Management of hepatic artery thrombosis after living donor liver transplantation: Endovascular thrombolytic therapy or surgical intervention? Role of hepatic arterial urokinase infusion

The hepatic artery (HA) related complications after living donor liver transplantation (LDLT) remains an important cause of increased risk of post-transplant mortality. The timing of occurrence of hepatic artery thrombosis (HAT) after transplantation and the timely intervention are the determining factors in the survival of the recipients. Re-exploration and revision of the hepatic artery anastomosis or medical treatment with urokinase therapy are the lifesaving treatment options. We describe our successful outcome after arterial urokinase infusion as an initial therapy for the LDLT recipients with HAT. Materials and Methods: From 10^th September 2002 till 31^st December 2017, a total of 908 LDLT surgeries were performed at China Medical University Hospital. A total of 12 patients that developed HAT in postoperative period were further studied. All the patients that were diagnosed to have HAT within 24 hours were re-explored whereas medical therapy with intra-arterial urokinase infusion was the first treatment modality for the HAT developing after 24 hours of LDLT. Results: 12 recipients (1.37%) developed HAT. Computed tomography (CT) angiography was done for all the recipients and arterial Urokinase infusion was given in 10 patients as the initial therapy whereas 2 patients were directly re-explored. All the urokinase treated patients had HAT 24 hours after LDLT. Five of the urokinase therapy patients developed complete re-canalization after urokinase therapy without any morbidity in post-transplant period. After successful re-canalization, there was no evidence of arterial stenosis in subsequent follow up with satisfactory liver graft functions. Remaining five patients underwent re-exploration with revision of hepatic artery anastomosis (n=2) and re-transplantation (n=3). Conclusions: Intra-arterial urokinase therapy is a feasible initial therapy in LDLT recipients with HAT with an acceptable HA recanalization rate that needs no further surgical intervention and can certainly be first choice of treatment in stable HAT patients. However, failure of re-canalization or deterioration of the patient’s clinical condition warrants urgent surgical intervention.