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Transplant Liver Procedures
Brandt C. Wible, MD; Matthew B. Wilkinson, MD, PhD; Lee S. Cummings, MD
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KEY FACTS

  • Terminology

    • Procedure

      TERMINOLOGY

      • Definitions

        • Orthotopic liver transplantation (OLT): Replacement of diseased native liver with donor allograft in same anatomic location
          • Living donor liver transplantation (LDLT)
            • Donor graft liver is partial
            • 10% overall complication rate
          • Deceased donor liver transplantation (DDLT)
            • Donor liver harvested with donor inferior vena cava (IVC)
            • 8% overall complication rate
          • OLT surgical technique
            • Piggyback technique
              • Donor liver anastomosed to recipient hepatic veins (not recipient IVC)
              • Donor IVC inferior to liver surgically ligated & not anastomosed to recipient
              • Allows continuous patency of recipient IVC during transplantation
              • 4 total anastomosis
            • Bicaval technique
              • Donor IVC anastomosed end to end or end to side to recipient IVC
              • Flow through recipient IVC interrupted during transplantation; can negatively affect renal function
              • 5 total anastomosis
            • Cavocavostomy
              • Side-to-side anastomosis between recipient & donor IVC
              • Rarely performed
            • 4-5 anastomoses are surgically created in following order, each with well-recognized complications
              • Hepatic veins/IVC anastomosis
              • Portal vein anastomosis
              • Hepatic artery (HA) anastomosis
              • Common bile duct anastomosis
        • HA complications
          • Most common posttransplantation vascular complication (5-25%)
          • HA anastomosis: Carrel patch, typically involving donor patch of aorta & recipient patch from HA bifurcation
          • Variable dependent on size & health of artery; can be located more proximal on donor side as needed
            • Read operative transplantation report
          • Predisposing risk factors for complications
            • Donor age > 60 years, variant arterial anatomy/small arterial size, extended cold ischemia time, CMV-positive donor status, hypercoagulable state in recipient, recipient tobacco use, primary sclerosing cholangitis, rejection
          • Diagnostic evaluation: Typically start with Doppler US of HA (92% accuracy rate)
            • Normal: Continuous diastolic flow, sharp systolic upstroke; resistive index (RI) = 0.5-0.8
            • Abnormal: Absent diastolic flow, peak systolic velocity (PSV) > 200 cm/s, dampened & prolonged systolic upstroke (i.e., tardus parvus); RI < 0.5
          • HA thrombosis: Most frequent arterial complication (> 50%)
            • Incidence: 5% at 30 days; 19% at 1 year
              • Adult liver transplantation: 4-12% incidence
              • Pediatric liver transplantation: 40% incidence
            • Early (≤ 30 days) thrombosis: Retransplantation often required, mortality rate up to 58%
            • Late (> 30 days) thrombosis: 1/3 do well without intervention; others develop biliary necrosis/abscess
            • Treatment options (early & late)
              • Catheter-directed thrombolysis (CDT)
              • Underlying lesion may require angioplasty/stent
          • HA stenosis
            • Incidence: 5-13% of liver transplants
              • Median time to presentation: 3-7 months
              • Majority are anastomotic stenoses
            • Clinical signs & symptoms are variable
              • Asymptomatic, liver function test abnormalities, bile duct stricture, sepsis, acute liver failure
            • Untreated HA stenosis results in
              • 65% HA thrombosis rate at 6 months
              • 2x ↑ in biliary complication rate; abnormal cholangiogram in up to 67% of patients with HA stenosis
            • Treatment options
              • Angioplasty & stent placement
          • HA pseudoaneurysm (PSA)
            • Rare occurrence after liver transplantation
              • Most occur within 1st postoperative month
              • If extrahepatic may be mycotic, anastomotic
              • High mortality rate if untreated
            • Treatment options
              • Coil embolization, covered stent PSA exclusion
              • Surgical resection, retransplantation in some cases
          • Splenic steal syndrome
            • Nonocclusive arterial hypoperfusion of liver with preferential celiac flow to spleen
            • Incidence: 4.7%
            • Predisposing risk factor may include pre-OLT ↑ splenic volume
            • Clinical signs & symptoms
              • Elevated liver function tests, cholestasis, thrombocytopenia, ascites, graft failure
            • Diagnostic evaluation: Seen during celiac arteriography
            • Treatment option
              • Splenic artery embolization, possible splenectomy
        • IVC complications
