IntroductionTransjugular intrahepatic portosystemic shunt (TIPS) placement after liver transplantation (LT) has been reported in a limited number of studies, with controversial results. Prognosis of these patients is still unclear. This study aims at evaluating both long-term graft-/patient-survival and which patients could eventually benefit from this procedure in the post-LT settingMethodsPatients who underwent TIPS for post-LT portal hypertension- or venous-related complications in our two Italian Transplant Centers were retrospectively evaluated. Clinical success was defined according with “SIR Quality Improvement Guidelines for TIPS”. Patients’ follow-up was until death or June 30th 2023.ResultsBetween 2002 and 2021, 74 patients underwent TIPS insertion after LT. Patients were more frequently males (77.0%), with a median age at LT of 52 years (range 18-69) and predominantly viral etiology (74.3%). TIPS was performed after a median time of 11 months (0.6-154) following LT. More frequent indications were: Refractory Ascites (44.6%), Sinusoidal Obstruction Syndrome-related ascites (31.1%), high-risk Gastroesophageal Varices (9.5%) and Portal Vein Thrombosis (6.8%). Recurrence of cirrhosis at the time of TIPS was documented in 30 patients (40.5%). Mean pre-TIPS MELD-score was 13.4±4.4; mean Porto-Systemic pressure Gradient was 15.2±5.4 mmHg pre-TIPS and 6.9±2.9 mmHg post-TIPS. Clinical success was achieved in 57 patients (77.0%). During the follow-up, 26 patients (35.1%) developed at least one episode of encephalopathy; shunt stenosis/occlusion was recorded in 19 patients (25.7%). Median follow up was 47.9 months (0.13-262). Graft- and patient-survival rates at 1, 3 and 5 years post-TIPS were 72.8%, 51.4%, 39.6% and 76.8%, 62.6%, 50.1% respectively. Graft-survival rates were significantly better in patients with age at TIPS <65 years, a time OLT-TIPS <12 months, a pre-TIPS MELD<15 and in patients without cirrhosis recurrence and a pre-TIPS SOS-related refractory ascites.ConclusionsPatients undergoing TIPS insertion after LT showed a 5-year graft-survival post-TIPS of nearly 40%; patient selection can improve survival rate to 65%.

MethodsThree LT types are included according to the donor: standard Deceased Brain Donors (DBDs); Deceased Cardiac Donors (DCDs); high-risk DBDs; Living donors (LDs). The data collection (retrospective/completed or prospective/ongoing includes [high volume (>65 LTs/yr) and intermediate-volume (≤65 LTs/yr)]. Each Center enrolled a fixed number of LT to minimize Center-volume bias.ResultsThe retrospective data consists of 3,884 LT from 2017 to 2019. There were 2958 (76.2%) standard DBDs, 797 (20.5%) DCD & amp; high-risk DBDs, 129 (3.3%) LDs. We stratified the cases into 5 geographical areas (Fig. 1A): Italy (N=1,766); Europe except-Italy (N=936); Asia-Oceania (N=496); North-America (N=377); South-America (N=309). Among the 53 LT centers of the retrospective cohort, there were 27 high-volume centers and 26 intermediate-volume centers). Italy and Asia had the larger adoption of machine perfusion, while DCDs were prevalent in Europe and North-America. Extended Criteria Donors (ECD) were mainly performed in Italy and North-America. Italy shows the highest donor age followed by Europe except Italy, North-America, South-America and Asia-Oceania. The mean recipient age was similar in all the areas, with a prevalence of hepatocarcinoma in Italy (Fig. 1B). The differences in the prevalence of other indications are summarised (Fig. 1C).ConclusionsThe analysis of IMPROVEMENT data depicts a screenshot of global liver transplant activity, never done before. Differences are due to epidemiological and logistic factors. The prospective data (ongoing) will provide more accurate information.

