Esquivel, CO

Makowka, L

Shimada, M

Starzl, TE

Tzakis, AG

Yanaga, K

English

PubMed

Name not available

Significance of blood flow measurement in clinical liver transplantation

D-Scholarship@Pitt

Significance of Blood Flow Measurement in Clinical Liver Transplantation K. Yanaga, M. Shimada, l. Makowka, C.O. Esquivel, A.G. Tzakis, and T.E. StaTzl VASCULAR complications are not uncommon after orthotopic liver transplantation (OL Tx).'-2 In order to further improve the outcome of OL Tx, intra- and post-operative adjunctive measures will be required to further improve such problems as hepatic artery thrombosis. Since the first successful measurement in 1945 by Bradley and others l with a dye clearance method using bromosulphthal-ein, various methods have been advocated for the accurate measurement of blood flow to the human liver.4 Of these, the electromagnetic flowmeter technique has emerged to be one of the most reliable, and allows the direct measurement of flow through the hepatic artery (HA) and the portal vein (PV) independently.4 The purpose of this study was to clarify the importance of blood flow measurements during or after OLTx. PATIENTS AND METHODS Between July I, 1987 and February 18, 1988, 230 patients under-went 272 OL Tx at the Presbyterian Unversity Hospital and Chil-dren's Hospital of Pittsburgh. Their ages varied from 6 months to 72 years old with a mean of 35.9 years; 125 were male (54.3%). During this eight month period, hepatic blood flows were measured in 51 liver allografts of 42 patients after OLTx (18.8%). Of these, 35 grafts in 28 pediatric patients underwent elective flow measure-ments, and II grafts in ten adult and one pediatric patient under-went emergency blood flow measurements. None of the patients were hemodynamically unstable at the time of flow measurement. Blood Flow Measurement Blood flows in the HA and PV were measured with a square-wave electromagnetic flowmeter, Cliniflow lit>, Model FM701 D (Caro-lina Medical Electronics, Inc., King, North Carolina). Probes which fit the vessels snugly were selected for the measurement. A zero flow reference was obtained by placing the probes in an isolated ground in a plastic beaker filled with normal saline. At the time of flow measurement, the heart rate, blood pressure, central venous pres-sure, urine output, the dose of va so pressors and, when available, pulmonary artery pressure and cardiac output were recorded. RESULTS Elective Blood Flow Measurement Of the 35 grafts in the 28 pediatric patients who underwent elective flow measurements, six (21.4%) had HA flows of less than 60 mL/min. Table 1 lists the flow data of these six patients. Of these six, five patients (83.3%) developed HA thrombosis; four with complete and one with partial throm-bosis. Three of these grafts in three patients (10.7%) demon-strated abnormally low HA flows in the presence of good pulsation of the HA (Cases 2, 3,4). Cases 2 and 3 received no additional definitive procedures, with an assumption that there was flowmeter malfunction. In both cases, HA throm-bosis was confirmed immediately postoperatively. In Case 4, Table 1. Flow Data among Pediatric Patlente Who Exhibited Abnormally Low Flow with Good Pulaatlon of the Hepatic Artery Liver Flow (ml/min) Cese Age/Sex Disease HA PV Outcome 1 10 molM CBA 50 - HAT, required OL Tx II 2 17 molF CBA 0 530 HAT, alive and well 3 36 mo I F Alagille 35 380 intraop. HAT of right branch, died during OL Tx II 4 23 molF CBA 0 1100 intraop HARec for HAT, (50)· recurrent HAT, OL Tx II 5 18 molF CBA 30 - HAT, required OL Tx II 6 7 molM CBA 50 200 HA patent, alive and well ( ). - now data after hepatiC artery reconstruction; HA -hepatic artery; PV - portal vein; CBA - congenital biliary atresia; HAT - hepatiC artery thrombosis; OL Tx II - second orthotopic liver transplantation; HARec - hepatiC artery reconstruction. HA thrombosis was confirmed intraoperatively by taking down the HA anastomosis. Replacement of the donor celiac axis and common hepatic artery with an interposition arte-rial graft (donor iliac artery) improved the flow to 50 mL/min. However, this patient also went on to develop HA thrombosis postoperatively. Emergency Blood Flow Measurement As shown in Table 2, 11 patients underwent emergency flow measurements. Indications were intraoperative or postopera-tive HA thrombosis in five (455'k) and clinical impression of poor HA flow in six patients (54.5%). Among the five patients who underwent flow measurements for intraopera-tive or postoperative HA thromboses, Case 10 underwent a composite HA reconstruction, in which an aortohepatic interposition graft was anastomosed to the donor proper hepatic artery, and the recipient aberrant right hepatic artery was anastomosed to the donor aberrant right