Treatment and outcomes of early hepatic artery thrombosis after living donor liver transplantation: 10 years of experience

Early hepatic artery thrombosis (eHAT) after living donor liver transplantation (LDLT) is associated with impaired graft function and reduced patient survival. In living donor liver transplantation (LDLT), the incidence of eHAT is higher compared with deceased donor liver transplantation (DDLT). The main reason is that the hepatic artery of the graft in LDLT is typically smaller in diameter, and the recipient arteries used for anastomosis are often selected from more distal segments, which are likewise of smaller caliber. In the present study we defined eHAT as HAT occurring within the first postoperative week after LDLT, as cases developing during this period may still be amenable to surgical intervention with thrombectomy and reanastomosis. This study aimed to evaluate incidence, management strategies, and patient/graft outcomes of eHAT after LDLT over a 10-year period. All LDLT recipients treated between January 2013 and May 2023 at a single center were retrospectively reviewed ( n = 2257). Patients with eHAT within 7 days were identified ( n = 64). Six patients were excluded because primary hepatic artery reconstruction could not be completed at the index transplant due to subintimal dissection. The remaining 58 patients were analyzed for demographics, revision strategy, success of revisions, need for re-transplantation, and survival outcomes. Overall incidence of eHAT after LDLT was 2.5% (3.1% in children; 2.4% in adults). Median time to diagnosis was 1 day (range 0–7). Thrombectomy with reanastomosis was performed as first-line treatment in 46 patients, achieving arterial salvage in 50%. Re-transplantation was required in 14 patients after failed thrombectomy/reanastomosis and was performed as primary treatment after HAT in 8 patients. Three patients were not operated on due to poor clinical condition. One- and five-year patient survival was 50% and 45% after thrombectomy/reanastomosis versus 67.9% and 54.4% after retransplantation. Overall graft survival at 1 and 5 years was 24.1%. Early diagnosis is crucial in eHAT after LDLT. Thrombectomy and reanastomosis can be an effective first-line approach to salvage graft and patient, while prompt consideration of re-transplantation is warranted after failed revision. Our therapeutic algorithm can be summarized as prioritizing thrombectomy and reanastomosis, followed by retransplantation if revision is unsuccessful.