Endovascular Treatment of Hepatic Artery Stenosis following Liver Transplantation
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1 Endovascular Treatment of Hepatic Artery Stenosis following Liver Transplantation W. Charles Sternbergh, III, MD Professor and Chief Vascular and Endovascular Surgery Vice Chair for Research Department of Surgery Ochsner Clinic Foundation New Orleans August 30, 2017
2 Disclosure I have no personal or professional financial relationships or interests with any proprietary entity producing healthcare goods/or services
3 Outline Endovascular Rx of Hepatic Artery Stenosis Incidence and associated morbidity Etiology Clinical Presentation Diagnostic Evaluation Indications (and contra-indications) for Treatment Endovascular technique Results Complications
4 Top 5 Liver Transplant Centers Volume Ochsner year survival Statistically Higher UCLA As expected Mayo/FL As expected UCSF As Expected Vandy As Expected Source: OPTN/UNOS & Scientific Registry for Transplant Recipients Dec. 2015
5 Hepatic Artery Stenosis Incidence and morbidity Affects 5-11% of orthotopic liver transplants 1 Can Lead to biliary complications (ischemic) Up to 65% chance of progressing to hepatic artery thrombosis (HAT) 2 Re-transplant required in up to 75% with HAT 3 Hepatic Artery Thrombosis 30-50% risk of Liver failure 4 1. Sabri SS et al. Endovascular Therapy for hepatic artery stenosis following liver transplantation. Vasc Endovasc Surg Orons PD et al. HAS in liver transplant recipients: prevalence and cholangiographic appearance of ass. biliary complications. AJR Am J Roentgenol Tucker N. et al. Primer on trasnplantation, 2 nd edition. Mt. Laurel, NJ: American Society of Transplantation Langnas AN et al. Vascular complications after orthotopic liver transplantation. Am J surg 1991.
6 Hepatic Artery Stenosis Common at anastomosis Etiology Less frequently at terminal proper Hepatic/R and L hepatic bifurcation Etiology 1 Technical error Vessel redundancy/kinking Clamp injury Rejection Ischemia of vaso vasorum Gi.jhsps.org 1. Carlos Pulitano et al. Hepatic Artery Stenosis after Liver Transplantation: Is Endovascular Treatment always Necessary? Liver Transplant 2013.
7 Hepatic Artery Stenosis Clinical Presentation Almost always asymptomatic Rarely causes transaminase elevation on its own Other causes of LFT elevation should be aggressively investigated Worsening HAS will frequently be seen in patients with associated sepsis or rejection. Underlying issue should be Rxed first HAS will typically improve/resolve WITHOUT intervention in these circumstances
8 Hepatic Artery Stenosis Diagnostic Evaluation Duplex Ultrasound (Phillips Ochsner) Studies performed: intra-operatively IF there are concerns POD 1 and 7 1,6 and 12 months More frequent for donation after circulatory death (DCD) donors
9 Hepatic Artery Stenosis (HAS) Diagnostic Evaluation Duplex Ultrasound Severe HAS *suggested by: Peak Systolic Velocity (PSV) of > cm/sec Resistive Index (RI) of <0.5 Presence of Tardus Parvus waveforms *Lall NU, Bluth EI, Sternbergh WC III. Ultrasound findings after endovascular stent deployment in transplant liver hepatic artery stenosis. AJR (Am J Roentgenol);202: , 2014
10 Tardus Parvus: HA Stenosis and Post Angioplasty Pre MHA RI =.33 LHA RI =.38 Post Post Angioplasty MHA RI =.63 LHA RI =.65
11 Hepatic Artery Stenosis (HAS) Diagnostic Evaluation Duplex Ultrasound Severe HAS *suggested by: Peak Systolic Velocity (PSV) of > cm/sec Resistive Index (RI) of <0.5 Presence of Tardus Parvus waveforms Rarely, critical HAS has no velocity elevation But has very low RI and + tardus parus waveforms *Lall NU, Bluth EI, Sternbergh WC III. Ultrasound findings after endovascular stent deployment in transplant liver hepatic artery stenosis. AJR (Am J Roentgenol);202: , 2014
12 Duplex: Common hepatic flow not well visualized, possibly thrombosed. R and L hepatic Resistive index (RI) with tardus parvus waveforms 99+% Proper Hepatic Stenosis
13 Occlusive with wire
14 After 2.75 x 18 DES placement
