between april 1999 and march 2001 , 32 ( 26 men and 6 women ; age range , 7 - 62 years ; mean age , 43 years ) of 195 patients who had undergone ldlt underwent 42 sessions of conventional arteriography in search of bleeding foci of arterial origin within 6 months of the operation .
arterial bleeding was suspected clinically if the symptoms or signs were as follows : abnormally increased drainage of fresh blood through the jackson - pratt ( jp ) tube in 26 sessions , hematochezia or melena in 8 sessions , hemothorax or hemoptysis in 5 sessions , hemobilia in 2 sessions , or an acute decrease in the hemoglobin level in one session .
six patients underwent two or three sessions of arteriography or tae , because of recurrent arterial bleeding .
however , the bleeding foci were different in each of the sessions conducted for the same patient . in all patients ,
the arterial bleeding occurred within two months ( mean , 14 days ; range , 1 - 56 days ) after ldlt .
arteriography was performed within three days ( mean , 1 day ) after the detection of arterial bleeding , depending on the patient 's condition .
the underlying causes of hepatic failure and ldlt in these 32 patients were hepatitis b - related liver cirrhosis with or without hepatocellular carcinoma ( n=29 ) , secondary biliary cirrhosis due to intrahepatic stones ( n=1 ) , fatal fulminant hepatitis due to wilson 's disease ( n=1 ) , and biliary atresia ( n=1 ) .
the grafts involved in the ldlt included the right lobe ( n=21 ) , left lobe ( n=8 ) , dual left lobe ( n=2 ) , and left lateral segment ( n=1 ) . in all patients
, informed consent was obtained from the patient or the patient 's family prior to arteriography .
once the right or left femoral artery was punctured , a 5-f end - hole catheter was introduced over a 0.035-inch guide wire ( terumo ; radiofocus , tokyo , japan ) . following the superior mesenteric and common hepatic arteriographies , which were performed to evaluate the patency of the portal and hepatic arterial anastomoses and potential bleeding foci , the suspected arteries destined for selective arteriography were selected .
a provisional identification of the bleeding arteries was made based on the patient 's symptoms or signs , radiological findings , including dynamic ct and rbc scans , and the surgical information obtained during ldlt . in the patients with abnormally increased drainage of fresh blood through the jp tube , selective arteriographies were performed of several specific arteries , for which the arterial bleeding might be stagnant in the jp tube placed area . in those patients with hematochezia or melena , inferior mesenteric or left gastric arteriography was performed following superior mesenteric and common hepatic arteriographies , according to the available clinical information . in those patients with hemothorax or hemoptysis , selective arteriographies of the inferior phrenic artery ,
intercostal arteries adjacent to the pleural drain tubes , subclavian artery and/or bronchial artery were performed according to the available clinical information .
aortography for the purpose of gaining an understanding of the arterial anatomy prior to selective arteriography was not routinely performed .
however , aortography was performed to rule out the possible of there being any missed bleeding foci , if the selective arteriographies of the presumptive arteries did not demonstrate any active bleeding foci . if the bleeding foci were present on the arteriograms , then either tae or surgery was undertaken to control the bleeding , subject to the mutual agreement of the surgeons and interventional radiologists .
tae was intended to be the primary treatment , however , surgical management was considered as the primary treatment if the bleeding foci were technically too difficult or dangerous to be embolized , such as in the case of a hepatic arterial anastomotic site or hepatic resection margin . for tae
, the bleeding arteries were superselected using a 3f - microcatheter ( microferret ; cook , bjaerverskov , denmark ) and embolized with 0.018-inch - hilal microcoils ( cook , bloomington , u.s.a . ) or 0.018-inch - tornado microcoils ( cook , bloomington , u.s.a . ) .
gelatin sponge particles ( gelfoam ; upjohn , kalamazoo , mi ) were also used in the case of several specific arteries ( intercostal , inferior phrenic and epigastric arteries ) prior to embolization using microcoils , to minimize any rebleeding from collateral vessels .
if the bleeding foci were absent on the selective arteriograms and aortogram , explorative laparotomy or clinical observation was chosen by the surgeons , depending on the patient 's condition . in all patients , a complete retrospective review of the medical and surgical records and radiological imaging were performed .
