Liver Transplant Complications

Biliary obstruction: 10-15%, most common, the “Achilles heel of liver transplantation”

Often 5-8 mo after transplant. Early obstruction is often due to anastomotic edema and inflammation that resolves conservatively.
Non-anastomotic strictures often due to ischemia from hepatic artery compromise and harder to treat. Other etiologies include ABO incompatibility, protracted cold ischemia, PSC, PBC, and CMV infection.
Endoscopic stent is first line with exchange every 3 mo, often for 12-24 mo.
Percutaneous biliary drain is second line and can be up to 85% successful.

Hepatic artery thrombosis: 9-12%

Associated with pediatric transplant, operator error, excess length with kinking, MALS, and hypercoagulability
Early thrombosis often more severe than late due to lack of collaterals leading to graft failure, biliary necrosis, abscesses.
~75% require retransplant. Catheter directed therapy with thrombolysis and stenting successful in ~46% with high complication rate and 42% still requiring retransplant within 2 months.
Stenting improves patency over angioplasty alone. Substantially decreased patency rates with stents <5 mm.

Hepatic artery stenosis: 5-12%

Often at anastomosis associated with operator error, kinking, or intimal hyperplasia.
Untreated, 65% progress to thrombosis within 6 mo. Endovascular treatment prevents this in 95% of cases.
Overall more of a role for endovascular management with angioplasty 80% successful compared to thrombosis.
Increased risk of arterial rupture with plasty if within 2 wks of transplant
Stenting superior to plasty alone in terms of 2yr patency (78% vs 0%) and longer time to reintervention

Venous anastomotic stenoses: >5 mmHg pressure gradient

Can be portal or hepatic veins, mildly more common with piggyback anastomoses.
Often treated with angioplasty +/- stenting, which can be done via transhepatic access.
If hepatic vein stenosis within 4 wks of transplant, primary stenting is better due to risk of rupture with aggressive venoplasty.
For piggyback, you often only need to stent the right hepatic vein.

Splenic steal syndrome: rare source of post-transplant hepatic dysfunction due to preferential splenic arterial flow