Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study
Abstract
:1. Introduction
2. Patients and Methods
2.1. Patients and Ethics
2.2. Data Collection and Follow-Up
2.3. Surgical- and Perioperative Approach
2.4. Contrast-Enhanced CT Detection of Coeliac Axis Stenosis and Other Vascular Alterations
2.5. European Survey
2.6. Statistical Analysis
3. Results
3.1. Imaging Based Preoperative Vascular Evaluation
3.2. Patient Characteristics and Perioperative Outcome
3.3. Long-Term Follow Up
3.4. European Survey
4. Discussion
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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All Patients (n = 286) | κ | |
---|---|---|
Normal vascular anatomy | 149 (52%) | 0.916 |
Intrinsic celiac axis stenosis/arteriosclerosis | 16 (6%) | 0.930 |
Extrinsic celiac axis stenosis/MALC | 34 (12%) | 0.892 |
Portal vein thrombosis | 20 (7%) | 0.848 |
Other vascular abnormalities | 93 (33%) | 0.777 |
All Patients (n = 286) | No MAL Compression (n = 252) | MAL Compression (n = 34) | P Value | |
---|---|---|---|---|
Donor age (years) | 56 ± 15 | 56 ± 15 | 52 ± 17 | 0.167 |
Donor BMI | 30 ± 7 | 30 ± 8 | 28 ± 6 | 0.146 |
Donor sex ratio (F:M) | 135 (47%):151 (53%) | 117 (46%):135 (54%) | 18 (53%):16 (47%) | 0.475 |
Pre-transplant Child-Pugh Score | 7.4 ± 2.0 | 7.4 ± 2.0 | 7.6 ± 2.2 | 0.683 |
Donor cause of death | CVA 181 (63%) | CVA 161 (64%) | CVA 20 (59%) | 0.565 |
Anoxia 60 (21%) | Anoxia 52 (21%) | Anoxia 8 (24%) | 0.697 | |
Trauma 34 (12%) | Trauma 30 (12%) | Trauma 4 (12%) | 0.981 | |
Other 11 (4%) | Other 9 (4%) | Other 2 (6%) | 0.626 | |
Extended Criteria Donors 1 | 181 (63%) | 162 (64%) | 19 (56%) | 0.325 |
Recipient age (years) | 54 ± 10 | 55 ± 11 | 52 ± 10 | 0.174 |
Recipient BMI | 27 ± 5 | 27 ± 5 | 25 ± 5 | 0.040 |
Recipient sex ratio (F:M) | 91 (32%):195 (68%) | 81 (32%):171 (68%) | 10 (29%):24 (71%) | 0.748 |
Etiology of liver disease | ALF 33 (12%) | ALF 26 (10%) | ALF 7 (20%) | 0.088 |
HCC 70 (24%) | HCC 61 (24%) | HCC 9 (26%) | 0.773 | |
Alcoholic cirrhosis 75 (26%) | Alcoholic cirrhosis 70 (28%) | Alcoholic cirrhosis 5 (15%) | 0.104 | |
Viral 22 (8%) | Viral 18 (7%) | Viral 4 (12%) | 0.312 | |
PSC/PBC 28 (10%) | PSC/PBC 25 (10%) | PSC/PBC 3 (9%) | 0.840 | |
AIH 9 (3%) | AIH 7 (3%) | AIH 2 (6%) | 0.291 | |
Other 49 (17%) | Other 45 (18%) | Other 4 (12%) | 0.404 | |
Pre-transplant labMELD | 19 ± 10 | 19 ± 10 | 20 ± 11 | 0.697 |
BAR Score 2 | 8.51 ± 5.45 | 8.45 ± 5.31 | 8.76 ± 6.30 | 0.863 |
Recipient pre-transplant mechanical/ventilation support 3 | 26 (9%) | 22 (9%) | 4 (12%) | 0.528 |
Recipient pre-transplant ICU | 65 (23%) | 56 (22%) | 9 (27%) | 0.579 |
Cold ischemic time (min) | 503 ± 126 | 503 ± 123 | 511 ± 147 | 0.716 |
Warm ischemic time (min) | 45 ± 8 | 45 ± 8 | 45 ± 7 | 0.996 |
Intra-operative red blood cell transfusions (units) | 9 ± 9 | 10 ± 10 | 8 ± 6 | 0.181 |
Post-operative red blood cell transfusions (units) 4 | 4 ± 7 | 4 ± 7 | 4 ± 6 | 0.717 |
Early allograft dysfunction 5 | 80 (28%) | 69 (27%) | 11 (32%) | 0.563 |
Major complications (≥CD3b) 6 | 145 (51%) | 127 (50%) | 18 (53%) | 0.814 |
