Successful hepatic artery reconstruction can normally be achieved with the donor celiac artery anastomosied to the recipient hepatic artery. Occasionally, the recipient hepatic artery is insufficient to provide arterial inflow to the graft. At our center, in these cases, we will use the iliac artery from the donor as a jump graft to the infrarenal aorta with good success [3
]. However, in this case the iliac arteries were damaged by severe atherosclerosis. With increasing use of extended donor criteria, in this case, an age of 75 years, poor quality of the iliac vessels may be encountered. In this situation, directly anastomosing the donor carrel patch to the supraceliac aorta is a viable alternative. Of course, this is a last resort before attempting use of an artificial conduit which has its own risk of nonhealing and infection in the face of immuosuppression.
Unfortunately, dissection of the hepatic artery can occur and is a difficult problem to overcome. In this patient, there were no preoperative risk factors such as TACE (transarterial chemoembolization), hypertension, or vascular disease, except age. The reason for the dissection then could have been technical or from positioning of a retractor during the anhepatic phase of the transplant. Once the dissection was recognized, the team immediately began determining options for arterializations, realizing that the donor iliac vessels were unusable and there were no compatible donor iliac vessels from previous transplants in storage. Because the donor celiac artery was lying on the aorta in perfect position we decided to perform the reconstruction described above. The main issue was dissection of the cura of the diaphragm. The previous hepatectomy had moved the stomach and exposed the cura. We preformed a muscle splitting dissection to preserve the cura. Then we placed two straight vascular clamps on the aorta. After the anastomisis was complete, the cura surrounded the reconstruction.
Two case series in the early 1990's described using the supraceliac aorta as arterial inflow to a liver graft. In Shaked et al. they preformed a primary end to side common hepatic artery and supraceliac anastomosis without the use of grafts in eleven adult patients mainly for small arteries <3
mm or for hepatic artery thrombosis [4
]. Hennein and colleagues described this anastomosis in one adult patient for retransplantation. Both of these reports have small numbers in adults, but, demonstrate positive outcomes [1
]. This approach is not completely without risk, and cross clamping of the aorta can significantly affect both renal and bowel function because of the ischemic time placed on these organs. However, based on the above data and our experience there does not appear to be an increased risk for hepatic artery thrombosis in this reconstruction.
While the modest experience thus far is generally good, direct anastomosis to the supraceliac aorta with the donor's aortic carrel patch should not be forgotten as an alternative anastomosis when the recipient and donor's anatomy dictate. With the increased use of older donors the iliac vessels are often not usable. There is a definite increased morbidity with this reconstruction, but, it can be performed successfully to provide adequate arterial inflow to liver grafts in difficult situations.