the following items were documented retrospectively : the presumptive causes and locations of arterial bleeding , the technical and clinical success rates of tae , and the complications .
a bleeding focus was defined as an extravasation of the contrast media or a pseudoaneurysm that was a likely cause of bleeding .
the arterial bleeding was divided into four categories according to the possible related causes : surgical bleeding was defined as an arterial bleeding related to the ldlt itself and included bleeding from the hepatic resection margin , hepatic arterial anastomotic site , incision wounds , and the hepaticojejunostomy site .
iatrogenic bleeding was defined as bleeding associated with percutaneous invasive procedures , such as transhepatic biliary drainage , central venous access and chest tube insertion .
spontaneous bleeding was defined as bleeding that developed spontaneously , such as gastrointestinal bleeding remote from the hepaticojejunostomy site .
non - classifiable bleeding was defined as bleeding that was not able to be classified properly .
the technical success of tae was defined as the complete disappearance of arterial bleeding following tae . technically impossible or incomplete
clinical success was defined as an amelioration of the presenting signs or symptoms of arterial bleeding following tae .
major complications were defined as those necessitating an increased level of care , surgery , prolonged hospital stay , permanent adverse sequelae or death .
between april 1999 and march 2001 , 32 ( 26 men and 6 women ; age range , 7 - 62 years ; mean age , 43 years ) of 195 patients who had undergone ldlt underwent 42 sessions of conventional arteriography in search of bleeding foci of arterial origin within 6 months of the operation .
arterial bleeding was suspected clinically if the symptoms or signs were as follows : abnormally increased drainage of fresh blood through the jackson - pratt ( jp ) tube in 26 sessions , hematochezia or melena in 8 sessions , hemothorax or hemoptysis in 5 sessions , hemobilia in 2 sessions , or an acute decrease in the hemoglobin level in one session .
six patients underwent two or three sessions of arteriography or tae , because of recurrent arterial bleeding .
however , the bleeding foci were different in each of the sessions conducted for the same patient . in all patients ,
the arterial bleeding occurred within two months ( mean , 14 days ; range , 1 - 56 days ) after ldlt .
arteriography was performed within three days ( mean , 1 day ) after the detection of arterial bleeding , depending on the patient 's condition .
the underlying causes of hepatic failure and ldlt in these 32 patients were hepatitis b - related liver cirrhosis with or without hepatocellular carcinoma ( n=29 ) , secondary biliary cirrhosis due to intrahepatic stones ( n=1 ) , fatal fulminant hepatitis due to wilson 's disease ( n=1 ) , and biliary atresia ( n=1 ) .
the grafts involved in the ldlt included the right lobe ( n=21 ) , left lobe ( n=8 ) , dual left lobe ( n=2 ) , and left lateral segment ( n=1 ) .
in all patients , informed consent was obtained from the patient or the patient 's family prior to arteriography .
once the right or left femoral artery was punctured , a 5-f end - hole catheter was introduced over a 0.035-inch guide wire ( terumo ; radiofocus , tokyo , japan ) . following the superior mesenteric and common hepatic arteriographies , which were performed to evaluate the patency of the portal and hepatic arterial anastomoses and potential bleeding foci , the suspected arteries destined for selective arteriography were selected .
a provisional identification of the bleeding arteries was made based on the patient 's symptoms or signs , radiological findings , including dynamic ct and rbc scans , and the surgical information obtained during ldlt . in the patients with abnormally increased drainage of fresh blood through the jp tube , selective arteriographies were performed of several specific arteries , for which the arterial bleeding might be stagnant in the jp tube placed area . in those patients with hematochezia or melena , inferior mesenteric or left gastric arteriography was performed following superior mesenteric and common hepatic arteriographies , according to the available clinical information . in those patients with hemothorax or hemoptysis , selective arteriographies of the inferior phrenic artery ,
intercostal arteries adjacent to the pleural drain tubes , subclavian artery and/or bronchial artery were performed according to the available clinical information .
aortography for the purpose of gaining an understanding of the arterial anatomy prior to selective arteriography was not routinely performed .
