Hepatic artery thrombosis after liver transplantation: radiologic evaluation

Abstract

Hepatic artery thrombosis after liver transplantation is a devastating event requiring emergency retransplantation in most patients. Early clinical signs are often nonspecific. Before duplex sonography (combined real-time and pulsed Doppler) capability was acquired in October 1984, 76% of all transplants in this institution referred for angiography with a clinical suspicion of hepatic artery thrombosis had patent arteries. In an effort to reduce the number of negative angiograms, CT, real-time sonography, and pulsed Doppler have been evaluated as screening examinations to determine which patients need angiography. Of 14 patients with focal inhomogeneity of the liver architecture detected by CT and/or real-time sonography, 12 (86%) had hepatic artery thrombosis, one had slow arterial flow with hepatic necrosis, and one had a biloma with a patent hepatic artery. In 29 patients undergoing duplex sonography of the hepatic artery, six (21%) had absence of a Doppler arterial pulse. All six had abnormal angiograms: Four had thrombosis, one had a significant stenosis, and one had slow flow with biopsy-proven ischemia. Of 23 patients with a Doppler pulse, two had hepatic artery thrombosis at surgery. However, real-time sonography demonstrated focal inhomogeneity in the liver in both cases. Our data demonstrate that pulsed Doppler of the hepatic artery combined with real-time sonography of the liver parenchyma currently is the optimal screening test for selecting patients who require hepatic angiography after liver transplantation. A diagnostic algorithm is provided.

Fig. 1

Focal area of hepatic parenchymal inhomogeneity (arrows) on sonogram of 3-year-old girl with hepatic artery thrombosis. At retransplantation, pathology revealed infected infarct.

Fig. 2

Large area of abnormal liver parenchyma on CT scan of 2-year-old girl with hepatic artery thrombosis. At retransplantation, pathology revealed infected infarct.

Fig. 3

Normal Doppler. A, Position of cursor line through hepatic artery (curved arrow) on sagittal view for Doppler waveform shown in B. Portal vein (straight arrow). B, Normal Doppler artery waveform.

Fig. 4

Collateral development after hepatic artery thrombosis. Late arterial film from celiac arteriogram 3 weeks after liver transplantation shows occlusion of common hepatic artery at its origin and reconstitution of intrahepatic branch arteries (small white arrows). Splenic artery (large arrowhead); left gastric artery (small arrowhead); portal vein (large white arrow).

Fig. 5

Diagnostic algorithm for radiologic evaluation of patient with suspected hepatic artery thrombosis after liver transplantation.