hepatic artery. Of the six patients who underwent flow measure-ments for poor inflow, three of these patients (50%) under-went a definitive procedure to increase inflow; 1) aortohe-From the Department of Surgery, University Health Center of Pittsburgh, University of Pittsburgh, and the Veterans Administra-tion Medical Center, Pittsburgh. Pennsylvania, USA. Address reprint request to Thomas E. Starzl. MD, PhD, Depart· ment of Surgery, 3601 Fifth Avenue, Falk Clinic 4 West, Pitts· burgh, Pennsylvania 15213, USA. Supported by Research Grants from the Veterans Administra· tion and Project Grant No. AM 29961 from the National Institute 01 Health, Bethesda, Maryland. <C> 1989 by Appleton & Lange,lnc. 0041:1345/89/$3.00/ +0 2330 Transplantation Proceedings, Vol 21, No 1 (February), 1989: pp 2330-2331 BLOOD FLOW MEASUREMENT Table 2. Flow Data among Patients Who Underwent Emergency Blood Flow Measurement Flow (mil min) Case Age/Sex Indication HA PV Outcome 36/F AHIG lor poor 190 HA patent, alive and inflow well 2 63/F SA ligation 200 1800 HA patent, alive and lor poor in· 650' 2100' well flow 3 57/M HARec with 150 2400 HA patent, alive and recipient 320' 1800' well RHA lor poor inflow 4 50/M weakHA 600 HA patent, alive and pulse well 5 39/F weak RHA 400t HA patent, alive and pulse 115* well 6 391M weakHA 300 PGNFN with HAT, pulse required OL Tx II 7 291M AHIG after in· 210' 1500' HA patent, alive and traop. HAT well 8 19/F Revision 01 900' 1000' died 01 ruptured AHIG after aortic pseudo· intraop. aneurysm HAT 9 211M Revision 01 70 650 HAT, required OL Tx AHIG for in· 120' II trsop. HAT 10 60/F compOSite 2oo't HA petent, alive and HARec al· 180'* well ter intraop. HAT 11 2/M AHIG after 45' HAT, alive and well postop. HAT 'flows after hepatic artery reconstruction; tf!ows in the proper hepatic artery; *"ows in the right hepatic artery; HA - hepatic artery; PV - portal vein; AHIG - aortohepatic interposition graft; SA - splenic artery; HARec - hepatic artery reconstruction; RHA - right hepatic artery; PGNFN - primary graft non·function; OL Tx II - second orthotopic liver transplantation; HAT - hepatic artery thrombosis. patic interpositon graft (Case I), 2) splenic artery ligation (Case 2) and 3) conversion of the inflow vessel to the recipient aberrant right hepatic artery (Case 3). The other three patients (50%) demonstrated ad~uate HA flow by 2331 flowmeter. Of these II patients, HA in nine patients (75%) remained patent, whereas three patients (25%) in whom HA had flows of 120, 300 and 45 mL/min. developed HA thrombosis. In case 6. HA thrombosis was found at the time of retransplantation for primary graft nonfunction at seven days after the inital OL Tx, DISCUSSION Of the various vascular complications during or following OL Tx. HA thrombosis represents one of the most significant and devastating complications, which has been attributed in large part to technical difficulties. which include anatomical variation. the deep location of the vessels as well as the caliber of the anastomosis.s" The present study clearly demonstrates that routine measurement of blood flow in pediatric OL Tx can be extremely helpful. since the flow determinations can alert the surgeon to an unrecognized HA thrombosis or to an abnormally low HA flow. This occurred in six out of 28 children (21.4%) in this study. The results from this study further emphasize that palpa-tion of the HA after HA anastomosis is not necessarily a reliable method to examine HA patency or flow, and that strong pulsatile flow from the amputated distal donor splenic artery merely suggests good inflow to that point, and does not necessarily verify the presence of distal arterial patency. The other contribution of blood flow measurements after OL Tx is the acquisition of objective data on hepatic arterial flow following reconstruction of the HA for HA thrombosis. Although our experience in the measurement of blood flow after such arterial revision has been limited, low HA flow after the revision may be associated with recurrent HA thrombosis. REFERENCES J. Tzakis AG. Gordon RD, Shaw BW Jr. et al: Transplantation 40:667,1985 2. Lerut J, Tzakis AG, Bron K. et al: Ann Surg 205:404. 1987 3. Bradley SE. Ingelfinger FJ. Bradley GP. Curry JJ: J Clin Invest 24:690, 1945 4. Mathie RT: In Mathie RT (cd.): Blood Flow Measurement in Man, London. Castle House. p 139, 1982 5. Shaw BW, Iwatsuki S, StarzI TE: Surg Gynecol Obstet. 159:491.1984 6. Esquivel CO, Koneru B. Karrer F. et al: J Pcdiatr 110:545, 1987 I I ) l 

Significance of blood flow measurement in clinical liver transplantation.

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Significance of blood flow measurement in clinical liver transplantation.

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