REVIEW

CURRENT
OPINION Hepatic artery reconstruction in living donor
liver transplantation
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Deniz Balci a and Chul-Soo Ahn b

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Purpose of review
Arterial reconstruction in living donor liver transplantation is a technically complex and challenging
procedure, requiring expertise handling multiple factors associated with successful outcomes. This review
describes and discusses the current methods of arterial reconstruction in living donor liver transplantation.
Recent findings
Arterial reconstruction in living donor liver transplantation requires multiple modifications of standard
anastomosis techniques, including familiarity with alternative methods of arterial reconstruction including
technical variants of anastomoses. We herein describe how these methods are employed in microsurgical
techniques, the newer alternatives as well as decision-making on graft-recipient vessel matching and its
complications.
Summary
This review provides comprehensive discussion of surgical techniques for arterial reconstruction in living
donor liver transplant recipients.
Keywords
arterial reconstruction, living donor liver transplantation, microsurgical anastomosis

INTRODUCTION determinant of the technique and outcome of

Living donor liver transplantation (LDLT) is a
technically complex procedure requiring various
levels of technical expertise within the procedure
itself. Historically, arterial complication rates
were reported between 15 and 25% after hepatic
artery reconstruction (HAR) hence, procedure itself
being the crucial step of the operation, with a
potentially significant cause of morbidity and mor-
tality [1]. Introduction of microsurgery dramati-
cally decreased complication rates, current series
reporting complication rates between 0 and 6%
[2]. Arterial anastomoses in LDLT are different than
deceased donor transplantation in regards to vas-
cular anatomy, diameter, hemodynamics, the ori-
entation of the graft and recipient vascular
structures. Here we describe the standard techni-
ques of HAR and outcomes in LDLT in view of the
current literature.
A successful HAR has three key factors, these are
selection of the recipient artery, the quality and
length of the graft artery, anastomosis technique
of which the latter not necessarily has the utmost
importance in every clinical scenario. A very short
graft arterial stump or an intimal detachment in the
recipient inflow artery could easily become the
HAR in any given patient.
GRAFT ARTERY
The donor artery by definition represent the highest
tissue quality from healthy donor; however, limited
by graft artery stump size and diameter both of
which have varying level of importance in HAR.
Further, in many experienced LDLT centers, it is
not handled in the back-table unless the surgeon
performing the back-table procedure is the same
person performing the anastomosis to prevent
unintended damage.
One of the most challenging scenarios would be
a rather short hepatic artery stump, coming from an
a
Department of Surgery and Transplantation, Ankara University School of
Medicine, Ankara, Turkey and bDepartment of Liver Transplantation and
HBP Surgery, Ulsan University School of Medicine, Asan Medical
Center, Seoul, South Korea
Correspondence to Chul-Soo Ahn, Asan Medical Center, Ulsan Univer-
sity School of Medicine, Department of Liver Transplantation and HBP
Surgery, Seoul, South Korea. E-mail: ahncs@amc.seoul.kr
Curr Opin Organ Transplant 2019, 24:631–636
DOI:10.1097/MOT.0000000000000697