15 Hepatic Artery Stenosis Diagnostic Evaluation In patients with severe HAS by US, a CTA is usually performed for endovascular case planning (rarely to confirm the Dx) Orientation of celiac Use brachial approach if signif caudal angulation (~30%) Aberrant inflow Recipient hepatic inflow via SMA from replaced R hepatic Unexpected high grade celiac artery stenosis with hepatic inflow through the SMA via retrograde GDA flow Aorta-hepatic conduit
16 Hepatic Artery Stenosis Indications for Endovascular Rx Severe HAS by duplex PSV > , RI <0.5, + tardus parvus waveforms Minimum of 3 wk post-op Completely arbitrary my fear of dilating a fresh anastomosis Peri-operative (typically POD1) HAT is managed surgically Contraindications Concurrent rejection or sepsis (HAS usually improves after Rx of primary issue)
17 Hepatic Artery Stenosis Indications for Endovascular Rx Severe HAS by duplex PSV > , RI <0.5, + tardus parvus waveforms Minimum of 3 wk post-op Completely arbitrary my fear of dilating a fresh anastomosis Peri-operative (typically POD1) HAT is managed surgically Contraindications Concurrent rejection or sepsis (HAS usually improves after Rx of primary issue)
18 Hepatic Artery Stenosis Indications for Endovascular Rx Severe HAS by duplex PSV > , RI <0.5, + tardus parvus waveforms Minimum of 3 wk post-op Completely arbitrary my fear of dilating a fresh anastomosis Peri-operative (typically POD1) HAT is managed surgically Contraindications Concurrent rejection or sepsis (HAS usually improves after Rx of primary issue)
19 Hepatic Artery Stenosis Rx Technique of delivering a stable platform Femoral or Brachial (30%) approach 6 fr RDC-1 guide (femoral), 5 fr multipurpose sheath (brachial) stiff angled glidewire into GDA followed by 5 fr glide catheter Sheath or guide then carefully telescoped into the distal common hepatic over catheter/wire wire and 5 fr catheter removed
20 Hepatic Artery Stenosis Rx Technique for Rx DA imaging (15 fps) frequently better than DSA platform (choice PT regular or extra support my fav) Use the least stiff wire that will allow balloon/stent to track Rapid exchange coronary balloons (2-5 mm) Coronary stents 2-5mm diameter, 8-28mm length Prefer DES if < 3.5mm diameter
21 Technique Main HA 99% Stenosis of proper hepatic artery coronary stent placement
22 Technique Proximal Flaring Balloon expandable coronary stent Completion hepatic angiogram
23 Technique Filling of hepatic vasculature PRE POST
24 Buddy Wire Technique Left HA stenosis Right HA occlusion Main HA
25 Buddy Wire Technique Pre-dilation with buddy wire in left HA Balloon expandable stent in right HA
26 Buddy Wire Technique Stenting of left hepatic artery
27 Buddy Wire Technique PRE POST
28
29 3.5 x 18 DES 2.25 x 12 DES
30
31 Primary stent placement for hepatic artery stenosis after liver transplantation Linda Le, MD, William Terral, MD, Nicolas Zea, MD, Hernan A. Bazan, MD, Taylor A. Smith, MD, George E. Loss, MD, Edward Bluth, MD, and W. Charles Sternbergh III, MD, New Orleans, La Aug 2009 Dec 2013 N=62 interventions in 42 patients 6.4% (42/654 Liver Transplants) need for HAS intervention Most interventions <3 months after transplant J Vasc Surg 2015;62:704-9
32 Results Time to Initial Intervention Mean time = 82.2 ± 56 days /3 within 3 months of transplant 6 Within 30 days Within 3 months After 3 months
33 62 Interventions 42 Initial Interventions 20 Re-interventions 25 initial stent 17 PTA 15 stent 5 PTA 5 Drug-eluting 4 Drug-eluting Median F/U= 19.1 ± 15 months
34 Results 95% Technical Success (59/62) 3.2% HAT risk 2.4% 30-day mortality 4.8% Re-transplant Rate (n=3) HAT Recurrent HCC cholangitis 4.8% Complication Rate (n=3) 2 dissections leading to HAT Hepatic artery extravasation, brachial artery thrombosis
35 PTA vs. Stent Patency PTA STENT J Vasc Surg 2015;62:704-9
36 PTA vs. Stent Patency PTA STENT J Vasc Surg 2015;62:704-9
37 Primary Assisted Patency 93% 24 month = 93% J Vasc Surg 2015;62:704-9
38 J Vasc Surg
