Celiac trunk compression by arcuate ligament and living-related liver transplantation: a two-step strategy for flow-induced enlargement of donor hepatic artery.

The median arcuate ligament is a tendinous arch joining the two medial borders of the diaphragm crura together. In 10-50% of subjects it is responsible for significant angiographic celiac trunk compression. In severe cases, a decrease in hepatic arterial blood flow with subsequent artery caliber reduction and reverse vascularization via the gastroduodenal artery is present. In liver transplantation, small-caliber hepatic arteries are higher risk factors for hepatic arterial thrombosis and frequent graft loss. We report a case of celiac trunk compression in a living-related donor and the two-step strategy we developed to perform a safer liver transplantation via flow-induced enlargement of the donor hepatic artery. A 29-year-old father was selected as a living-related liver donor for his 4-year-old daughter. Angiography revealed celiac trunk compression by the median arcuate ligament with reverse vascularization of the middle hepatic artery via the gastroduodenal artery, a proper hepatic artery 2 mm in diameter irrigating the left lateral segment exclusively, and a right hepatic artery irrigating the right lobe and segment 4. First-step division of the median arcuate ligament and gastroduodenal artery ligation were performed. Repeat angiography at the third week showed a 50% enlargement of the middle hepatic artery (3 mm). Second-step left lobectomy was performed at the fifth week. The transplantation was achieved with an arterial anastomosis between the middle hepatic arteries of donor and recipient. This two-step strategy including median arcuate ligament division provided flow-induced enlargement of the donor middle hepatic artery for a safer transplantation with arteries of more suitable calibers.