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

 Hot topics in living donor liver transplantation
KEY POINTS
 A successful HAR has three key factors, these are
selection of the recipient artery, the quality and length
of the graft artery and the selected
anastomosis technique.
 The setup for anastomosis is the most important aspect
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for a convenient HAR, the surgeon needs to tackle
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several obstacles (e.g. deep, moving field, graft and
recipient vessel qualities and anatomic orientations) that
are inherent to the procedure itself.
 The size and the quality of graft artery will determine
the inflow artery; therefore, it is crucially important to
have all three hepatic arteries (left, middle, right with
secondary branches) undamaged during
hepatoduodenal ligament dissection in the recipient.
 With experience, technical variants for microvascular
anastomosis can be performed under microscope
safely. There is a learning curve that requires
supervision; however, as an alternative, using surgical
loupes by experienced vascular surgeons may provide
similar results.
older donor with relatively poorer vessel quality and
smaller arterial diameter. This scenario should be
anticipated in preoperative planning and discussed
by the donor and recipient surgical teams during the
donor operation. Once the graft is procured, it could
only be handled with precise anastomosis technique
by an experienced vascular or microsurgeon. As
rotation of the short stump graft artery will not be
possible, the back-wall first technique will be neces-
sary. If the surgeon is not familiar with the back-wall
first technique, extension of the graft artery with an
arterial graft at the back-table would probably be the
safest approach [3]. The authors prefer radial artery,
a segmental part of recipient hepatic artery or gastro-
epiploic artery for conduit [4–5].
More than 40% of left lobe grafts and 5% of
right lobe graft had multiple hepatic arteries and
there is a dilemma on which one or both stumps
should be reconstructed [6]. In general, back bleed-
ing from recessive arterial stump after reconstruc-
tion of dominant stump was most important clue
to anastomosis or ligation of the former. This can
also be tested during graft harvest on the donor side
with cooperation with the donor team. There were
some controversies on the incidence of biliary
complications between single and multiple anas-
tomosis [7]. We prefer multiple anastomosis when-
ever it is feasible on the right lobe graft and
selectively on the left lobe graft for the following
reasons; identification of dominant stump may
sometimes be difficult because almost half of dual
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arterial stumps have similar size making it difficult
to appreciate the dominant one. Second, recessive
stump usually located deeper site than dominant
stump, especially in the right lobe graft. So previous
dominant arterial reconstruction may make sec-
ond anastomosis difficult or sometimes even
impossible. Again, one key element for decision
is during graft harvest with cutting the recessive
one first to see the arterial backflow when the
dominant artery was intact. Oftentimes, one will
see there is good flow but it is not the exact pulsatile
flow that comes from the dominant hepatic artery.
There is obviously a pressure difference arising
from intrahepatic resistance and circulation. On
the right graft, when the recessive artery is respon-
sible from the anterior section inflow and pressure
drive for the venous outflow, one can speculate
that might also have an impact on outflow recon-
structions patency rate [8].
RECIPIENT ARTERY
There are several important factors for inflow artery
selection. The size and the quality of graft artery will
determine the inflow artery. It is crucially impor-
tant to have all three hepatic arteries (left, middle,
right with secondary branches) undamaged during
hepatoduodenal ligament dissection in the recipi-
ent. After confirming satisfactory flow, recipient-to-
graft vessel orientation, diameter match and inti-
mal quality are more important factors for selec-
tion. A final key step is choosing the anastomosis
site on the inflow artery. Although fulminant liver
failure or metabolic liver disease patients without
cirrhosis have relatively spared hepatic arteries,
there are various clinical factors with the cirrhotic
recipient that may have an impact on the arterial
quality. Hyperdynamic circulation of cirrhotic
patient especially with portal vein thrombosis,
hepatic arteries got stiffer with intimal thickness
despite an increase in diameter. Transarterial embo-
lization procedures have been reported to be asso-
ciated with diseased and/or damaged hepatic
arteries, which may cause arterial intimal thicken-
ing resulting with easy detachment [9]. Atheroscle-
rosis leads to media layer calcifications, which
should be avoided with further cutting proximally
until a healthy segment for anastomosis site
is achieved.
The anatomical anastomosis may be the first
choice for the HAR to the extent possible [10]. In
reported series, more than 90% of anastomosis are
anatomical ones, referring anastomoses of branches
of recipient hepatic artery to graft hepatic artery [11].
A major issue when selecting the inflow site is size
discrepancy between graft and recipient artery [12].
Volume 24  Number 5  October 2019

