Impending arterial thrombosis in pediatric liver transplantation: Initial experience with alteplase - A case report.

Introduction and importance: Early hepatic artery thrombosis is a serious complication following pediatric liver transplantation, often associated with high morbidity and mortality. While surgical revascularization and retransplantation are the standard treatments, thrombolytic therapy has emerged as a potential alternative. However, clinical reports remain limited and standardized protocols are lacking.

Presentation of case: A 13-month-old infant with biliary atresia post-Kasai procedure underwent living donor liver transplantation. On postoperative day 9, Doppler ultrasound detected signs of impending hepatic artery thrombosis, which was confirmed by computed tomography angiography. The patient was treated with intravenous alteplase at a dose of 0.3 mg/kg/h. After 3.5 hours of infusion, Doppler ultrasound showed improved hepatic artery flow. The infusion was stopped early due to intra-abdominal bleeding, which was managed conservatively. The patient stabilized without surgical intervention and was discharged on postoperative day 32 with stable hepatic artery flow. At six-month follow-up, the hepatic artery remained patent, and the patient was clinically stable.

Clinical discussion: This case supports the effectiveness of alteplase administration in treating incomplete hepatic artery thrombosis, despite its bleeding risk. We recommend lower dose regimens to reduce hemorrhagic complications. However, further studies are needed to optimize the alteplase dosage.

Conclusion: Thrombolytic therapy with alteplase is a possible and effective alternative in managing eHAT, particularly where conventional options are not indicated or limited.