Jpn J Intervent Radiol Vol.26 No.4 2011

State of the Art
Interventional Radiology for Complications after Liver Transplantation

An Introduction  
Toshiya Shibata 
Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine

1. Current Status of Liver Transplantation in Japan

Institute of Gastroenterology, Tokyo Women’s Medical University
Hiroto Egawa

 Living donor LT (LDLT) accounts for the majority of liver transplantations (LTs) in Japan. Following the revision of the transplantation law in 2010, the number of deceased donor liver transplants (DDLT) has also increased. Notably, the 10-year survival rate of DDLT (70.1%) is not significantly different from that of LDLT (72.4%). In the last decade, there were two major innovations in LDLT: resolution of graft size mismatch and resolution of blood type mismatch. Graft size mismatch includes both small-for-size (SFS) grafts and large-for-size (LFS) grafts. For a successful LDLT for infants, strategies for LFS grafts are important. Hyper-reduced left lateral segments and a monosegment graft using segment 2 have been reported. To overcome SFS grafts, considerable efforts have been made to obtain larger grafts, reconstruct outflow without congestion, and adjust the portal flow. To obtain larger grafts, a right lobe graft was first introduced and then a right lobe graft with the middle hepatic vein was used. After encountering a donor death in which a right lobe graft with the middle hepatic vein was obtained from a donor with nonalcoholic steatohepatitis, considerable efforts were made to improve LDLT with the left lobe.

Key words

  • Liver transplantation
  • Vascular complication
  • Living donor


2. Endoscopic Treatment for Biliary Strictures after Liver Transplantation

Division of Gastroenterology and Hepatology, Digestive Disease Center,Kitano Hospital The TazukeKofukai Medical Reserch Institute
Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University
Akira Kurita, Yuzo Kodama, Tsutomu Chiba

 Biliary complications remain a serious problem for some recipients after liver transplantation. The incidence of biliary complications after living-donor liver transplantation, 18-47%, is significantly higher than that after deceased-donor liver transplantation, 10-15%. Endoscopic or percutaneous treatment tends to be selected first for biliary reconstruction with duct-to-duct anastomosis and Roux-en Y hepaticojejunostomy (RYHJ), respectively. Owing to double balloon enteroscopy, however, anastomotic biliary stenosis after RYHJ can be treated endoscopically. Nowadays endoscopic treatment has become a first-line therapy for biliary stricture chosen after liver transplantation regardless of the biliary reconstruction method chosen, although some complicated cases require both endoscopic and percutaneous approaches simultaneously.

Key words

  • Living-donor liver transplantation
  • Biliary complication
  • Anastomotic stricture
  • Non-anastomotic stricture
  • Biliary leakage


3. Interventional Radiology for Hepaticojejunal Biliary Anastomotic Strictures after Living-Donor Liver Transplantation

Department of Radiology, Kobe City Medical Center, General Hospital
Kyo Itoh, Hiroyuki Ueda

 Living-donor liver transplantation (LDLT) is now recognized as an important option for fatal liver diseases including fulminant hepatitis, cirrhosis, and hepatocellular carcinoma. Biliary complications including bile leakage, anastomotic stenosis, biloma, or stone formation are known as the most common complication after liver transplantation. Among them hepaticojejunal biliary anastomotic strictures are often encountered and can be treated safely by percutaneous balloon dilatation with temporary tube stenting. In our percutaneous balloon dilatation cases with hepaticojejunal biliary anastomotic stricture, technical success rate is 67% and a patency rate of 72% is obtained.
 LDLT will continue to be an important therapy for severe liver diseases because of the small number of cadaver organs available in our country. Interventional radiology plays an important role in achieving successful results of LDLT.

Key words

  • Liver transplantation
  • Biliary stricture
  • Interventional radiology


4. Interventional Radiology for Portal Vein Stenosis after Liver Transplantation

Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital
Yusuke Sakuhara, Daisuke Abo, Yu Hasegawa, Takeshi Soyama, Satoshi Terae

 Interventional radiology treatment plays a very important role in the management of portal vein (PV) complications after liver transplantation. The factors underlying PV complications include 1) decreased PV inflow, 2) the presence of portosystemic shunts, 3) traction on anastomosis, 4) tension in the interposition graft, 5) difference in caliber between smaller recipient PV and larger donor PV, 6) twisting or kinking of the vascular conduit, and 7) prior splenectomy. PV complications occur more frequently in segmental liver transplantation than in whole liver transplantation. The incidence is relatively high in pediatric recipients. Diagnosis of PV stenosis is clinically suggested by the presence of ascites, diarrhea, gastrointestinal varices and splenomegaly, and confirmed by Doppler ultrasonography.
 Balloon venoplasty or stent placement for PV stenosis is performed by percutaneous transhepatic approach or transileocolic approach, and their initial technical success rate is high. Balloon venoplasty is very effective, but recurrent stenosis may occur and repeated procedures are sometimes required in patients who have undergone only balloon venoplasty. Stent placement is also effective and its recurrence rate is very low. It should be especially performed for balloon-resistant and elastic stenosis. However, long-term patency is unknown and indications for pediatric patients are not established yet. Anti-coagulant therapy during and after the procedure is also important.

Key words

  • Liver transplantation
  • Portal vein stenosis
  • Balloon venoplasty
  • Stent placement


5. Interventional Radiology for Anastomotic Stenosis of Hepatic Vein after Living Donor Liver Transplantation

Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine
Minoru Yabuta, Toshiya Shibata, Toyomichi Shibata, Hiroyoshi Isoda, Kaori Togashi

 In Japan, living donor liver transplantation (LDLT) has been widely performed for patients with end-stage liver disease because of graft shortage. The rates of vascular complications in LDLT are higher than those in orthotopic liver transplantation because of the technical difficulty of anastomosis of short pedicles. Anastomotic stenosis of hepatic vein (HV) is an uncommon complication, but it might lead to graft failure if appropriate management is not performed. Percutaneous transluminal angioplasty (PTA) is believed to be non-invasive and effective for anastomotic stenosis, and now it is the first-line treatment. We have performed PTA with/without stent placement for anastomotic stenosis of HV since 1997. In this study, strategies of diagnosis, procedures of PTA with/without stent placement, outcomes, complications, and long-term patency were described.

Key words

  • Living donor liver transplantation(LDLT)
  • Anastomotic stenosis of hepatic vein
  • PTA
  • Stent placement

Case Report

Treatment of Iatrogenic Femoral Pseudoaneurysm with Ultrasound-guided Manual Compression; A Case Report

Department of Radiology, and Neurosurgery1), Hamamatsu University School of Medicine
Shuhei Yamashita, Hisaya Hiramatsu1), Mika Kamiya,Hatsuko Nasu, Harumi Sakahara

Apatient who underwent carotid artery stenting with a 9Fr. introducer sheath developed a pseudoaneurysm at the femoral artery puncture site two days after stenting despite the use of a vascular closure device. The pseudoaneurysm was unsuccessfully compressed with an ultrasound probe, but eventually treated by manual compression for about one hour under ultrasound guidance. Manual compression was performed to obstruct the neck of the pseudoaneurysm while monitoring the flow signal within the pseudoaneurysm. Although vascular closure devices quickly seal femoral artery punctures following catheterization procedures, pseudoaneurysms can still develop. We successfully treated the pseudoaneurysm by manual compression under the observation of blood flow with ultrasound. This method is effective because pinpoint compression of the bleeding site is possible.

Key words

  • Vascular closure device
  • Pseudoaneurysm
  • Ultrasound-guided manual compression