Back Table Arterial Reconstructions Using the Recipient Hepatic Arterial Tree in Living Donor Liver Transplantation

Some right lobe (RL) and many left lobe (LL) grafts provide multiple arterial branches that require reconstruction when arterialized back-bleeding is not present. Reconstruction on the back table provides optimal operative conditions while use of the recipient hepatic arterial system for reconstruction provides choices of size-matched branches. Between 2001 and 2022, we performed back table reconstruction using the recipient hepatic arterial tree on 29 of 379 (7.7%) of patients who underwent living donor liver transplantation (LDLT) at our center. All reconstructed arterial trees were anastomosed in situ using a gastroduodenal branch patch to a corresponding patch in the recipient. Cold ischemia times were significantly longer in back table reconstruction patients (n = 29) compared to patients at our center with anomalous arterial anatomy and sufficient back bleeding who did not require reconstruction (n = 8, p < 0.001). One back table reconstruction patient developed hepatic artery thrombosis (HAT) 6 days after reconstruction of a two artery LL, requiring re-transplantation. A second back table reconstruction patient developed HAT 114 days after reconstruction of a four artery RL but the graft had adequate collateral circulation and survived. HAT rates did not differ significantly between back table reconstruction patients and all other LDLT patients at our center. The 1- and 5-year survival rate for patients who underwent back table reconstruction were 89.6% and 82.6%, respectively. Back table reconstruction of complex arterial anatomy is an option when arterialized back-bleeding is not present and can be successfully performed utilizing the recipient hepatic tree in LDLT.