39 Study Design Retrospective Review: August 2009 March 2016 Tertiary care institution Ochsner Clinic Foundation, New Orleans, LA Largest US volume of OLTx since 2011 Objective Define potential risks associated with early intervention for HAS Describe salvage techniques for endovascular repair IRB Approved
40 Results 79 pts, 1129 OLTx in 6.5 yrs 6.9% HAS Rate 79 Patients Interventions 34 PTA Alone 65 Stent
41 Results 79 pts, 1129 OLTx in 6.5 yrs 6.9% HAS Rate n=106 angiograms 79 Patients Interventions 7 Diagnostic Interventions 34 PTA Alone 65 Stent
42 Results 79 pts, 1129 OLTx in 6.5 yrs 6.9% HAS Rate n=106 angiograms 79 Patients Interventions 7 Diagnostic Mean Age = 51 yo (Range 11-72) Femoral Approach = 72.6% Median Time to Intervention = 71 days Interventions 34 PTA Alone 65 Stent
43 7 Initial Diagnostic 106 Angiograms for HAS 73 Initial Interventions 26 Re-interventions Initial Stent PTA PTA Stent Diagnostic Re-intervention Rate = 26.5% (21/79) Time to Re-intervention = 97 days
44 n=2 Major Complication HAS could not be treated Technical Success n=2 Major Complication HAS Aborted 91% (90/99) n=5 >30% Residual Stenosis
45 Major Complications 3 Ruptures, 5 dissections: 7.5% rate (8/106)
46 Major Complications 3 Ruptures, 5 dissections: 7.5% rate (8/106) 6/8 (75%) had successful endovascular Rx Ruptures all successfully Rxed with Jomed covered stent (n=2) or balloon tampanode (n=1) Dissections Rxed with stents if true lumen access could be obtained No open Rx was required
47 Major Complications 3 Ruptures, 5 dissections: 7.5% rate (8/106) 6/8 (75%) had successful endovascular Rx Ruptures all successfully Rxed with Jomed covered stent (n=2) or balloon tampanode (n=1) Dissections Rxed with stents if true lumen access could be obtained No open Rx was required However, 4/8 patients (50%) went on to HAT, compared to 1.4% (1/71) in the noncomplication cohort (P<0.001)
48 Mortality 1 year all cause mortality Complication Cohort: 12.5% (1/8) Non-complication Cohort: 7% (5/71) P =.484
49 Risk Factors for Complications Tortuosity Non-complication Cohort P = % (34/98) interventions had tortuous anatomy Complication Cohort 75% (6/8) interventions had tortuous anatomy 2 fold increase
50 Risk Factors for Complications Re-transplants Non-complication Cohort P = % (9/71) patients had 2 liver transplants Complication Cohort 37.5% (3/8) patients had 2 liver transplants 3 fold increase
51 Hepatic Artery Rupture 11 y/o boy with Budd Chiri 1 st liver Transplant 12/10/13 Open Exploration for hepatic artery thrombosis 2 nd Liver Transplant 12/12/13 Colon perforation/exploration 12/24/13 Severe HAS, angio on 1/13/14 (POD 31)
52 HAS
53 Proper Hepatic Artery Rupture Extravasation
54 3x20 Balloon Tamponade
55
56
57 Jomed 3x16 Covered Stent
58 Resolution of HAS & hepatic rupture
59 Hepatic Artery Dissection
60
61 Proper Hepatic Artery Dissection True Lumen False Lumen
62 Coronary Steerable Catheter
63
64 3.5x33 Bare Metal Stent
65
66 Meta-analysis Stent placement vs angioplasty for HAS after liver transplant: a meta-analysis of case series Rostambeigi et al (U Minnesota), Eur Radiol : interventions from 26 studies 147 PTA, 116 stent
67 Meta-analysis Stent placement vs angioplasty for HAS after liver transplant: a meta-analysis of case series Rostambeigi et al (U Minnesota), Eur Radiol : interventions from 26 studies 147 PTA, 116 stent Procedure success: 89% (PTA) vs 98% (stent) Complication rate: 16% (PTA) vs 19% (stent) Arterial Patency: 76% (PTA) vs 68% (stent) Re-intervention: 22% (PTA) vs 25% (stent) Re-transplantation: 20% (PTA) vs 25% (stent) Conclusion: PTA and stent Rx are equivalent
68 Meta-analysis Stent placement vs angioplasty for HAS after liver transplant: a meta-analysis of case series Rostambeigi et al (U Minnesota), Eur Radiol : interventions from 26 studies 147 PTA, 116 stent Procedure success: 89% (PTA) vs 98% (stent) Complication rate: 16% (PTA) vs 19% (stent) Arterial Patency: 76% (PTA) vs 68% (stent) Re-intervention: 22% (PTA) vs 25% (stent) Re-transplantation: 20% (PTA) vs 25% (stent) Conclusion: PTA and stent Rx are equivalent