          • Anastomotic stricture or kink
            • Predisposing risk factors
              • Donor-to-recipient vessel size discrepancy, graft rotation, IVC kinking, tight suture
            • Effective treatment requires understanding of anastomotic anatomy used in transplant
              • Piggyback reconstruction: Preservation of recipient IVC with anastomosis of cuff formed from recipient hepatic veins to donor IVC
              • End-to-side/end-to-end/cavoatrial anastomoses require intraoperative veno-veno bypass
            • Clinical signs & symptoms
              • Hepatic congestion, ascites, hepatomegaly, lower extremity edema, abnormal liver function texts, pleural effusion
            • Diagnostic evaluation: Typically start with Doppler US
              • Normal: Triphasic IVC & hepatic vein waveforms
              • Abnormal: Turbulent flow at stenosis; > 3:1 PSV anastomotic to preanastomotic segment
              • Confirmatory venography: IVC venous gradient > 10 mm Hg abnormal; gradient < 10 mm Hg can still be symptomatic
            • Treatment options
              • Metal stents can provide long-term patency
              • Angioplasty less effective due to IVC elasticity
          • Caval obstruction: Incidence of 1-4%
          • Caval thrombosis: Incidence of 0.3%
        • Portal vein complications
          • Portal vein stenosis
            • Incidence: 0.3-3.7%
            • Can occur in perioperative period or years later
            • Clinical signs & symptoms
              • Portal hypertension in symptomatic patients (e.g., ascites, gastroesophageal varices)
              • Majority asymptomatic; detected on screening
            • Diagnostic evaluation
              • Typically start with Doppler US
              • Normal: Monophasic with respiratory variation
              • Abnormal: PSV > 125 cm/s; > 3:1 PSV anastomotic to preanastomotic segment
              • Confirmatory transhepatic portography: > 5 mm Hg pressure gradient significant for stenosis
            • Treatment options
              • Angioplasty ± stent placement
          • Portal vein thrombosis (PVT)
            • Incidence: 3-7%
              • Can be fatal for transplant & patient
            • Predisposing risk factors
              • Small portal vein size (< 5 mm), PVT noted at transplantation, reconstruction with venous conduit, prior splenectomy, redundancy, or tension of portal vein anastomosis
            • Treatment options
              • CDT (if thrombus detected early), stenting
              • Anticoagulation necessary; surgical thrombectomy should be considered
        • Biliary complications
          • Overall incidence: 23%
          • Biliary anastomosis: 2 potential types
            • Choledochocholedochostomy (ideally, donor common bile duct to recipient common hepatic duct)
            • Roux-en-Y: Used when recipient duct too short, narrow, or diseased (e.g., sclerosing cholangitis); donor to recipient duct size mismatch; ERCP not possible
          • Biliary strictures
            • Anastomotic strictures: Incidence 15%
            • Nonanastomotic strictures: Incidence 5-15%
              • Often multiple strictures present
              • Can result in transplant loss of 46% after 2 years
            • Predisposing risk factors
              • HA thrombosis, CMV infection, model of end-stage liver disease score > 25, primary sclerosing cholangitis, malignancy, donor age > 60 years, macrovesicular graft steatosis, duct-to-duct anastomosis, cold ischemic time > 12 h, use of T-tube, acute rejection
            • Clinical signs & symptoms
              • Fever, abdominal pain, jaundice, elevated liver function tests
            • Diagnostic evaluation
              • MRCP, cholangiogram
            • Usually occur within 5-8 months after transplant
            • Treatment options
              • Endoscopic vs. percutaneous drainage
              • Balloon dilation
              • Stenting (metallic covered retrievable vs. plastic)
              • Surgical revision
          • Bile leak
            • Incidence: 8.5%, (reported range: 1-25%)
            • Typically occur within 1-3 months
            • Early leak suggests technical issue; consider OR
            • Late leak suggests stricture, consider ERCP or percutaneous cholangiogram (PTC) ± percutaneous biliary drain (PBD)
            • Most occur at anastomosis or T-tube insertion site
              • T-tube use for biliary anastomosis stenting is associated with bile leak & cholangitis at removal
              • Routine T-tube use abandoned in many centers
            • Clinical signs & symptoms
              • Fever, abdominal pain, peritonitis
            • Diagnostic evaluation
              • Nuclear scintigraphy, cholangiography, aspiration of biloma
          • Bile duct stones, sludge, & casts
            • Relatively infrequent compared to leaks & strictures
            • Predisposing risk factors
              • Ischemia, infection, postoperative bile duct edema, CMV cholangitis
          • Treatment: Endoscopic, percutaneous, or surgical

