Outcomes After Unsuccessful Revascularization Following Hepatic Artery Occlusion in Living Donor Liver Transplantation: Results From an International Multicenter Study.

Hepatic arterial occlusion after living donor liver transplantation (LDLT) can be catastrophic, yet outcomes when revascularization fails are incompletely defined. We conducted a retrospective multicenter cohort study across 10 International Living Donor Liver Transplantation Group institutions (2008-2022), including LDLT recipients in whom durable hepatic arterial inflow could not be achieved-either intraoperatively or after postoperative occlusion despite surgical or endovascular attempts. Twenty-five patients met criteria. Median time to occlusion was 8 days (IQR 2-46). Etiologies were hepatic artery thrombosis (72%), occlusion after transarterial embolization (12%), intimal dissection (12%), and severe anastomotic stricture (4%). Diagnosis was imaging-based in 84%. Revascularization was attempted in 16 patients, restoring temporary flow in 6. Portal vein arterialization was used in 3 intraoperative failures. Biliary complications occurred in 56%, and infectious complications in 76%. Collateral-driven restoration of arterial flow occurred in 3 patients, and all three remain alive without graft failure. Using the date of failed revascularization as time zero, graft survival at 1/3/5 years was 48%/31%/23% (median 306 days, IQR 21-604), and overall survival 60%/50%/50% (median 574 days, IQR 65-1926); seven patients underwent retransplantation (median 430 days). Failure to revascularize within 30 days was associated with worse overall survival, while graft survival was similar. Unsuccessful revascularization after LDLT predicts poor graft outcomes with substantial biliary and infectious morbidity; collateral reperfusion, though uncommon, may enable long-term graft survival.