Hepatic artery thrombosis and graft ischemia in the presence of preserved arterial inflow: Not a contradiction but a real possibility

A 25-year-old Caucasian male underwent orthotopic liver transplantation in June 2000 because of Caroli’s disease.Hewas retransplanted inMay 2001 due to intractable chronic rejection. Retransplantation was performed with a conventional technique using veno-venous bypass, anastomosis between the hepatic artery of the graft and the common hepatic artery of the recipient, and a Roux-en-Y choledochojejunostomy.An episode of acute rejectionwas diagnosedinthesecondpostoperativeweekthat respondedto high-dose steroids, and the patient was discharged 34 days after retransplantation. No significant abnormality in the graft function was detected until June 2003, when the patient developed fever and leukocytosis associated with biochemical signs of cholestasis followed by jaundice; transaminases remained normal or showed minimal increase.Hepatic ultrasonogram revealedmoderate dilatation of the intrahepatic bile ducts with 2 small bilomas, whileDoppler US showed normal intraparenchymal arterial resistive index and systolic acceleration time. Abdominal computed tomography scan confirmed diffuse dilatation of the bile ducts with hypodense areas consistent with biloma (Fig. 1). Selective celiac arteriography showed a complete obstruction of hepatic artery (Fig. 2), while the arteriogram of the superior mesenteric artery demonstrated the presence of compensatory collateral vessels recruited from the jejunal vascular arcade of the Roux