you tryna to is

impede flow cut that circulation that cycle so you can actually reverse that blood back to the back to deliver now in theory are you just stopping the splenic artery and diverting blood back to the liver based on the splenic field theory

or are you slowing down the portal vein and so you trying to reduce that kind of and trying to increase the category that's all theory based on the aetiology but either way breaking the cycle is the key thing to actually improve hip

adequate Irial flow whether it's a direct response or a or a reflex response to reduce portal vein I'm going

common some bleep some believe it or not

it's unfortunately self subjective criteria for for diagnosis diagnosing it and the key thing regardless of what the causes are which could be very varied and complex the key thing is to break the cycle and the easiest place to break

the cycle is Monica artery by embolize approximately next is hepatic arterial

injuries that includes arterial portals especially bleeding and ruptures and pseudo aneurysms okay so we just finished the occlusive disease and then

we moved to the noah syndrome which is non occlusive but slow flow and now we're talking about the third category of hepatic arterial complications and transplant which is injuries some sort of injury in the

india pata carter e the most likely or most common call a prevalence injury is an arterial portal fistula not a pseudoaneurysm and not bleeding for the same kind of theories behind the how hepatic artery presents because if

you're bleeding you either die or you stop bleeding and or and if you have a pseudoaneurysm you probably die or stop bleeding and so what's more prevalent as a population the people that survived all their arterial portal officially

those are the people that actually survived or the others have been fixed some way so our tiruppur official the most prevalent okay and just looking at biopsies biopsies is a common cause of intra Pat exceeding aneurysms and most

common as the most common cause of or to report officially just looking at either animal studies or actually human studies about a four point two percent four to five percent risk of some sort of injury that happens and this is the whole list

and this is what I was talking about contusions and extravagan is usually acute it stops or they die and pseudo androgens are about the same thing in the most common prevalence on the long run is arterial portal or to report

officially this is an example of a

biopsy on up to a coaxial and then you get you get bleeding you know the residents and fellows running around panicking this blood coming out of the thing what do you do put your thumb on

it what do we do now what do we do now and and let's get some oils and we're going to coil that track just like they did before right well there's no rush you're in a portal vein not an artery we actually put a manometry on this and did

a pressure measurement ok so we squirted the square root of it which is what this is see you've got a program and so you're in portal vein we actually got pressures out of it so might as well the injuries there take the opportunity to

make a diagnosis okay and and you actually did a pressure measurement of the portal vein next is a joke but we also got instead of a biopsy we also got a porta gram and we've got a pressure measurement out of it just good

for car payments so so just take the opportunity injuries happen there's no point burying it or hiding it we did the diagnosis and then we basically coil we basically coil our way out now arterial

portal officially again these are the

most common type and they come in all sorts of sizes i'm going to skip through this they come through all sorts of sizes in theory native livers okay are more likely to form fish alize than transplant livers for some reason okay

theories behind that a transplant liver had basically has bad arterial flow anyway so that pressure of maintaining a biopsy tracks between the archery and the portal vein keeps it open and actually grows it and develops it that's

one theory another theory is that a native liver is usually more compliant and softer okay so it's more likely to just stay open when a liver transplant liver is actually stiffer ins and may may have an issue with helping out

closing closing a transplant but most likely it is compromised of the LP of the hepatic arterial flow so transplants despite being under constant imaging surveillance are less likely to find out your portal Fisher than natives for some

reason like I said they come in all sorts of sizes is actually a whole spectrum of them from a small little miniscule one that means nothing two big ones this seal all the blood away from the from the graft the top ones actually

are not detected by Doppler they're detected by detailed angiography the bottom ones that are significant or detected by doctor so what do we match you the bottom two is actually progression over two and a half months

so which ones do we treat we treat the ones that are symptomatic and they present usually with ascites and liver dysfunction one of them one of the other or both we also treat big ones so how do we

diagnose or how do we define big ones a big one is usually it there are changes in Doppler on the portal site or to realization of the portal flow it becomes pulsatile reversal of flow in the main portal vein that's signs of the

hemodynamically significant one and that's what those are the ones that we actually go after in addition to the symptomatic ones so symptomatic you get treated asymptomatic but significantly hemodynamically would still go after or

like I showed you on the other one rapidly progressing ones because the bigger they get the more difficult it is to treat them because you're going to take out more and more arterial territory and the artery is important

for their paragraphs and we usually coil them imaging it's the same on Angira and geography and and and CT you actually see a portal venous phase blush on an arterial phase angiogram basically that's basically the diet of the

diagnosis so to the side here you actually see a portal venous phase blanching on the CT early in your aterial phase of the graft the graft the liver is in the dark but the area that's under the influence of the portal vein

is already portal venous face because this shunting right there and that's how that's how you pick up a arterial coral fistula okay and you treat it by basically emboli Xena's much as possible the key is not to shut it down

completely if you shut it down completely without any repercussions that's great but the key thing is just to impede flow to reverse the hemodynamic effects by Doppler which is the RT realization of the portal flow