BackgroundIn pts with ALD and ACLF a clear characterization of bacterial (BI) and fungal infections (FI) and their impact on survival is still lacking.Aimsto define prevalence and characteristics of BI/FI and their influence on survival and liver transplant need in a population with ACLF and alcoholic cirrhosis(AC).Materials and methods62 pts with ACLF and AC were consecutively admitted at our center from Jan 2016 to Jan 2023. Data on BI and FI were recorded at diagnosis and during hospitalization.Results36 patients at admission (58% of the whole population) presented with FI (5-13.9%) or BI (31- 86.1%). In 6 cases (16.6%) infections coexisted with AH. The distribution of the infection site and identified pathogens is shown in Figure 1. FI were severe, with 2 cases of Aspergillus pneumonia and 3 invasive Candidiasis. Also pts with a suspicious BI were treated. Piperacillina/tazobactam was the most frequent first-line empirical treatment (31 pts -56.5%).A switch to targeted therapy was necessary in 18 pts (58%);antifungal therapy was always targeted. A severe ACLF (grade II or III) was more frequent in infected patients (group A) compared to the others (group B - 72% vs 50%; p=0.07). At OLT, 8 (61.5%) among gA had an ACLF grade 2 or 3 (vs 3- 42.8% gB; p = 0.42).29 pts (46.7%) died, 20 in gA (55.6%) and 9 in gB (34.6%; p=0.10; OR gA/gB 2.36). The OLT free survival was 48 days in gA vs 56 days in gB; p=0.20. None of the pts with MDRO/FIs before transplant had a recurrence of the same pathogen after OLT.Conclusionsour study suggests the tendency to a worse outcome in infected patients. The prevalence of combined MDRO plus FI was high (30.5%). Among the recipients with MDRO/fungal before surgery, none showed a recurrence of the same pathogens.

BackgroundOLT is an effective option in ACLF, AH and sAH. However, is still unclear how many patients with a potential indication, can eventually access this option.Aimsto evaluate the real access rate of waitlisting for liver transplant and the rate of recurrence of alcohol use disorder (AUD) after OLT in pts with ACLF and ALD.Materials and methodsWe retrospectively analyzed 62 patients with ACLF and ALD admitted at our center from Jan16 to Jan23. The following scores were used to assess patient status at baseline and during fup: MELD-Na, Maddrey DF, GAHS, ABIC, Lille, Child-Pugh, CLIF-ACLF, CLIF-SOFA. Alcohol relapse after OLT was defined by the presence of signs/biochemical alterations associated with heavy alcohol use.ResultsThe clinical characteristics of the population are summarized in Table 1. 57 pts (92%) were potentially transplantable for age. 19 pts (31.6 %) were waitlisted or experienced a change in UNOS priority after the development of ACLF. 3 patients (4.8%) were already waitlisted maintaining an unmodified UNOS status after ACLF development.40 pts (66.6%) were never waitlisted: the most common reasons for ineligibility are shown in Table 2. Overall 20 pts were transplanted. Among them, the prevalence of AUD was relevant (7 pts-35%). During follow-up, 6 recipients (30%) experienced alcohol misuse after a median time of 1019 d [410-1564 d]; 2 pts (10%) developed ALD and died of liver failure.ConclusionsOLT represents an effective option in pts with ACLF and ALD. However, the access to waitlist is very limited mostly because of multiple active substances abuse and inadequate psychosocial profile. The recurrence of alcohol abuse was more frequent in pts without AUD at admission. The involvement of addiction center specialists in post-LT follow-up might be enforced as a potentially protective action against alcohol abuse.

BackgroundPatients with ACLF superimposed to alcoholic cirrhosis (AC) represent a peculiar subpopulation characterized by hampered access to OLT, potentially risk of graft failure due to alcohol use relapse and increased susceptibility to infections. Aims: To assess the evolution of ACLF superimposed to alcoholic cirrhosis (AC), need for critical care, transplantation and survival rates.Materials and methodsThe clinical data of 62 patients with ACLF and AC admitted at our center from Jan16 to Jan23, were retrospectively analyzed. The following scores were adopted to assess patient status: MELD-Na, Maddrey DF, GAHS, ABIC, Lille, Child-Pugh, CLIF-ACLF, CLIF-SOFA. Patient's eligibility for transplantation were routinely evaluated by a multidisciplinary team.Resultsthe clinical characteristics of the population are summarized in Table 1. The majority of patient (54 - 87%) presented with an identifiable trigger, with bacterial infections being the most common, followed by acute alcoholic hepatitis. 6 pts (9.6%) presented with both infection and AH. ACLF grades at presentations were: 34% ACLF-1, 37% ACLF-2, 29% ACLF-3.29 pts (47%) showed a rapid and positive response to the first line treatment, while 14 (23%) remained stable and 19 (30%) worsened. 20 pts (32%) were admitted at ICU/HDCU with the following median scores: CLIF-ACLF score 61 [52-65]; CLIF-SOFA 13 [IQR 12-14]; Meld 29 [26-35]. Seven pts (37%) needed continuous renal replacement therapy (RRT); 14 pts (74%) needed major vasopressor support; 10 patients underwent orotracheal intubation (OI) both for lung failure (7 pts- 37%) or severe HE (3 pts-15%).20 patients (32%) were transplanted, with the following condition severity at the time of OLT: 33% no ACLF, 6% ACLF-1, 28% ACLF-2, 33% ACLF-3. 29 patients died during follow-up (47%), 7 of which after OLT (35%). No deaths were observed in waitlisted patients while 2 recipients (10%) died in the immediate post-operative period. OLT-free survival at 1 year was very poor (20%), while overall survival (OS) at 1 and 5 years in transplanted patients was 90% and close to 60%.ConclusionsOLT represents an effective therapeutic option in patients with ACLF and alcoholic cirrhosis, with most patients showing an improvement in survival after OLT despite the severity of the condition at the time of transplantation. However, OLT is not a viable option in most of such patients due to the presence of severe psychosocial contraindications, frequently associated with AUD.

