A proper reconstruction of afferent and efferent vessels is a sine qua non condition for successful liver transplantation. Reduced blood inflow due to technical problems often lead to early postoperative graft loss or long-term complications and need for retransplantation.1 Vascular complications ranges from 2% to 25% in most publications.2 Arterial complications prevail, and thrombosis is the most common. According to a systematic review by Bekker et al.,3 the incidence of early hepatic artery thrombosis (eHAT) was 8.3% in children and 2.9% in adults (p <0.001) with an overall retransplantation rate of 61.9% in children and 50% in adults. The overall mortality rate of patients with eHAT was 33.3% (range: 0% to 80%). Mortality in adults (34.3%) was higher than in children (25%, p <0.03). Thus, the determination of the preoperative vascular status of the recipient is mandatory, as well as in the donor organ. Given that the vascular status of the donor organ is not always possible to assess preoperatively, a very careful harvest of the organ is necessary for optimal transplant revascularization due to the multitude of arterial variants and pathologic changes in the afferent liver vasculature.
Embryologically, the hepatic artery develops late in the gestational period; therefore, anatomic variants are found in a large proportion of the population (33% to 45%).4 The most frequent situation is a common hepatic artery arising from the celiac trunk to form the gastroduodenal and proper hepatic artery, divided next into left and right branches (Fig. 71-1). The following anatomic variations2 in frequency are an accessory or replaced left hepatic artery originating from the left gastric artery or an accessory or replaced right hepatic artery arising from the superior mesenteric artery (Fig. 71-2). Less frequently, the common hepatic artery arises completely from the superior mesenteric artery (4%) (Fig. 71-3).
Normal anatomy. The common hepatic artery arises from the celiac trunk to form the gastroduodenal and proper hepatic artery, divided next into left and right branches.
An accessory (A) or replaced (B) left hepatic artery originating from the left gastric artery and an accessory (C) or replaced (D) right hepatic artery arising from the superior mesenteric artery.
The common hepatic artery arising completely from the superior mesenteric artery.
There are several options for the arterial anastomosis, depending on the diameter and length of the vessels, as well as anatomic variations. Prior to initiating the anastomosis, the preparation of the arterial ends is mandatory. Size mismatch between the graft and recipient artery is frequently encountered, and in most cases ...