S3212 Very Late Hepatic Artery Thrombosis After Orthotopic Liver Transplantation

Introduction: Hepatic artery thrombosis (HAT) is a serious complication after orthotopic liver transplantation (OLT) and is the most common vascular complication. It is often categorized into early HAT which is defined as occurring < 30 days after liver transplantation & late HAT defined as occurring > 30 days post transplantation. The etiology of HAT is often related to surgical factors, such as vessel kinking, anastomotic stenosis, and intimal dissection, but can factors such as hypercoagulability, elderly donors, and rejection episodes can contribute. Symptoms can often be vague with common complaints being abdominal pain, fever, nausea, & emesis. Case Description/Methods: A 68-year-old male with OLT (20 years prior to presentation) for primary sclerosing cholangitis (PSC), ulcerative colitis presented with 1 month history of nausea, emesis, and weakness. He was afebrile & hemodynamically stable. On physical exam, abdomen was soft, nontender, nondistended, and patient was jaundice. Laboratory data was notable for a two-month elevation of alkaline phosphatase, ALT, AST, direct bilirubin. An ultrasound of the liver with doppler evaluation was obtained that demonstrated an absence of flow in the left and right hepatic arteries within the liver. A computed tomography angiography (CTA) of the abdomen was obtained that confirmed these findings (Figure 1). Due to the history of PSC, a magnetic resonance cholangiopancreatography was obtained that showed no biliary dilation or evidence of recurrent PSC. A liver biopsy demonstrated paucicellular ductopenia with cholestasis consistent with chronic arterial insufficiency and no significant fibrosis. Transplant surgery and interventional radiology were consulted for potential recanalization. However, due to prolonged elevations in liver enzymes >4 weeks, both teams determined that recanalization would likely provide no benefit yet held greater risk. Discussion: This case highlights an uncommon, very late presentation of HAT. In the literature, late HAT has been described in the order of months, not years as it was in this case. It is usually associated with a less fulminant presentation and a milder course, in comparison to cases of HAT that present earlier in the post-transplant course. This case highlights the importance of considering HAT as a diagnosis in a patient with history of OLT who presents with abdominal pain, nausea, and emesis.Figure 1.: Focal filling defect in the hepatic artery seen in this venous phase CTA.