      PREPROCEDURE

      • Indications

        • Contraindications

          • Preprocedure Imaging

            • Getting Started

              PROCEDURE

              • Procedure Steps

                • Alternative Procedures/Therapies

                  OUTCOMES

                  • Complications

                    • Expected Outcomes

                      Selected References

                      1. Addeo P et al: The learning curve for piggyback liver transplantation: identifying factors challenging surgery. Surgery. 169(4):974-82, 2021
                      2. Cambridge WA et al: Meta-analysis and meta-regression of survival after liver transplantation for unresectable perihilar cholangiocarcinoma. Ann Surg. 273(2):240-50, 2021
                      3. Kulik L et al: Therapies for patients with hepatocellular carcinoma awaiting liver transplantation: a systematic review and meta-analysis. Hepatology. 67(1):381-400, 2018
                      4. Li C et al: Current understanding and management of splenic steal syndrome after liver transplant: a systematic review. Transplant Rev (Orlando). 31(3):188-92, 2017
                      5. Copelan A et al: Iatrogenic-related transplant injuries: the role of the interventional radiologist. Semin Intervent Radiol. 32(2):133-55, 2015
                      6. Nemes B et al: Biliary complications after liver transplantation. Expert Rev Gastroenterol Hepatol. 9(4):447-66, 2015
                      7. Saad WE: Nonocclusive hepatic artery hypoperfusion syndrome (splenic steal syndrome) in liver transplant recipients. Semin Intervent Radiol. 29(2):140-6, 2012
                      8. Ayoub WS et al: Biliary complications following liver transplantation. Dig Dis Sci. 55(6):1540-6, 2010
                      9. Khalaf H: Vascular complications after deceased and living donor liver transplantation: a single-center experience. Transplant Proc. 42(3):865-70, 2010
                      10. Singhal A et al: Endovascular treatment of hepatic artery thrombosis following liver transplantation. Transpl Int. 23(3):245-56, 2010
                      11. Duffy JP et al: Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg. 208(5):896-903; discussion 903-5, 2009
                      12. Wojcicki M et al: Vascular complications following adult piggyback liver transplantation with end-to-side cavo-cavostomy: a single-center experience. Transplant Proc. 41(8):3131-4, 2009
                      13. Karakayali H et al: Venous complications after orthotopic liver transplantation. Transplant Proc. 38(2):604-6, 2006
                      14. Andrews JC: Vascular complications following liver transplantation. Semin Intervent Radiol. 21(4):221-33, 2004
                      15. Cotroneo AR et al: Stent placement in four patients with hepatic artery stenosis or thrombosis after liver transplantation. J Vasc Interv Radiol. 13(6):619-23, 2002
                      16. Hesse UJ et al: Hepato-venous reconstruction in orthotopic liver transplantation with preservation of the recipients' inferior vena cava and veno-venous bypass. Langenbecks Arch Surg. 385(5):350-6, 2000
                      17. Orons PD et al: Hepatic artery angioplasty after liver transplantation: experience in 21 allografts. J Vasc Interv Radiol. 6(4):523-9, 1995
                      18. Dodd GD 3rd et al: Hepatic artery stenosis and thrombosis in transplant recipients: Doppler diagnosis with resistive index and systolic acceleration time. Radiology. 192(3):657-61, 1994
                      Related Anatomy
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                      Related Differential Diagnoses
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                      References
                      Tables

