Endovascular salvage of graft hepatic artery dissection with intrahepatic extension following right lobe living donor liver transplantation: a case report with literature review.

Abstract

Introduction: Hepatic artery complications after liver transplantation are uncommon but potentially catastrophic because the biliary tree depends entirely on the arterial blood supply. Graft hepatic artery dissection (GHAD) is extremely rare following living donor liver transplantation (LDLT), and optimal management strategies remain unclear.

Case presentation: A 68-year-old man with hepatocellular carcinoma and underlying alcohol-related cirrhosis underwent right-lobe LDLT. During donor hepatectomy, intimal dissection of the graft hepatic artery, extending deep into the liver parenchyma, was identified. After arterial reconstruction, intraoperative Doppler ultrasound demonstrated absent arterial flow. The abdomen was closed, and the patient was transferred for urgent endovascular intervention. Angiography confirmed compromised arterial inflow, and a drug-eluting stent was deployed across the arterial anastomosis, followed by catheter-directed thrombolysis using alteplase. Postoperatively, the patient developed intra-abdominal bleeding requiring emergency re-laparotomy for hemostasis. Despite this complication, hepatic arterial perfusion was successfully restored. Liver function gradually improved, and follow-up imaging confirmed adequate graft perfusion. The patient was discharged 3 weeks after transplantation with preserved graft function.

Discussion: GHAD is a rare but serious vascular complication that may result in graft ischemia, biliary complications, and graft failure if not promptly treated. When surgical revision is not feasible, endovascular techniques - including stent placement and thrombolysis - can serve as effective salvage strategies. However, thrombolytic therapy carries a significant risk of hemorrhagic complications, requiring careful postoperative monitoring.

Conclusion: Early diagnosis and multidisciplinary management are essential for the successful salvage of GHAD after LDLT.