A 51-year-old male smoker of more than 60 cigarettes a day, with moderate COPD, IgA nephropathy with mild CRF and primary Sjögren's syndrome.
She was admitted for liver transplantation for embolic cirrhosis diagnosed 6 years ago associated with varices grade I-II, hyperkinesia, hepatopulmonary syndrome and an isolated episode of encephalopathy grade II.
An orthotopic transplant of a cadaveric donor is performed, which is classified as suboptimal. The donor hepatic artery is left blank and has a negative serology.
During surgery the arterial and portal flow are measured: 93 and 670 cc/min respectively, so it is decided to explore the celiac trunk with Fogarty's probe, to extract normal atheroma flow.
Recipient immunosuppression begins with mycophenolate, tacrolimus and steroids.
After the first 24 h, the patient remained intubated with a significant cytolysis pattern, progressive renal dysfunction, INR of 2.12, and an echo-ppler where no arterial flow appears.
Abdominal CT showed areas of hepatic ischemia and a patent portal vein arterioform.
A retransplantation was performed 72 hours after surgery and necrosis of segments II, IV and VIII was observed in the explant.
Before anastomoses, the new liver was dilated with a Fogarty catheter and intra-arterial heparin was injected.
After new vascular anastomoses, intraoperative blood flows of 123 and 2,070 cc/min are measured in the artery and portal, respectively.
Immunosuppression was performed with mycophenolate, daclizumab and steroids and late incorporation of tacrolimus.
After retransplantation, the patient presented adequate flow curves in the portal and suprahepatic eco-ppler but not in the hepatic artery.
A aretriography was requested in which we found a patent butiform proximal hepatic artery with a marked increase in caliber of the gastroduodenal artery.
The patient is diagnosed with probable gastroduodenal steal syndrome.
Conservative treatment was initiated with prostaglandin E1 and sodium heparin, ruling out the possibility of embolization of the gastroduodenal artery in this patient due to the risk of secondary pancreatitis.
On the 5 day the patient is stable and on the 6 day he is extubated.
There is progressive improvement in renal and hepatic function, with normalization of transaminases until the patient is discharged on the 25 day after stopping heparinization.
Vascular complications in patients undergoing OLT account for 9%; if we consider only those of arterial origin, the most frequent are thrombosis of the hepatic artery (4-12%), stenosis of the hepatic artery (5-11%), and pseudoaneurysm.