                      Tables

                      KEY FACTS

                      • Terminology

                        • Procedure

                          TERMINOLOGY

                          • Definitions

                            • Orthotopic liver transplantation (OLT): Replacement of diseased native liver with donor allograft in same anatomic location
                              • Living donor liver transplantation (LDLT)
                                • Donor graft liver is partial
                                • 10% overall complication rate
                              • Deceased donor liver transplantation (DDLT)
                                • Donor liver harvested with donor inferior vena cava (IVC)
                                • 8% overall complication rate
                              • OLT surgical technique
                                • Piggyback technique
                                  • Donor liver anastomosed to recipient hepatic veins (not recipient IVC)
                                  • Donor IVC inferior to liver surgically ligated & not anastomosed to recipient
                                  • Allows continuous patency of recipient IVC during transplantation
                                  • 4 total anastomosis
                                • Bicaval technique
                                  • Donor IVC anastomosed end to end or end to side to recipient IVC
                                  • Flow through recipient IVC interrupted during transplantation; can negatively affect renal function
                                  • 5 total anastomosis
                                • Cavocavostomy
                                  • Side-to-side anastomosis between recipient & donor IVC
                                  • Rarely performed
                                • 4-5 anastomoses are surgically created in following order, each with well-recognized complications
                                  • Hepatic veins/IVC anastomosis
                                  • Portal vein anastomosis
                                  • Hepatic artery (HA) anastomosis
                                  • Common bile duct anastomosis
                            • HA complications
                              • Most common posttransplantation vascular complication (5-25%)
                              • HA anastomosis: Carrel patch, typically involving donor patch of aorta & recipient patch from HA bifurcation
                              • Variable dependent on size & health of artery; can be located more proximal on donor side as needed
                                • Read operative transplantation report
                              • Predisposing risk factors for complications
                                • Donor age > 60 years, variant arterial anatomy/small arterial size, extended cold ischemia time, CMV-positive donor status, hypercoagulable state in recipient, recipient tobacco use, primary sclerosing cholangitis, rejection
                              • Diagnostic evaluation: Typically start with Doppler US of HA (92% accuracy rate)
                                • Normal: Continuous diastolic flow, sharp systolic upstroke; resistive index (RI) = 0.5-0.8
                                • Abnormal: Absent diastolic flow, peak systolic velocity (PSV) > 200 cm/s, dampened & prolonged systolic upstroke (i.e., tardus parvus); RI < 0.5
                              • HA thrombosis: Most frequent arterial complication (> 50%)
                                • Incidence: 5% at 30 days; 19% at 1 year
                                  • Adult liver transplantation: 4-12% incidence
                                  • Pediatric liver transplantation: 40% incidence
                                • Early (≤ 30 days) thrombosis: Retransplantation often required, mortality rate up to 58%
                                • Late (> 30 days) thrombosis: 1/3 do well without intervention; others develop biliary necrosis/abscess
                                • Treatment options (early & late)
                                  • Catheter-directed thrombolysis (CDT)
                                  • Underlying lesion may require angioplasty/stent
                              • HA stenosis
                                • Incidence: 5-13% of liver transplants
                                  • Median time to presentation: 3-7 months
                                  • Majority are anastomotic stenoses
                                • Clinical signs & symptoms are variable
                                  • Asymptomatic, liver function test abnormalities, bile duct stricture, sepsis, acute liver failure
                                • Untreated HA stenosis results in
                                  • 65% HA thrombosis rate at 6 months
                                  • 2x ↑ in biliary complication rate; abnormal cholangiogram in up to 67% of patients with HA stenosis
                                • Treatment options
                                  • Angioplasty & stent placement
                              • HA pseudoaneurysm (PSA)
                                • Rare occurrence after liver transplantation
                                  • Most occur within 1st postoperative month
                                  • If extrahepatic may be mycotic, anastomotic
                                  • High mortality rate if untreated
                                • Treatment options
                                  • Coil embolization, covered stent PSA exclusion
                                  • Surgical resection, retransplantation in some cases
                              • Splenic steal syndrome
                                • Nonocclusive arterial hypoperfusion of liver with preferential celiac flow to spleen
                                • Incidence: 4.7%
                                • Predisposing risk factor may include pre-OLT ↑ splenic volume
                                • Clinical signs & symptoms
                                  • Elevated liver function tests, cholestasis, thrombocytopenia, ascites, graft failure
                                • Diagnostic evaluation: Seen during celiac arteriography
                                • Treatment option
                                  • Splenic artery embolization, possible splenectomy
                            • IVC complications
                              • Anastomotic stricture or kink
                                • Predisposing risk factors
