Arterial Reconstruction with Replaced Hepatic Arteries

Paolo R. Salvalaggio

Jefferson A. Alves

Roberto F. Meirelles Jr

Sergio P. Meira Filho

Marcelo B. Rezende

PATIENT HISTORY AND PHYSICAL FINDINGS

A detailed history of the recipient must be obtained. In particular, a history of diabetes, hypercoagulability, hypertension, obesity, portal vein thrombosis, hepatocellular carcinoma, cardiovascular disease, previous abdominal and/or vascular surgeries, and smoking might be relevant.
Perform a full physical exam, with particular attention for signs of portal hypertension, ascites, abdominal diameter, previous scars, and pulses at the extremities.
In most cases, different surgical teams perform the donor and the recipient operation. Close communication between the teams is critical for the selection of the best technique to reconstruct the replaced and/or accessory arteries.¹

IMAGING AND OTHER DIAGNOSTIC STUDIES

Most transplant centers include an ultrasound during the workup of the recipient. This test will describe portal and arterial flow at the level of the hilum.
If available, a computed tomography (CT) scan or magnetic resonance imaging (MRI) can further detail portal and arterial anatomy of the recipient, including the presence of flow, size (diameter or caliber) of the vessels, and presence of replaced and/or accessory anatomy.

FIG 1 • Arteriogram shows a right replaced artery from the SMA. A replaced right hepatic artery usually branches within 1 to 2 cm from the origin of the SMA.
For recipients who have hepatocellular carcinoma and underwent transcatheter arterial chemoembolization (TACE) and/or radiofrequency ablation (RFA), a review of the current arteriogram may depict inconsistent flow, thrombosis, or aberrant anatomy that can alter surgical planning (FIG 1).

SURGICAL MANAGEMENT

Preoperative Planning

Arterial reconstruction with replaced and/or accessory hepatic artery should take in consideration all data from history, physical examination, laboratory, and imaging tests of the recipients as well as the report of the surgical team that have procured the liver allograft.
There are many variations in hepatic arterial anatomy. These are classified in Table 1.²
Avoid the terms accessory or replaced, because it is often difficult to determine which the appropriate designation is. “Accessory” infers redundant arterial supply, but it is rarely possible to know if the supply is truly redundant and thus can be ligated. Use the terms aberrant left or right artery, not aiming to identify whether the vessel is accessory or replaced.
Record the donor and recipient arterial anatomy in the operative record.

Table 1: Classical Description of Arterial Anatomy Variation

Type	Description
I	Conventional type: main hepatic artery originating from celiac truncus gives off the gastroduodenal artery and the proper hepatic artery and the proper hepatic artery splits into the left and the right hepatic arteries
II	Replaced left hepatic artery: Left hepatic artery originates from left gastric artery
III	Replaced right hepatic artery: Right hepatic artery originates from superior mesenteric artery
IV	Combination of replaced right and replaced left hepatic artery
V	Accessory left hepatic artery: Left hepatic artery originates from hepatic artery proper
	Accessory left hepatic artery originates from left gastric artery
VI	Accessory right hepatic artery: Right hepatic artery originates from hepatic artery proper
	Accessory right hepatic artery originates from superior mesenteric artery
VII	Accessory left and right hepatic artery
VIII	Replaced right hepatic artery originates from superior mesenteric artery
	Accessory left hepatic artery originates from left gastric artery or replaced left hepatic artery with accessory right hepatic artery
IX	Main hepatic artery originates from superior mesenteric artery
X	Main hepatic artery originates from left gastric artery Other types
From Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg. 1966;112:337-347, with permission.