90-days CCI 7 | 52 ± 32 | 52 ± 32 | 56 ± 30 | 0.544 |
90-days morbidity | CD3 96 (34%) | CD3 82 (33%) | CD3 14 (41%) | 0.317 |
CD4 78 (27%) | CD4 70 (28%) | CD4 8 (24%) | 0.602 | |
CD5 14 (5%) | CD5 12 (5%) | CD5 2 (6%) | 0.676 | |
90-days graft loss | 25 (9%) | 22 (9%) | 3 (9%) | 0.542 |
Alternative arterial revascularization 8 | 21 (7%) | 17 (7%) | 4 (12%) | 0.274 |
ICU stay (days) 9 | 12 ± 20 | 12 ± 20 | 12 ± 16 | 0.379 |
Hospital stay (days) 10 | 38 ± 35 | 39 ± 36 | 36 ± 23 | 0.707 |
First Author | Type of Study | Patients n (%) * | Management n (%) | Structured Summary |
---|---|---|---|---|
Czigany et al. (present study) | Retrospective cohort | 34/286 (12%) | MAL division 26/34 (77), Alternative reconstruction 4/34 (12) | Treatment of MALC with MAL division was feasible and safe and may be considered in patients with relevant celiac axis stenosis as assessed by preoperative ceCT imaging. |
Fukuzawa et al., 1993 [20] | Retrospective cohort | 5/307 (1.6%) | Aorto-hepatic reconstruction 2/5 (40), MAL division 3/5 (60) | Celiac axis compression resulted in decreased hepatic artery flow to the allograft. In three cases, celiac decompression by division of the arcuate ligament resulted in adequate flow improvement. |
Jurim et al., 1993 [17] | Retrospective cohort | 17/164 (10%) | MAL division 17/17 (100), Aorto-hepatic reconstruction after unsuccessful MAL division 2/17 (12) | Identification and removal of the obstruction of the celiac axis by MAL division is crucial to prevent severe complications and potential graft loss. |
Agnes et al., 2001 [15] | Retrospective cohort | 5/140 (3.6%) | MAL division 5/5 (100) | Celiac compression must be identified and corrected in liver transplant recipients to avoid acute or chronic ischemic complications. Surgical therapy consists of arcuate ligament division, usually with excellent prognosis. |
Lubrano et al., 2008 [14] | Retrospective cohort | 10/168 (6%) | Aorto-hepatic reconstruction 4/10 (40), MAL division 1/10 (10) | The presence of an arcuate ligament does not contraindicate a routine hepatic artery reconstruction and MAL division should be performed if required. |
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Czigany, Z.; Boecker, J.; Morales Santana, D.A.; Bednarsch, J.; Meister, F.A.; Amygdalos, I.; Isfort, P.; Liebl, M.; Neumann, U.P.; Lurje, G. Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study. J. Clin. Med. 2019, 8, 550. https://doi.org/10.3390/jcm8040550
Czigany Z, Boecker J, Morales Santana DA, Bednarsch J, Meister FA, Amygdalos I, Isfort P, Liebl M, Neumann UP, Lurje G. Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study. Journal of Clinical Medicine. 2019; 8(4):550. https://doi.org/10.3390/jcm8040550
Chicago/Turabian StyleCzigany, Zoltan, Joerg Boecker, Daniel Antonio Morales Santana, Jan Bednarsch, Franziska Alexandra Meister, Iakovos Amygdalos, Peter Isfort, Martin Liebl, Ulf Peter Neumann, and Georg Lurje. 2019. "Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study" Journal of Clinical Medicine 8, no. 4: 550. https://doi.org/10.3390/jcm8040550