Introduction: Patients with biliary atresia (BA) undergoing liver transplantation often have complex vascular reconstructions of the portal vein (PV) due to PV hypoplasia. The use of venous homograft (VH) is a surgical option in demanding PV reconstruction to guarantee optimal venous inflow. The long-term outcomes of this procedure are still unclear. Methods: We selected paediatric patients under 3 years of age affected by BA who underwent split liver transplantation (SLT) with left lateral segments (LLS) from donation after brain death (DBD) between 2006 and 2022. The split liver technique was conducted in vivo through the umbilical fissure and plate. Results: A total of 144 SLT was selected. Kasai procedure had previously been performed in 88.2%. 21 patients underwent VH placement (VH group) and 123 performed direct PV anastomosis (non-VH group). We compared the results between the two groups. The median follow-up period was 12.5 years in the VH group and 4.8 in the non-VH group. PV complications occurred in 24 patients (16.7%), respectively 2 in the VH group and 22 in the non-VH group (p = 0.53). Thrombosis and stenosis occurred in 10 (0 vs 10) and 14 (2 vs 12) cases. The re-transplantation rate was similar (14.3% vs 14.6%). 5-year graft (81.0% vs 82.3%) and patient survival rates (85.4% vs 93.3) did not differ significantly in the two groups. Conclusions: VH interposition in LLS is an effective alternative to direct PV anastomosis for paediatric patients with BA. This procedure does not impact on complication rate and long-term outcomes.

Introduction: A totally “de-arterialized” liver is an organ characterized by simultaneous hepatic artery (HA) ligation/resection associated with complete interruption of all collateral sources of arterial inflow. In this situation, if the HA is not reconstructed, biliary ischaemia is inevitable and liver failure is possible. Portal vein arterialization (PVA) is a surgical procedure aimed to supply a de-arterialized liver with arterial blood flow through the portal vein (PV). Most frequently, PVA is a “rescue” procedure in unexpected HA thrombosis or injury; instead, in an oncological setting it can be “planned” to resect liver lesions abutting the distal HA. Case presentation: We describe a case of a 49-year-old patient who underwent left hepatectomy with caudate lobe resection for an hilar cholangiocarcinoma (Bismuth type 3b). At the end of the procedure, there is no flow in the right HA, which appears dissected on section. All attempts to resect and anastomose right HA failed due to the progression of the thrombosis. We performed termino-lateral anastomosis between common HA and PV. Pathological report showed a small (diameter 0.3 mm) moderately differentiated cholangiocarcinoma. After 9 months a TC scan shows a PV confluence size increased (diameter 45 mm), but no portal flow inversion, nor biliary duct stenosis. Indeed, no bleeding, nor ascites, nor progression of fibrosis is found during follow up. Conclusion: PVA is a procedure burdened by severe surgical complications, conditioning a high rate of morbidity and mortality. In selected cases, it can play an important rescue role in the surgical therapy of cholangiocarcinoma.

Introduction: Hepatocellular carcinoma (HCC) recurrence rates after liver transplantation (LT) range between 8 and 20%. Elevated alpha-fetoprotein (AFP) levels at transplant can predict post-transplant HCC recurrence, however a clear cut-off value is needed in order to identify patients at higher risk, aiming at improving surveillance program after LT.

Mycotic aneurysm of the hepatic artery (HA) is a rare, unpredictable, and potentially lethal complication of liver transplantation (LT). Pediatric LT is not exempt from it but the related literature is rather scanty. We present our experience with post-LT mycotic aneurysm of the HA in pediatric age, describing four cases occurred with a special focus on the possible risk factors for its development and a proposal for the management of high-risk recipients.