Appraisal of the order of revascularization in human liver grafting: A controlled study

Background: By current convention, the liver graft is revascularized, first with portal blood flow, and thereafter with arterial blood flow. Although experimental studies showed no detrimental effects of primary arterialization, this order of revascularization has not been investigated in clinical transplants. Study Design: Twenty-nine patients were included in our controlled study to investigate and compare, by means of a technical procedure that permits either initial arterial revascularization (IAR) or initial portal revascularization (IPR), the effects of graft revascularization by IAR and by IPR in clinical transplants. Results: Patients were equally divided in the LAR group (n = 15) and the IPR group (n = 14), and were homogeneous in terms of recipients and graft characteristics. Graft reperfusion was uniform and diffuse in all grafts with IAR versus 10 (71%) with IPR (p < 0.05). After reperfusion, the time taken for completion of the procedure was shorter in the IAR group (159 +/- 28 versus 242 +/- 39 minutes) (p < 0.01). Both mean blood transfusions and antifibrinolytic requirements were lower in the IAR group: 5.4 +/- 1.8 versus 7.6 +/- 3.5 packed red cell units, and 13% versus 50%, respectively (p < 0.05). Postoperative ASAT level, clotting factor V level, and bile flow were not different between the two groups. Early postoperative vascular or biliary complications did not occur. During a mean follow-up of 16 months (range, 7-20), one hepatic artery thrombosis occurred in the IPR group, and one anastomotic biliary stricture occurred in each group. Conclusion: Under adequate portal decompression, IAR is a safe option and results in better graft reperfusion, shorter post revascularization phase, and reduced transfusion and antifibrinolytic requirements. (C) 1997 by the American College of Surgeons.