In experimental models, the size discrepancy was
reported to result with lower patency rates [13]. The
size discrepancy between graft and recipient artery
can be seen in both internal diameter as well as
intimal thickening. To address the former, the
authors prefer not to go for more than 1 : 2 propor-
tion, which would mean any of the inflow or out-
flow arteries do not have an internal caliber of more
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than two times of the counterpart. In order to have
better size match, high hilar dissection is important
to obtain a healthy segment of secondary branches
of the right hepatic artery. This is not much of an
issue on the left lobe and left lateral grafts. During
HAR, size discrepancy of the anastomosis vessel
ends should be shared by both the anterior and
posterior walls. With the stay sutures in position,
the discrepancy in vessel circumference can be
gradually compensated for with individual stitches
during suturing.
ANASTOMOSIS TECHNIQUES
For a convenient HAR, the surgeon needs to tackle
several obstacles that are inherent to the procedure
itself. The anastomosis is located in a deep, moving
field. Close cooperation between surgical and anes-
thesiology teams are necessary to control the depth
of the respirations limiting the tidal volumes which
will limit the superior–inferior movement of the
surgical field. This is especially important while
placing critical sutures; that are sutures at the angles
or for hemostasis with where high magnification
under surgical microscope is used. Depending on
the recipient size, deep abdominal cavity may
require longer instruments (18–21 cm). In order to
decrease anteroposterior (A-P) distance, we prefer to
rotate the table to the surgeons’ side 45–608 (right),
place several gauzes under and behind the graft to
elevate it and use self-retaining retractor to the
medial graft side to fix it.
Approximator clamp, an atraumatic double-
armed clamp moving on a side bar is a vital instru-
ment for HAR and greatly facilitates the procedure
FIGURE 1. Schematic drawings of basic techniques for microvascular hepatic artery reconstruction. (a) Interrupted anterior
wall. (b) Interrupted anterior wall. (c) Interrupted posterior wall.
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Hepatic artery revascularization Balci and Ahn
providing orientation and tension-free anastomosis.
The authors use an appropriately sized Acland
Clamp (S&T Gmbh, Switzerland) for this purpose.
The anastomosis preparation is started with
graft artery evaluation, arterial ends should be
trimmed to have a smooth anastomotic interface,
flushed with heparinized saline (10 U/ml) and
gently dilated under magnification. Any clots are
removed as well as adventitial tissues around the
arterial orifice that could interfere with the anasto-
mosis. The approximator clamp is placed about 1 cm
from the arterial ends in both sides. We prefer to
place a 2 cm x 2 cm rectangular mat cut from sterile
glow for background contrast. Before starting the
anastomosis, it is extremely important that the posi-
tion is convenient for the surgeon, anastomosis site
is tension free and stable as much as possible.
We prefer 7.0 prolene suture for arteries with
internal diameters at least 3.5 mm, 8.0 for 2.0–
3.5 mm, 9.0 for 1.5–2.5 mm and 10.0 for 1.0–
1.5 mm diameter arteries, respectively (Fig. 1).
INTERRUPTED TECHNIQUE
There are very different approaches to perform a
HAR, the surgeon should be familiar with different
variants and be ready to employ them in different
clinical scenarios. Here we describe basic techni-
ques, with evolving experience clinical microsur-
geon will find it easy to make variations or
employ a combination of techniques at a given
clinical scenario.
After placement of the approximator clamp, stay
sutures at 0’ and 180’ are placed and cut with a long
suture stump for retraction. Then, the first suture
will be in the middle of two stay sutures and not tied
for easy visual inspection of the posterior layer. The
second and third sutures will be between each stay
suture and the middle suture. After evaluating the
orientation of the sutures, free back-wall and con-
firming correct suture placement, the second, third
and the middle sutures are tied at least three times. A
surgical knot (double tie) is helpful in sutures with
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 Hot topics in living donor liver transplantation

