Biliary Leak With Tardus Parvus Arterial Waveform After Liver Transplantation
Year: 2012
Type: editorial
Abstract: American Journal of Transplantation Images in Transplantation—Continuing Medical Education (CME) Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace. This month's feature article is titled: “Biliary Leak With Tardus Parvus Arterial Waveform After Liver Transplantation.” Accreditation and Designation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians. Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Statement of Need Complications related to hepatic arterial inflow following orthotopic liver transplantation can be devastating to the allograft and require timely identification and management. This exercise will present a case that illustrates several learning points related to this topic. Purpose of Activity Improve the ability to diagnose and manage hepatic arterial insufficiency after liver transplantation, specifically in the context of a biliary complication. Identification of Practice Gap The accurate and timely detection of inadequate arterial flow to liver allografts can be challenging. Failure to identify hepatic arterial disturbances in the setting of a biliary complication will negate any attempts at correction of the biliary defect. Learning Objectives Upon completion of this educational activity, participants will be able to: Understand the importance of hepatic arterial inflow in liver allografts Diagnose hepatic arterial insufficiency using duplex ultrasound Appropriately manage arterial complications following liver transplantation, especially in the setting of concomitant biliary disturbances Target Audience This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation. Disclosures No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable. The following authors, editors and staff reported no relevant financial relationships with respect to this activity. Editor-in-Chief Allan D. Kirk, MD, PhD, FACS Editors Sandy Feng, MD, PhD Douglas W. Hanto, MD, PhD Authors Gregory R. Veillette, MD, Damanpreet S. Bedi, MD and Sandy Feng, MD, PhD ASTS Staff Mina Behari, Director of Education This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review. Instructions on Receiving CME Credit This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months. Follow these steps to participate, answer the questions and claim your CME credit: Log on to https://www.wileyhealthlearning.com/ajt Read the learning objectives, target audience and activity disclosures. Read the article in print or online format. Reflect on the article. Access the CME Exam, and choose the best answer to each question. Complete the required evaluation and print your CME certificate. A 49-year-old woman with end-stage liver disease secondary to hepatitis C and alcoholic cirrhosis underwent orthotopic liver transplant. Preoperative duplex ultrasound demonstrated slightly diminished hepatic arterial upstrokes. Both the donor and the recipient had conventional arterial anatomy. The arterial reconstruction was performed using a branch patch of the celiac axis and the splenic artery orifices on the donor side to a branch patch of the gastroduodenal and proper hepatic arteries on the recipient side. The distal gastroduodenal artery of the recipient was ligated and divided. Biliary reconstruction was achieved with choledochocholedochostomy using a running suture of 6–0 Maxon, because both ducts were relatively large (approximately 1 cm in diameter). The patient was diagnosed with a bile leak on posttransplant day 29, ultimately requiring revision to a Roux-en-Y choledochojejunostomy on posttransplant day 40. Duplex ultrasound demonstrated flow in the hepatic artery, but with tardus parvus waveform and elevated diastolic flow (Figure 1A). An abdominal aortogram was performed (Figure 1B) and resulted in an operative intervention. Duplex ultrasound of the allograft main hepatic artery (MHA) at the time of bile leak. Note the low amplitude waveform and prolonged systolic upstroke (tardus parvus morphology). Lateral projection aortic and visceral angiogram at the time of bile leak. Both the celiac (thick arrow) and SMA (thin arrow) demonstrate antegrade filling (A, aorta). What is the most likely reason this patient developed a biliary complication? Tension on the biliary anastomosis Inadequate hepatic arterial inflow Inadequate portal venous inflow Hepatic venous outflow obstruction Unrecognized pre-existing cholangitis Which of the following is true of the tardus parvus waveform seen on duplex ultrasound? It has a low flow velocity It has a prolonged systolic acceleration time It is a very accurate marker for detecting a proximal stenosis If found, it should prompt further radiographic evaluation All of the above What is the etiology of the abnormal arterial waveforms seen in this case? Atherosclerosis of the hepatic artery Acute hepatic artery thrombosis Hepatic venous outflow obstruction Extrinsic compression of the celiac axis (median arcuate ligament syndrome) Dissection of the hepatic artery Why are transplant recipients particularly vulnerable to ischemia secondary to hepatic arterial insufficiency in the setting of this problem? Ligation of the recipient right gastric artery Ligation of the recipient gastroduodenal artery Ligation of the donor left gastric artery Ligation of the donor gastroduodenal artery Steal syndrome from the recipient splenic artery What is the initial procedure of choice to try and fix this problem? Balloon angioplasty of the arterial anastomosis Infusion of tissue plasminogen activator into the celiac axis Exploration with attempt at hepatic artery thrombectomy Aorto-hepatic bypass (graft from aorta to hepatic artery distal to anastomosis) Release of the median arcuate ligament To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt
Authors: G.R. Veillette, D.S. Bedi, S. Feng
Institution: University of California, San Francisco
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,300
OpenAlex ID: W2091609508