                                  • Donor-to-recipient vessel size discrepancy, graft rotation, IVC kinking, tight suture
                                • Effective treatment requires understanding of anastomotic anatomy used in transplant
                                  • Piggyback reconstruction: Preservation of recipient IVC with anastomosis of cuff formed from recipient hepatic veins to donor IVC
                                  • End-to-side/end-to-end/cavoatrial anastomoses require intraoperative veno-veno bypass
                                • Clinical signs & symptoms
                                  • Hepatic congestion, ascites, hepatomegaly, lower extremity edema, abnormal liver function texts, pleural effusion
                                • Diagnostic evaluation: Typically start with Doppler US
                                  • Normal: Triphasic IVC & hepatic vein waveforms
                                  • Abnormal: Turbulent flow at stenosis; > 3:1 PSV anastomotic to preanastomotic segment
                                  • Confirmatory venography: IVC venous gradient > 10 mm Hg abnormal; gradient < 10 mm Hg can still be symptomatic
                                • Treatment options
                                  • Metal stents can provide long-term patency
                                  • Angioplasty less effective due to IVC elasticity
                              • Caval obstruction: Incidence of 1-4%
                              • Caval thrombosis: Incidence of 0.3%
                            • Portal vein complications
                              • Portal vein stenosis
                                • Incidence: 0.3-3.7%
                                • Can occur in perioperative period or years later
                                • Clinical signs & symptoms
                                  • Portal hypertension in symptomatic patients (e.g., ascites, gastroesophageal varices)
                                  • Majority asymptomatic; detected on screening
                                • Diagnostic evaluation
                                  • Typically start with Doppler US
                                  • Normal: Monophasic with respiratory variation
                                  • Abnormal: PSV > 125 cm/s; > 3:1 PSV anastomotic to preanastomotic segment
                                  • Confirmatory transhepatic portography: > 5 mm Hg pressure gradient significant for stenosis
                                • Treatment options
                                  • Angioplasty ± stent placement
                              • Portal vein thrombosis (PVT)
                                • Incidence: 3-7%
                                  • Can be fatal for transplant & patient
                                • Predisposing risk factors
                                  • Small portal vein size (< 5 mm), PVT noted at transplantation, reconstruction with venous conduit, prior splenectomy, redundancy, or tension of portal vein anastomosis
                                • Treatment options
                                  • CDT (if thrombus detected early), stenting
                                  • Anticoagulation necessary; surgical thrombectomy should be considered
                            • Biliary complications
                              • Overall incidence: 23%
                              • Biliary anastomosis: 2 potential types
                                • Choledochocholedochostomy (ideally, donor common bile duct to recipient common hepatic duct)
                                • Roux-en-Y: Used when recipient duct too short, narrow, or diseased (e.g., sclerosing cholangitis); donor to recipient duct size mismatch; ERCP not possible
                              • Biliary strictures
                                • Anastomotic strictures: Incidence 15%
                                • Nonanastomotic strictures: Incidence 5-15%
                                  • Often multiple strictures present
                                  • Can result in transplant loss of 46% after 2 years
                                • Predisposing risk factors
                                  • HA thrombosis, CMV infection, model of end-stage liver disease score > 25, primary sclerosing cholangitis, malignancy, donor age > 60 years, macrovesicular graft steatosis, duct-to-duct anastomosis, cold ischemic time > 12 h, use of T-tube, acute rejection
                                • Clinical signs & symptoms
                                  • Fever, abdominal pain, jaundice, elevated liver function tests
                                • Diagnostic evaluation
                                  • MRCP, cholangiogram
                                • Usually occur within 5-8 months after transplant
                                • Treatment options
                                  • Endoscopic vs. percutaneous drainage
                                  • Balloon dilation
                                  • Stenting (metallic covered retrievable vs. plastic)
                                  • Surgical revision
                              • Bile leak
                                • Incidence: 8.5%, (reported range: 1-25%)
                                • Typically occur within 1-3 months
                                • Early leak suggests technical issue; consider OR
                                • Late leak suggests stricture, consider ERCP or percutaneous cholangiogram (PTC) ± percutaneous biliary drain (PBD)
                                • Most occur at anastomosis or T-tube insertion site
                                  • T-tube use for biliary anastomosis stenting is associated with bile leak & cholangitis at removal
                                  • Routine T-tube use abandoned in many centers
                                • Clinical signs & symptoms
                                  • Fever, abdominal pain, peritonitis
                                • Diagnostic evaluation
                                  • Nuclear scintigraphy, cholangiography, aspiration of biloma
                              • Bile duct stones, sludge, & casts
                                • Relatively infrequent compared to leaks & strictures
                                • Predisposing risk factors
                                  • Ischemia, infection, postoperative bile duct edema, CMV cholangitis
                              • Treatment: Endoscopic, percutaneous, or surgical