and and the reversal of flow in the portal vein and there's just some examples of embolization successful

are not on are quite rare in some institutions are common for some for

surgical reasons but there's actually quite rare less than 1% there are two types there's intrahepatic and there nastik mathematic is quite dangerous that's kind of a grenade needs to get treated usually they're mycotic the best

way to treat them as surgery is not us okay we just do the diagnosis either by CT but in the case of emergency we contemporize things by amba lysing them or sting craft across them and I'm running out of time so I'm just going to

show you some cases so even in the setting of my kotik would actually put stent grafts in okay and then we leave it to leave it to the surgeons do you want to you know you want to fix this or do you want to just leave it as is

usually they will just leave it as is but in theory anastomotic ones are usually infected they're usually associated with by leaks they usually associated with sub hepatic collections with and usually those are by lomas

they're also associated with Barry and Tareq and asked Moses instead of ducted duct anastomosis those are more likely to leak as well this is an example of a

big light bulb in the middle of the abdomen and that's basically anastomotic

pseudoaneurysm that is a that is basically you know a bomb waiting to go off so you have to fix that and the best way to treat it by the book is because it's infected is a surgical as a surgical bypass extra anatomical okay

it's basically an aortal hepatic conduits and you don't do an end to end because that whole hilum is infected so you do it you to a conduits from from the aorta to the to deliver and it's usually you cannot use a graph it has to

be something native is it a vein or a vein or artery ms your typical class book textbook exam answer extra anatomic bypass in the real world we would temporize this with a sink raft or or with or with coils they're not

uncommonly associated with a paddock artery stenosis by the way

there is an endemic in certain institutions of pseudo aneurysms in the hepatic artery and the reason for that is ERCP sometimes PTC and billiard rains

but ers eps look at this hepatic artery running across and these are two plastic stents the bill redux are actually right up against it so in an aggressive ercp institution with with barbs you know these plastic sense come with barbs on

them what they do is every three months they'll go to that plastic then they pull it down and that barb rubs against the hepatic artery on its way down and then new one rubs up against a pat on the way up they keep changing and there

they're just rubbing up against that artery creating pseudo aneurysms so that's actually quite a common cause of that and you talk to GI guys they actually don't they actually don't know that because all they know they just see

through holes they don't know what's going on outside as a you know if they say if they see the world outside of that hole they'll they'll they panic which is a true statement like doing a scope like a colonoscopy and then you

find the perineum on the camera that's use not good so this is a this is just

an example angiography with these transplants is not very good it's been picking up suit mannerisms and this is this is an example of it which where do

you think is a pseudoaneurysm in this artery is it dis you know maybe that's the pseudoaneurysm right there you know is it here where is it because it's a surgical artery there are a lot of curves a lot of areas of mismatches you

don't know where the pseudoaneurysm is actually this patient does not have a pseudoaneurysm at all that's just hepatic artery okay so it's very important to get a CT it helps us out that at least know where it is along the

artery and then you do the angiogram the NGOs tweeting out for the diagnosis actually going in and trying to fix the problem so the answer that is CTU in with all these we'll bumps nooks and crannies you don't

really know just by an angiogram with pseudoaneurysm is you'll be embolization be amble icing anyway treating them is

usually by coiling stent grafts the rights by the book textbook is surgical bypass extra anatomical by pat's with

something that is native vein or artery and not a gore-tex graft for example that's the that's the best thing also another surgical equivalence is actually just ligate the artery that's also a very comforting thought going into doing

an embolization because if you're if one of the alternative is just a light gate the artery then you can just screw up the artery as you like right and just embolize it completely or let its pazzo from bos but anyway that is one of

that's actually one of the alternatives and sometimes we go into these cases and all we see is just an artery bleeding into the perineum we don't see anything else and we just coil that artery it's the alternatives or the ligation until

they mobilize and they do the bypass if they want okay so this is another

example of extensibility stent rubbing up against an artery and causing a pseudoaneurysm we actually stained grafted this patient so we try to sting

craft them if not oil if not call them but ideally we actually spent Grafton is kind of a complete blowouts where we act

and this is a case where completed this is another case where it's a complete blow at me just coil it stop the

bleeding save the patients and then let them handle the graphs where they're going to re transplant or do a bypass so

that's another option always remember another case another very stamp same theme rubbing up against the artery

causing a pseudoaneurysm so it's if there's a stint in there there's been a lot of many relations with its a metal stent or whether it's classic stents always look around that stance because that's where the student has amused is

okay with that stent rubbing up against the artery almost always this is a

stance this is an aneurysm this is where actually would put two I cast those are balloon expandable sensory angioplasty impatient did very well give them

antibiotics because in theory it's and infected mycotic aneurysm and the patient did

complete blowout where we put stent grafts balloon expandable stance

deployed them and save that patients save that patients life actually this one they didn't we well they were stable but they were brain-dead on this particular patient so that we were a little bit too late on that one this is

another case where we followed up where where you see the pseudoaneurysm go away and the hematoma goes away with time they do actually they actually do very well okay

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