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©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
Diagnosis and management of hepatic artery in-stent restenosis after liver transplantation by optical coherence tomography: A case report
Francisco Leonardo Galastri, Guilherme Moratti Gilberto, Breno Boueri Affonso, Leonardo Guedes Moreira Valle, Priscila Mina Falsarella, Adriano Mendes Caixeta, Camila Antunes Lima, Marcela Juliano Silva, Lucas Lembrança Pinheiro, Conrado Dias Pacheco Annicchino Baptistella, Márcio Dias de Almeida, Rodrigo Gobbo Garcia, Nelson Wolosker, Felipe Nasser
Francisco Leonardo Galastri, Guilherme Moratti Gilberto, Breno Boueri Affonso, Leonardo Guedes Moreira Valle, Priscila Mina Falsarella, Camila Antunes Lima, Marcela Juliano Silva, Lucas Lembrança Pinheiro, Conrado Dias Pacheco Annicchino Baptistella, Rodrigo Gobbo Garcia, Felipe Nasser, Hospital Israelita Albert Einstein, Department of Interventional Radiology, São Paulo 05652900, Brazil
Adriano Mendes Caixeta, Hospital Israelita Albert Einstein, Department of Interventional Cardiology, São Paulo 0562900, Brazil
Márcio Dias de Almeida, Hospital Israelita Albert Einstein, Department of Liver Transplant, São Paulo 05652900, Brazil
Nelson Wolosker, Hospital Israelita Albert Einstein, Department of Vascular Surgery, São Paulo 05652-000, Brazil
Author contributions: Galastri FL, Nasser F and Affonso BB were the patient’s interventionists, reviewed the literature and revised the manuscript, Valle LGM and Falsarella PM reviewed the literature; Caixeta AM was the interventional cardiologist who helped perform the OCT procedure; Gilberto GM, Lima CA, Silva MJ, Pinheiro LL and Baptistella CDPA reviewed the literature, contributed to the manuscript, interpreted the imaging findings; Almeida MD, Garcia RG and Wolosker N were responsible for revision of the manuscript for important intellectual content; All authors issued final approval for the version to be submitted.
Informed consent statement: Consent for publication was obtained for every individual person’s data included in the study.
Conflict-of-interest statement: The authors have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Francisco Leonardo Galastri, MD, PhD, Doctor, Staff Physician, Department of Interventional Radiology, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, São Paulo 05652900, Brazil. francisco.galastri2@einstein.br
Received: January 15, 2020
Peer-review started: January 15, 2020
First decision: March 5, 2020
Revised: April 2, 2020
Accepted: May 19, 2020
Article in press: May 19, 2020
Published online: July 27, 2020
BACKGROUND
Percutaneous transluminal angioplasty and stenting represent an effective treatment for hepatic artery stenosis after liver transplantation. In the first year after stenting, approximately 22% of patients experience in-stent restenosis, increasing the risk of artery thrombosis and related complications, and 50% experience liver failure. Although angiography is an important tool for diagnosis and the planning of therapeutic interventions, it may raise doubts, especially in small-diameter arteries, and it provides low resolution rates compared with newer intravascular imaging methods, such as optical coherence tomography (OCT).
CASE SUMMARY
A 64-year-old male developed hepatic artery stenosis one year after orthotropic liver transplantation and was successfully treated with percutaneous transluminal angioplasty with stenting. Five months later, the Doppler ultrasound results indicated restenosis. Visceral arteriography confirmed hepatic artery tortuosity but was doubtful for significant in-stent restenosis (ISR) and intrahepatic flow reduction. To confirm ISR, identify the etiology and guide treatment, OCT was performed. OCT showed severe stenosis due to four mechanisms: Focal and partial stent fracture, late stent malapposition, in-stent neointimal hyperplasia, and neoatherosclerosis.
CONCLUSION
Intravascular diagnostic methods can be useful in evaluating cases in which initial angiography results are not sufficient to provide a proper diagnosis of significant stenosis, especially with regard to ISR. A wide range of diagnoses are provided by OCT, resulting in different treatment options. Interventional radiologists should consider intravascular diagnostic methods as additional tools for evaluating patients when visceral angiography results are unclear.
Core tip: This is the first case report of optical coherence tomography in the evaluation of in-stent restenosis in a transplant hepatic artery. In this case, optical coherence tomography proved to be valuable in grading the significance of stenosis, identifying its possible causes, and providing measures for choosing appropriate devices for re-treatment. In this case, this additional and modern tool helped in the diagnosis and the therapeutic planning after a doubtful angiography result.
