Chapter 70: Arterial Grafts

INTRODUCTION

Arterial flow is essential for the allograft in orthotopic liver transplantation (OLT). The recipient hepatic artery (HA) or celiac trunk is usually suitable for standard revascularization of the liver graft. When the recipient’s celiac trunk is not appropriate for arterial anastomosis, a conduit from the aorta to the HA is necessary. The use of arterial conduits in OLT with cadaveric donors is often not necessary; about 2% to 15% have been reported in adult patients.^1,2

Precise indications for arterial conduits usage are:^1,3,4

• Severe HA atherosclerosis

• Arcuate ligament syndrome

• Arterial injuries during liver procurement or recipient’s hepatectomy

• Donor’s anatomic abnormalities

• Arterial damage after thrombectomy

• Retransplantation

Retransplantation is the most frequent clinical situation where we need an arterial conduit.¹ When it is required, a conduit between the donor’s artery and the recipient’s aorta is used. In these cases, iliac arteries obtained from the same donor (preserved in preservation solution) or cryopreserved vascular grafts are used. We recommend that during liver procurement, the iliac artery and vein should be recovered. After that, the vessels are transported and preserved in HTK or Wisconsin solution. It is not well established how long these vessels can be preserved; it is generally advised to use them within 15 days after procurement (Fig. 70-1A and B).

Usually, alternative sources to place the arterial conduit are the:^1–3,5,6

• Infrarenal aorta

• Supraceliac aorta

• Thoracic aorta

• Iliac arteries

The most widely utilized place for an arterial conduit is the infrarenal localization.¹ To perform the conduit, we need to mobilize the colon and the small bowel. Next, we look for the inferior mesenteric vein and the root of the small bowel mesentery and identify the beating of the aorta. We start dissecting the anterior surface, identifying the inferior mesenteric artery and some lumbar branches. The aorta is exposed and partially clamped with a Satinsky clamp. After that, the aorta is opened and the anastomosis between it and the grafts is fashioned with a running 7-0 polypropylene. Later, we need to tunnel the conduit through the mesocolon. In this manner, it is anterior to the pancreas, behind the stomach, to the left of the duodenum, and to the right of the colic vessels.⁷ This route (antepancreatic) is utilized to avoid the retroperitoneal varices and decrease the surgical bleeding. Once the graft is positioned, the anastomosis between it and the liver arteries can be performed (Figs. 70-2 through 70-5).