                          PREPROCEDURE

                          • Indications

                            • Contraindications

                              • Preprocedure Imaging

                                • Getting Started

                                  PROCEDURE

                                  • Procedure Steps

                                    • Alternative Procedures/Therapies

                                      OUTCOMES

                                      • Complications

                                        • Expected Outcomes

                                          Selected References

                                          1. Addeo P et al: The learning curve for piggyback liver transplantation: identifying factors challenging surgery. Surgery. 169(4):974-82, 2021
                                          2. Cambridge WA et al: Meta-analysis and meta-regression of survival after liver transplantation for unresectable perihilar cholangiocarcinoma. Ann Surg. 273(2):240-50, 2021
                                          3. Kulik L et al: Therapies for patients with hepatocellular carcinoma awaiting liver transplantation: a systematic review and meta-analysis. Hepatology. 67(1):381-400, 2018
                                          4. Li C et al: Current understanding and management of splenic steal syndrome after liver transplant: a systematic review. Transplant Rev (Orlando). 31(3):188-92, 2017
                                          5. Copelan A et al: Iatrogenic-related transplant injuries: the role of the interventional radiologist. Semin Intervent Radiol. 32(2):133-55, 2015
                                          6. Nemes B et al: Biliary complications after liver transplantation. Expert Rev Gastroenterol Hepatol. 9(4):447-66, 2015
                                          7. Saad WE: Nonocclusive hepatic artery hypoperfusion syndrome (splenic steal syndrome) in liver transplant recipients. Semin Intervent Radiol. 29(2):140-6, 2012
                                          8. Ayoub WS et al: Biliary complications following liver transplantation. Dig Dis Sci. 55(6):1540-6, 2010
                                          9. Khalaf H: Vascular complications after deceased and living donor liver transplantation: a single-center experience. Transplant Proc. 42(3):865-70, 2010
                                          10. Singhal A et al: Endovascular treatment of hepatic artery thrombosis following liver transplantation. Transpl Int. 23(3):245-56, 2010
                                          11. Duffy JP et al: Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg. 208(5):896-903; discussion 903-5, 2009
                                          12. Wojcicki M et al: Vascular complications following adult piggyback liver transplantation with end-to-side cavo-cavostomy: a single-center experience. Transplant Proc. 41(8):3131-4, 2009
                                          13. Karakayali H et al: Venous complications after orthotopic liver transplantation. Transplant Proc. 38(2):604-6, 2006
                                          14. Andrews JC: Vascular complications following liver transplantation. Semin Intervent Radiol. 21(4):221-33, 2004
                                          15. Cotroneo AR et al: Stent placement in four patients with hepatic artery stenosis or thrombosis after liver transplantation. J Vasc Interv Radiol. 13(6):619-23, 2002
                                          16. Hesse UJ et al: Hepato-venous reconstruction in orthotopic liver transplantation with preservation of the recipients' inferior vena cava and veno-venous bypass. Langenbecks Arch Surg. 385(5):350-6, 2000
                                          17. Orons PD et al: Hepatic artery angioplasty after liver transplantation: experience in 21 allografts. J Vasc Interv Radiol. 6(4):523-9, 1995
                                          18. Dodd GD 3rd et al: Hepatic artery stenosis and thrombosis in transplant recipients: Doppler diagnosis with resistive index and systolic acceleration time. Radiology. 192(3):657-61, 1994