69 Meta-analysis Stent placement vs angioplasty for HAS after liver transplant: a meta-analysis of case series Rostambeigi et al (U Minnesota), Eur Radiol : interventions from 26 studies 147 PTA, 116 stent Procedure success: 89% (PTA) vs 98% (stent) Complication rate: 16% (PTA) vs 19% (stent) Arterial Patency: 76% (PTA) vs 68% (stent) Re-intervention: 22% (PTA) vs 25% (stent) Re-transplantation: 20% (PTA) vs 25% (stent) Conclusion: PTA and stent Rx are equivalent
70 Meta-analysis Stent placement vs angioplasty for HAS after liver transplant: a meta-analysis of case series Rostambeigi et al (U Minnesota), Eur Radiol : interventions from 26 studies 147 PTA, 116 stent Procedure success: 89% (PTA) vs 98% (stent) Complication rate: 16% (PTA) vs 19% (stent) Arterial Patency: 76% (PTA) vs 68% (stent) Re-intervention: 22% (PTA) vs 25% (stent) Re-transplantation: 20% (PTA) vs 25% (stent) Conclusion: PTA and stent Rx are equivalent
71 Meta-analysis Stent placement vs angioplasty for HAS after liver transplant: a meta-analysis of case series Rostambeigi et al (U Minnesota), Eur Radiol : interventions from 26 studies 147 PTA, 116 stent Procedure success: 89% (PTA) vs 98% (stent) Complication rate: 16% (PTA) vs 19% (stent) Arterial Patency: 76% (PTA) vs 68% (stent) Re-intervention: 22% (PTA) vs 25% (stent) Re-transplantation: 20% (PTA) vs 25% (stent) Conclusion: PTA and stent Rx are equivalent
72 Meta-analysis Stent placement vs angioplasty for HAS after liver transplant: a meta-analysis of case series Rostambeigi et al (U Minnesota), Eur Radiol : interventions from 26 studies 147 PTA, 116 stent Procedure success: 89% (PTA) vs 98% (stent) Complication rate: 16% (PTA) vs 19% (stent) Arterial Patency: 76% (PTA) vs 68% (stent) Re-intervention: 22% (PTA) vs 25% (stent) Re-transplantation: 20% (PTA) vs 25% (stent) Conclusion: PTA and stent Rx are equivalent
73 Literature, HAS intervention Date N Technical success (%) Complication rate (%) Present Study In press Sommacale Saad Ueno Sabri Rajakannu Kodama
74 Literature, HAS intervention Date N Technical success (%) Complication rate (%) Present Study In press Sommacale Saad Ueno Sabri Rajakannu Kodama
75 Literature, HAS intervention Date N Technical success (%) Complication rate (%) Present Study In press Sommacale Saad Ueno Sabri Rajakannu Kodama
76 Take home clinical pearls Hepatic artery Intervention Only Rx high grade stenosis PSV > , RI <0.5 (usually <0.4), + tardus parvus waveforms Overall, I Rx <50% of cases I m asked to see
77 Take home clinical pearls Hepatic artery Intervention Only Rx high grade stenosis PSV > , RI <0.5 (usually <0.4), + tardus parvus waveforms Overall, I Rx <50% of cases I m asked to see Don t treat in setting of rejection or sepsis
78 Take home clinical pearls Hepatic artery Intervention Only Rx high grade stenosis PSV > , RI <0.5 (usually <0.4), + tardus parvus waveforms Overall, I Rx <50% of cases I m asked to see Don t treat in setting of rejection or sepsis Case plan carefully (femoral vs brachial)
79 Take home clinical pearls Hepatic artery Intervention Only Rx high grade stenosis PSV > , RI <0.5 (usually <0.4), + tardus parvus waveforms Overall, I Rx <50% of cases I m asked to see Don t treat in setting of rejection or sepsis Case plan carefully (femoral vs brachial) Meticulous technique is essential Can be technically challenging/unforgiving Experienced in rapid exchange systems Need availability of bail-out devices
80 Summary Endovascular Rx of Hepatic Artery Stenosis Endovascular Intervention for HAS is effective with excellent primary-assisted patency rates Primary stent placement (particularly DES) appears to reduce the need for secondary intervention in my experience Meta-analysis suggest equivalent results Severe hepatic artery tortuosity and/or retransplantation increase the risk of a major complication by 2-3 fold
81 Summary Endovascular Rx of Hepatic Artery Stenosis Complication rate (7.5%) is acceptable in light of the frequently challenging anatomy While most major complications can be Rxed endovascularly (75%), the subsequent rate of HAT is very high (50% vs 1.4%) Prudent case selection is essential
82
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