tension and size mismatch. The approximator is

rotated and above steps repeated for the posterior
layer, which is now anterior position with rotation.
(Fig. 1a–c).
There are several variants reported in the liter-
ature, which authors may also employ time to time.
A practical one, is continuous suture interrupted tie
technique, which provides a faster anastomosis [14].
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CONTINUOUS TECHNIQUE
Continuous technique has several advantages; it is
faster and provides easy adaptation to size mis-
match. This technique also starts with stay suture
placement at 0’ and 180’. The tied edge suture
continuous with repeated sutures on both arteries.
It should be applied cautiously in the diseased recip-
ient artery with intimal thickening and detachment
unless inside-to-outside bites are taken from the
inflow artery (Fig. 2a and b).
An application of 1% lidocaine hydrochloride
on the adventitial side of the vessel was performed
to dilate the vessels to improve the volume of blood
flow. Bleeding from needle holes usually stopped
with the application of a small piece of oxidized
regenerated cellulose (Surgicel 1902GB, Ethicon
Inc). In case, conservative measures were not suffi-
cient for bleeding control, we prefer to control the
bleeding with a meticulously placed interrupted
suture to prevent postoperative hemorrhage. The
surgeon should not hesitate to apply a bulldog
clamp to control inflow in order to achieve correct
suture placement. Doppler ultrasonography was
performed immediately to demonstrate patency of
the anastomosis. We prefer routine Prostaglandine
E1 for all LDLT procedures and low molecular
weight heparin whenever international normalized
ratio is 2 or less.
FIGURE 3. Schematic drawings of basic techniques for
microvascular hepatic artery reconstruction. Backwall first
technique.
BACKWALL FIRST TECHNIQUE
Backwall first technique is used when there is short
graft artery stump preventing rotation [15]. Further,
this technique can also be used when both the
arteries are fragile or diseased that the rotation
might result with further damage. This technique
could be performed with a running or an interrupted
fashion. After the stay sutures, the interrupted tech-
nique starts with donor side outside inside and
recipient side inside out and tied until the second
stay suture is reached. The anterior wall is performed
in a routine fashion described above. The continu-
ous technique may require more expertise and
manipulation of the graft artery and may require
more technical expertise (Fig. 3).
LOUPES VS. MICROSCOPE
The usage of surgical microscope is being criticized
by its large hardware causing maneuvering issues in
the operating room, requiring expertise with a long

FIGURE 2. Schematic drawings of basic techniques for microvascular hepatic artery reconstruction. (a) Continuous suturing,
anterior wall. (b) Completion of continuous suturing.

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 Hepatic artery revascularization Balci and Ahn

learning curve to use the device and representing
difficulties for teaching [16]. Microvascular recon-
struction of hepatic artery is a complex procedure
and for a surgeon from general or transplantation
surgery background, it is a challenging task to
acquire skills for basic microsurgery and then tran-
sitioning to clinical microsurgery. In a recent study,
five neurosurgeons with 5-year surgical experience
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anastomosis anytime there is an LDLT case, or worse
when an arterial complication arises.
On the other hand, there is a growing body of
literature suggesting equivalent results using surgi-
cal loupes instead of microscope (Table 1). Li et al.
&&
[18 ] recently reported a large experience of 766
recipients with a short beginning era with micro-
scope (25 recipients) followed by 741 recipient HAR

