Peritransplant vascular complications: An IR approach

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Ahmed and Ramalingam
Muneeb Ahmed and Vijay Ramalingam

In the USA, liver transplantation continues to be the best chance at long-term survival for patients suffering from the sequelae of end-stage liver disease. However, recent data from the Organ Procurement and Transplant Network (OPTN) suggest that there are 13,000 patients in the USA who are listed for liver transplant at any given time. Of that number, a high percentage of patients will either pass away while waiting for liver transplantation or be delisted due to complications of liver disease making transplantation difficult or impossible. For many of these patients, we have found that interventional radiology (IR) and the techniques we are able to offer can help prolong patient survival on a waiting list or reduce the number of delistings due to technical limitations.

With that said, many of the patients who do go on to receive a successful liver transplant, will end up with post-transplant liver complications. This could be as many as 30% of patients, and a significant number can benefit from endovascular or percutaneous intervention. The benefit of a multidisciplinary approach and, specifically, the use of endovascular techniques for many peritransplant vascular complications, is the ability to avoid major surgery or revisions.

Although peri-liver transplant patients comprise such a complex group, of whom many could benefit from these IR services, there are data to suggest that a large number are still not being offered interventional services in both a pre- and post-transplant setting. Some of the contributing factors are lack of awareness among referring providers regarding the services we can provide; lack of patient awareness; and lack of consensus among interventional radiologists themselves about the best treatment plans for these
complex patients.

Our own experience has been that when patients are offered interventional radiology services, the outcomes of liver transplantation for our centre as a whole improves. Formal incorporation of IR into the Multidisciplinary Liver Transplant group (including representation on the Liver Selection Committee), and establishment of an IR and hepatology-led multispecialty portal venous thrombosis clinic are some of the ways in which our IR team has provided access to many of the advanced techniques that should be offered to the Liver Transplant patient cohort. Indeed, use of advanced portal vein recanalisation techniques, pretransplant large portosystemic shunt embolization, and optimisation of liver graft arterial flow through hepatic artery stenting and splenic embolization for portal hyperperfusion are examples of how IR can maximise liver transplant centre outcomes.

Given the current issues facing pre- and post-hepatic transplantation vascular management, we proposed the ‘Advanced IR hepatic and splenic vascular interventions in peritransplant patients’ course as a new forum for the recent Society of Interventional Radiology (SIR) 2022 Annual Scientific Meeting, Boston, USA. This session provided a forum for experts in the field to discuss these complex cases in a format that generated robust discussion and questions.

Muneeb Ahmed is chief of the division of vascular and interventional radiology and vice chair for interventional services at Beth Israel Deaconess Medical Center, Boston, USA. He is also associate professor of radiology at Harvard Medical School, Boston, USA.

Vijay Ramalingam is co-director of interventional radiology for the Mesenteric Venous Thrombosis Program at Beth Israel Deaconess Medical Center. He is also an instructor at Harvard Medical School.

The authors declared no relevant disclosures.


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