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Reply to letter to editor by Yilmaz S, et al.

  • Min Xu
    Affiliations
    Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nankai District, Tianjin 300192, China

    Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, No. 24 Fukang Road, Nankai District, Tianjin 300192, China
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  • Wei Gao
    Correspondence
    Corresponding author.
    Affiliations
    Department of Pediatric Transplantation, Organ Transplantation Center, Tianjin First Central Hospital, No. 24 Fukang Road, Nankai District, Tianjin 300192, China

    Tianjin Key Laboratory of Organ Transplantation, Tianjin First Central Hospital, No. 24 Fukang Road, Nankai District, Tianjin 300192, China
    Search for articles by this author
      We have received a letter from the reader regarding our article entitled “Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age”, which was published in the Journal of Pediatric Surgery [
      • Xu M.
      • Dong C.
      • Sun C.
      • et al.
      Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age.
      ]. The reader has mentioned a series of very helpful questions about this article. After careful discussion of these questions among the authors, we would like to offer the following answers to these questions.
      • 1.
        First, we would like to emphasize that the donors in our study were all younger than one year of age, which is very different from the literature [
        • Kutluturk K.
        • Sahin T.T.
        • Karakas S.
        • et al.
        Early hepatic artery thrombosis after pediatric living donor liver transplantation.
        ,
        • Sheiner P.A.
        • Varma C.V.
        • Guarrera J.V.
        • et al.
        Selective revascularization of hepatic artery thromboses after liver transplantation improves patient and graft survival.
        ,
        • Lin T.S.
        • Vishnu Prasad N.R.
        • et al.
        What happened in 133 consecutive hepatic artery reconstruction in liver transplantation in 1 year?.
        ] enumerated by the reader and is also a special point we would like to emphasize.
      • 2.
        We agree that the therapeutic choices, such as surgical intervention, radiological intervention, and conservative anticoagulant therapy are based on the condition of the recipients, including clinical manifestations, liver function tests (LFTs), the findings of hepatic artery by ultrasound (US), timing of hepatic artery thrombosis (HAT), etc. If LFTs show mild elevation and US shows a weak arterial waveform, conservative anticoagulant therapy may be selected, and the patients must be closely followed. In fact, we also choose different treatment options according to the specific condition of the recipients. Re-transplantation should be considered immediately for the recipients with deteriorated liver function without tendency to reverse. For recipients with slight changes in graft function, we choose regular monitoring and anticoagulant therapy. Since we maintained the international normalized ratio (INR) between 2 and 2.5, it was safe for the recipients, and no recipients suffered from bleeding. So, we did not mention bleeding-related complications in the study.
      • 3.
        Surgical thrombectomy and interventional therapy were performed in our center at an early period for pediatric recipients who received young donors, but the success rate was low. Because of the small sample size, statistical analysis could not be used. We tend to think that the prognosis of HAT in recipients who received younger donors was different from those who received older donors. The possibility of graft loss is higher in the latter population once HAT occurs. This may be related to the greater vulnerability of older donors when they are subjected to injury [
        • Feng S.
        • Lai J.C.
        Expanded criteria donors.
        ]. In contrast, children receiving younger donors may have different outcomes after HAT, but the mechanism is unclear.
      • 4.
        Our article focuses on the analysis of recipients who received liver grafts from donors under one year of age. Because of the high variability of the pediatric population, this result may not be applied to recipients who received older grafts. For patients with early HAT after living donor liver transplantation (LDLT), surgical thrombectomy and re- anastomosis will be the first treatment once thrombosis occurs [
        • Channaoui A.
        • Tambucci R.
        • Pire A.
        • et al.
        Management and outcome of hepatic artery thrombosis after pediatric liver transplantation.
        ], although the incidence of HAT was extremely low for LDLT. From 2014 to 2019, the incidence of HAT in LDLT in our center was 0.47% (3/638). On the other hand, as was mentioned in the literature [
        • Akbulut S.
        • Kutluturk K.
        • Yilmaz S.
        Hepatic artery reconstruction technique in liver transplantation: experience with 3000 cases.
        ] cited by the reader, “There is no clear answer to the question of up to which day surgical revascularization can be performed in the early post-transplant period. Although surgical revascularization attempts have been performed until the second month after LT, the success rate of this procedure after the first 5 days is poor.”. Therefore, we think the conservative coagulation therapy is a more ideal treatment in these cases.
      • 5.
        There was no HAT related liver abscess in our follow-up data. This may be because of the formation of arterial collaterals that maintain the blood supply to the graft, thereby avoiding the development of an abscess. However, a small number of patients receiving older grafts developed HAT related liver abscess and needed percutaneous drainage. Despite the higher incidence of biliary complications in this subset of recipients who developed HAT, all achieved satisfactory outcomes with interventional treatment [
        • Lee A.Y.
        • Lehrman E.D.
        • Perito E.R.
        • et al.
        Non-operative management of biliary complications after Liver Transplantation in pediatric patients: a 30-year experience.
        ,
        • Peregrin J.H.
        • Kováč J.
        • Prchlík M.
        • et al.
        Interventional radiological treatment of paediatric liver transplantation complications.
        .
      • 6.
        The reader mentioned that there is consensus that GRWR was an ideal ratio between 2% and 3%. However, our previous studies have also shown that GRWR less than 2.2% was identified as independent risk factor for HAT [
        • Ma N.
        • Song Z.
        • Dong C.
        • et al.
        Risk factors of hepatic artery thrombosis in pediatric deceased donor liver transplantation.
        ]. Obviously, small GRWR are more likely to cause HAT. In addition, artery reconstruction techniques are equally important. During artery reconstruction, we usually take the coeliac trunk patch at the junction between coeliac trunk and aorta from the donor; as for recipient, the patch at the junction of the right and left hepatic artery or the patch at the junction of the common hepatic artery and gastroduodenal artery was prepared for patch-to-patch continuous anastomosis. In a few cases, the artery anastomosis was performed between donor coeliac trunk end and recipient proper hepatic artery end in an interrupted manner.
      • 7.
        Extremely desirable donors are difficult to obtain because of donor shortage [
        • Hsu E.K.
        • Mazariegos G.V.
        Global lessons in graft type and pediatric liver allocation: a path toward improving outcomes and eliminating wait-list mortality.
        ]. As expected from all transplant physicians, we are also hoping to reduce the mortality to zero among children on the waiting list [
        • Mazariegos G.V.
        • Soltys K.A.
        • Perito E.R.
        Wait list mortality in pediatric liver transplantation: the goal is zero.
        ]. Although the incidence of HAT in recipients was higher and the occurrence of HAT was more likely to lead to biliary complications in this type of donor, the recipient survival and graft survival under effective treatment was still acceptable, as shown in our study [
        • Xu M.
        • Dong C.
        • Sun C.
        • et al.
        Management and outcome of hepatic artery thrombosis with whole-liver transplantation using donors less than one year of age.
        ]. Therefore, we still hold on to our view that when determining whether such donors can be used, patient survival and graft survival should be used as the decisive criteria, rather than whether HAT occurs. If HAT occurs in a relatively high proportion but has less impact on graft survival, it can still be applied with strict selection.
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