Ann Liver Transplant.  2022 Nov;2(2):157-161. 10.52604/alt.22.0026.

Asymptomatic migration of hemashield vascular graft used for middle hepatic vein reconstruction of living donor liver transplantation

• Oh RK
• Ahn CS
• Moon DB
• Ha TY
• Song GW
• Jung DH
• Park GC
• Kang WH
• Yoon YI
• Lee H
• Hwang S

• KMID: 2560912
• DOI: http://doi.org/10.52604/alt.22.0026

Abstract

Middle hepatic vein (MHV) reconstruction with interposition vessel graft has been established as a standard procedure for living donor liver transplantation (LDLT). Unwanted migration of a synthetic vascular graft into the hollow viscus has been sporadically reported. We herein present a case of Hemashield graft migration into the duodenum following LDLT. A 64-year-old male patient presented with LDLT due to liver cirrhosis and hepatocellular carcinoma. The MHV openings in the right liver graft were reconstructed with a 10 mm-sized Hemashield graft, which was anastomosed to the common opening of the recipient middle-left hepatic vein trunk. The patient had uneventful recovery after LDLT surgery. Computed tomography (CT) scans taken at one year and two years showed no abnormal finding. However, gastroduodenoscopic examination at two years revealed accidental migration of the Hemashield graft into the duodenal bulb. The patient had no signs or symptoms and no problems with diet. The Hemashield graft migration was identified by retrospective review of 1-year and 2-year CT scans probably due to no radio-opacity of Hemashield graft. Because of the potential risk of Hemashield graft migration-associated complications, surgical removal was recommended, but the patient wished to observe more. The patient has been doing well for two years six months after LDLT. In conclusion, every synthetic vascular graft can penetrate adjacent organs and soft tissues, and its incidence is not negligibly low. Lifelong surveillance is necessary to detect unexpected rare complications in LDLT recipients who have MHV reconstruction using synthetic vascular grafts.

Keyword

Hepatic venous congestion; Liver transplantation; Hemashield graft; Middle hepatic vein; Hollow viscus

Figure

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  Figure 1 Computerized tomography (CT) findings before and after liver transplantation. Pretransplant CT images showed over liver cirrhosis (A, B). CT scan taken 1 week after transplantation showed no abnormal findings with good patency of the Hemashield graft conduit (C, D) (arrows).

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  Figure 2 Follow-up computerized tomography (CT) scans. The Hemashield conduit showed good patency at the 1-month CT (A), partial occlusion at the 2-month CT (B), and near-complete occlusion at the 3-month CT (C). One-year CT scan showed complete luminal occlusion of the Hemashield graft conduit, but its location within the duodenum was not identified (D). Arrows indicate the location of a Hemashield graft conduit.

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  Figure 3 Follow-up computerized tomography (CT) scans with overt findings of Hemashield graft migration (arrows). A Hemashield graft was located within the duodenum in the 2-year CT scan, but this finding was missed due to lack of radio-opacity (A, B). Follow-up CT scan taken after two years and six months showed no significant change in the location of the migrated Hemashield graft and its surrounding tissue reaction (C, D). Arrows indicate the location of the Hemashield graft.

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  Figure 4 The gastroduodenal endoscopic finding of Hemashield graft migration taken years after transplantation. The distal stump of the Hemashield graft is located within the duodenum (A). The Hemashield graft penetrates the duodenal wall without severe inflammation at the duodenal wall (B).

Reference

1. Hwang S, Jung DH, Ha TY, Ahn CS, Moon DB, Kim KH, et al. 2012; Usability of ringed polytetrafluoroethylene grafts for middle hepatic vein reconstruction during living donor liver transplantation. Liver Transpl. 18:955–965. DOI: 10.1002/lt.23456. PMID: 22511404.

2. Yi NJ, Suh KS, Lee HW, Cho EH, Shin WY, Cho JY, et al. 2007; An artificial vascular graft is a useful interpositional material for drainage of the right anterior section in living donor liver transplantation. Liver Transpl. 13:1159–1167. DOI: 10.1002/lt.21213. PMID: 17663413.

3. Ha TY, Hwang S, Jung DH, Ahn CS, Kim KH, Moon DB, et al. 2014; Complications analysis of polytetrafluoroethylene grafts used for middle hepatic vein reconstruction in living-donor liver transplantation. Transplant Proc. 46:845–849. DOI: 10.1016/j.transproceed.2013.10.054. PMID: 24767363.

4. Hsu SC, Thorat A, Yang HR, Poon KS, Li PC, Yeh CC, et al. 2017; Assessing the safety of expanded polytetrafluoroethylene synthetic grafts in living donor liver transplantation: graft migration into hollow viscous organs - diagnosis and treatment options. Med Sci Monit. 23:3284–3292. DOI: 10.12659/MSM.902636. PMID: 28683053. PMCID: PMC5510995.

5. Jung IJ, Hwang S, Ha TY, Song GW, Jung DH, Ahn CS, et al. 2020; Long-term patency and complications of ringed polytetrafluoroethylene grafts used for middle hepatic vein reconstruction in living-donor liver transplantation. Korean J Transplant. 34:31–37. DOI: 10.4285/kjt.2020.34.1.31. PMID: 35770268. PMCID: PMC9186820.

6. Kim MJ, Kim HB, Han JK, Suh KS, Kim SH, Baek JH, et al. 2011; Injuries of adjacent organs by the expanded polytetrafluoroethylene grafts in the venoplasty of middle hepatic veins in living-donor liver transplantation: computed tomographic findings and possible risk factors. J Comput Assist Tomogr. 35:544–548. DOI: 10.1097/RCT.0b013e318227a68a. PMID: 21926846.

7. Sultan AM, Shehta A, Salah T, Elshoubary M, Wahab MA. 2018; Spontaneous migration of thrombosed synthetic vascular graft to the duodenum after living-donor liver transplantation: a case-report. Int J Surg Case Rep. 45:42–44. DOI: 10.1016/j.ijscr.2018.03.013. PMID: 29571064. PMCID: PMC6000742.

8. Sevmiş M, Zarbaliyev E, Yıldız H, Alkara U, Aktaş S, Sevmiş Ş. DOI: 10.1080/00015458.2021.1966185. PMID: 34374632.

9. Koc C, Akbulut S, Bilgic Y, Otan E, Sarici B, Isik B, et al. 2020; Artificial vascular graft migration into hollow viscus organs in patients who underwent right lobe living donor liver transplantation. Acta Chir Belg. 120:404–412. DOI: 10.1080/00015458.2020.1778266. PMID: 32496869.

10. Woo HY, Hong SK, Cho JH, Lee JM, Choi Y, Yi NJ, et al. 2021; Complications of polytetrafluoroethylene graft use in middle hepatic vein reconstruction in living donor liver transplantation: a retrospective, single-centre, long-term, real-world experience. Transpl Int. 34:455–464. DOI: 10.1111/tri.13807. PMID: 33368682.

11. Park GC, Hwang S, Ha TY, Song GW, Jung DH, Ahn CS, et al. 2019; Hemashield vascular graft is a preferable prosthetic graft for middle hepatic vein reconstruction in living donor liver transplantation. Ann Transplant. 24:639–646. DOI: 10.12659/AOT.919780. PMID: 31844037. PMCID: PMC6936210.