but without any experience in bypass surgery per-
formed microscopic anastomosis on progressively
&
smaller caliber silastic tubes [17 ]. In the cognitive
phase of learning, that is, the beginning of learning,
the trainees had a lot of information bits to learn,
there was a high degree of change in performance
with plateauing, which could be discouraging, how-
ever, with guidance and motivation from the
instructors, their performance increased to a consis-
tency level that represents a sign of passing beyond
the cognitive stage of learning, and formation of a
motor pattern. The overall direction of the learning
curve was ascending, indicating the general progress
in performance. Their results showed that for the
task of microvascular anastomosis, 10 initial prac-
tice trials are required to pass through the cognitive
stage and beginning of consistency phase. This
results could also be applied to transplant surgeons
trained to perform HAR as was the case in authors’
experience also from the mentor–trainee perspec-
tive. The process is an achievable goal with adequate
training and constant supervision during the learn-
ing curve and surely, with continuous practice.
From an administrative perspective, training a team
member for microsurgery could be seen as an invest-
ment worth considering. Fundamentally, it is solv-
ing a major logistics issue of transplant teams, that is
being dependent on an either a microsurgeon or
a cardiovascular surgeon to perform the arterial
performed by surgical loupes by cardiovascular sur-
geons with a hepatic artery thrombosis rate of 1.2%
and with a significantly faster anastomosis times. An
important criticism was a possible purse string effect
possibly resulting with biliary ischemia and anasto-
&
motic strictures [19 ,20]. This is infact a major con-
cern when tying continuous suture lines using
loupes an untoward and potentially underestimated
technical fault that is very rare tying under micro-
scope because of the completely diverse nature of
handling suture material in different settings. Yagi
et al. also reported replacing microvascular anasto-
mosis to a continuous suture using 3.5 magnifica-
tion with loupes with comparable outcomes [21].
The authors explain their good results with delayed
tying with fully expanded anastomosis line. In order
to prevent a purse string effect, tying under high
power magnification with the operation microscope
offers two advantages over using loops. These are
better visibility and limited force application to the
microsurgical suture.
On the basis of our experience, the benefits of
HAR with operating microscope in LDLT setting is
not limited to performing the anastomosis itself, but
also enable the surgeon to evaluate the donor and
recipient vessels and eliminate the potential risk
factors associated with HAT, such as damaged inti-
mal edges separation of the intima and medial layer
resulting with flaps, soft thrombi within the lumen

Table 1. Recent literature comparing surgical microscope vs. loupes for hepatic artery reconstruction
Hepatic A.
N, Surgical Time Flow rate Complication thrombosis
Author [ref.] Year patients technique (minutes) (ml/min) rate (%) rate Anticoagulation Anastomosis

Lee et al. [15] 2008–2015 325 Microscope 130.7  93.2 0.3 1 None 10  15
Harada et al. 1996–2016 104 Microscope n.a 159  136 1 1 None
[12]
Wei et al. [9] 1993–2002 152 Microscope 2 3 None 10  15
Song et al. [20] 2004–2010 522 Microscope n.a n.a. 4.7 1.7 Low-molecular
weight
heparine
&&
Li et al. [18 ] 2007–2016 741 Loupe 10  5 153  70 1.2 9 Continuous
Yagi et al. [21] 1996–2008 209 Microscope 72.3  31.9 vs. n.a. 11.7% vs. Continuous
vs. Loupe 24.1  18.9 2.6%
Iida et al. [22] 1996–2009 673 Microscope n.a. % 6.4 43 i.v. heparine
vs. loupe p.o dipridamol

n.a., not applicable.

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 Hot topics in living donor liver transplantation
of the arterial stumps and incorrect placement of
hemostatic sutures.
CONCLUSION
In many institutions, consulting microsurgeons per-
form the HAR in LDLT. We believe transplant sur-
geons adequately trained and supervised using the
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standardized microsurgical techniques should be
able to obtain excellent results. As with all demand-
ing procedures, there is a learning curve. Close
mentorship is essential in successful arterial recon-
struction of living or deceased donor partial grafts,
regardless of the device whether surgical microscope
or loupe is used.
Acknowledgements
We would like to thank Celal Bayar for his assistance
with graphics of the study.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
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been highlighted as:
& of special interest
&& of outstanding interest
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Here, an in-depth description of hepatic arterial reconstruction techniques using a
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22. Iida T, Kaido T, Yagi S, et al. Hepatic arterial complications in adult living donor
liver transplant recipients: a single-center experience of 673 cases. Clin
Transplant 2014; 28:1025–1030.
Volume 24  Number 5  October 2019