Ask the Experts - Use of PTFE for Arterial Revascularization in Liver...
I transplanted a young man with Wilson's disease who was in fulminant hepatic failure (FHF). The graft came from a 78-year-old donor. We used a piggyback technique with a temporary portocaval shunt. During the dissection of the hepatic artery, we found an early division with 3 branches to the left lobe and 2 to the right lobe, which was deemed unsuitable for the arterial anastomosis. The donor's iliac vessels had multiple arteriosclerotic plaques and could not be used for a jump graft, and the recipient's saphenous veins were varicosed. We then used a 6-mm polytetrafluoroethylene (PTFE) conduit as a jump graft from the infrarenal aorta to the recipient's hepatic artery. The patient has done well so far (2 months posttransplantation). Should I expect complications related specifically to the use of the PTFE for arterial revascularization?

Lorenzo Toselli, MD

The question is a little unclear about whether the arterial anomaly was in the donor or recipient hepatic artery. I assume the description is of the recipient artery, with a reconstruction performed between the donor aortic carrel patch and the infrarenal aortic PTFE conduit.

When we encounter multiple early bifurcations of the recipient hepatic artery, we generally dissect the recipient artery proximally and perform a branch patch anastomosis to the gastroduodenal artery (GDA)/hepatic artery confluence. A full-length donor hepatic artery should have no difficulty reaching the GDA without tension; in fact, a full-length hepatic artery with an Ao carrel patch can often reach the supraceliac aorta directly.

In most instances, conduits are required because the recipient hepatic artery is unusable. In our experience, this is most often due to poor inflow (indicating celiac disease) or dissection/trauma of the recipient artery precluding anastomosis. When conduits are necessary, both the infrarenal and supraceliac aorta are possible locations for inflow. The supraceliac aorta may allow anastomosis without a conduit or with a very short segment of conduit. The infrarenal aorta is technically easier in exposure, but a longer conduit is required. When the donor iliacs are diseased, we often procure the carotids and/or descending aorta, which make excellent conduits.

The published data indicate that infrarenal conduits using iliac artery grafts have identical thrombosis rates compared with direct hepatic arterial anastomosis. Data using the supraceliac aorta also indicate a low rate of thrombosis. I am not aware of using PTFE for this purpose, but in general, arterialized PTFE grafts are quite durable and relatively infection-resistant after they are completely bioincorporated. We tend not to use PTFE in transplantation because of the early risk of infection in the setting of ascites, bile leak, etc. However, this patient is now 2 months posttransplant and doing well; I do not expect you will have a problem with arterial thrombosis of the graft at this stage unless a superimposed problem occurs (eg, severe rejection with vasculitis). It is possible that the anastomosis may develop neointimal hyperplasia and stenosis, which should be evaluable by serial duplex velocities. Good luck.