Hepatic artery complications after liver transplantation can be divided into 2 main categories: Steno-occlusive and non-occlusive. Steno-occlusive is more common and includes hepatic artery thrombosis (HAT), hepatic artery stenosis (HAS), and hepatic artery kinks (HAK) (Fig 1). Respectively these complications represent approximately 58%, 31% and 6% of arterial post-transplantation complications respectively. Non-occlusive arterial complications represents less than 5% of post-transplant arterial complications and is classified into decreased hepatic arterial flow, arteriovenous fistulae, pseudoaneurysms and arterial rupture.1,2

This article provides a brief review of the techniques required to obtain an accurate diagnosis of transplant arterial complications and then outlines endovascular or percutaneous management of these complex clinical scenarios. In addition, we will discuss relevant evidence to help support treatment options for these different situations. Due to the rarity of some of these complications, especially non-occlusive ones, management and treatment approaches remain anecdotal.

Due to the considerable variations in surgical anatomy, it is important to perform diagnostic angiography when encountering these complications despite of the prevalence and availability of diagnostic imaging including CTA and MRA. It is important to understand the type of arterial conduit as it will determine not only which vessel to interrogate but also guide the appropriate catheter selection.

Hepatic angiography is performed with standard catheter technique usually from a transfemoral approach however some angles may allow for easier access via a transradial or transbrachial approach. From a transfemoral approach, the native celiac artery is catheterized using 5 French catheters (C2 Cobra, Simmons, or SoS catheters). Aortohepatic conduits are more likely to course cephalad and can usually be accessed using 5 French angled catheters (Vertebral, H1 or Kumpe). In the current climate with the growth of cross-sectional imaging the authors generally do not perform abdominal aortography routinely.

Once the desired artery has been selected an arteriogram is performed using a power injector and digital subtraction angiography. Multiple projections including cephalad-caudad should be used to completely visualize all segments of the hepatic artery. These projections can often be deduced from careful review of prior cross-sectional imaging (Fig. 2). If an ostial stenosis is suspected then a lateral aortogram can be used to decrease time to first order characterization. In cases of poor renal function CO2 angiography can be used for first and second order angiography and gadolinium can be used in subselective angiograms.

Complete evaluation of the hepatic artery requires selective characterization to differentiate between hepatic artery thrombosis versus distal critical hepatic artery stenosis. After completion of the diagnostic arteriograms careful frame by frame analysis should be undertaken to detect subtle angiographic findings and define ideal projections for future interventions.