however , aortography was performed to rule out the possible of there being any missed bleeding foci , if the selective arteriographies of the presumptive arteries did not demonstrate any active bleeding foci . if the bleeding foci were present on the arteriograms , then either tae or surgery was undertaken to control the bleeding , subject to the mutual agreement of the surgeons and interventional radiologists .
tae was intended to be the primary treatment , however , surgical management was considered as the primary treatment if the bleeding foci were technically too difficult or dangerous to be embolized , such as in the case of a hepatic arterial anastomotic site or hepatic resection margin . for tae
, the bleeding arteries were superselected using a 3f - microcatheter ( microferret ; cook , bjaerverskov , denmark ) and embolized with 0.018-inch - hilal microcoils ( cook , bloomington , u.s.a . ) or 0.018-inch - tornado microcoils ( cook , bloomington , u.s.a . ) .
gelatin sponge particles ( gelfoam ; upjohn , kalamazoo , mi ) were also used in the case of several specific arteries ( intercostal , inferior phrenic and epigastric arteries ) prior to embolization using microcoils , to minimize any rebleeding from collateral vessels . if the bleeding foci were absent on the selective arteriograms and aortogram , explorative laparotomy or clinical observation was chosen by the surgeons , depending on the patient 's condition .
in all patients , a complete retrospective review of the medical and surgical records and radiological imaging were performed .
the following items were documented retrospectively : the presumptive causes and locations of arterial bleeding , the technical and clinical success rates of tae , and the complications .
a bleeding focus was defined as an extravasation of the contrast media or a pseudoaneurysm that was a likely cause of bleeding .
the arterial bleeding was divided into four categories according to the possible related causes : surgical bleeding was defined as an arterial bleeding related to the ldlt itself and included bleeding from the hepatic resection margin , hepatic arterial anastomotic site , incision wounds , and the hepaticojejunostomy site .
iatrogenic bleeding was defined as bleeding associated with percutaneous invasive procedures , such as transhepatic biliary drainage , central venous access and chest tube insertion .
spontaneous bleeding was defined as bleeding that developed spontaneously , such as gastrointestinal bleeding remote from the hepaticojejunostomy site .
non - classifiable bleeding was defined as bleeding that was not able to be classified properly .
the technical success of tae was defined as the complete disappearance of arterial bleeding following tae . technically impossible or incomplete
clinical success was defined as an amelioration of the presenting signs or symptoms of arterial bleeding following tae .
major complications were defined as those necessitating an increased level of care , surgery , prolonged hospital stay , permanent adverse sequelae or death .
conventional arteriography demonstrated 42 bleeding foci of arterial origin in 30 sessions ( 23 patients ) .
the number of bleeding foci detected were one in 22 sessions ( 15 patients ) , two in six sessions ( 6 patients ) , and more than three in two sessions ( 2 patients ) .
the bleeding foci originated most frequently from the hepatic artery ( 14/42 , 33% ) and intercostal artery ( 11/42 , 26% ) .
based on a complete review of the clinical , interventional and surgical data , the bleeding foci were classified into 4 categories corresponding to the most likely causes of arterial bleeding ( table 2 ) . in this way
, it was demonstrated that , in addition to surgical bleeding ( 36% ) , iatrogenic bleeding ( 40% ) was also a major cause of arterial bleeding after ldlt .
tae was technically successful in 33 of the 42 foci of active arterial bleeding ( table 1 ) ( figs . 1 , 2 )
however , tae failed in the remaining 9 foci of active arterial bleeding , due to technically difficult superselection of the corresponding bleeding artery or the potential high risk associated with tae ( fig .
3 ) . these bleeding foci consisted of hepatic artery anastomotic sites ( n=2 ) , hepatic resection margins ( n=4 ) and hepaticojejunostomies ( n=3 ) , and they were treated by surgery .
however , in three sessions , additional immediate surgery had to be conducted following successful tae for the evacuation of hematoma .
however , there was no evidence of active arterial bleeding in the operation field in any of these cases .
in 20 of the 21 sessions , the patients showed a clinical improvement in the active arterial bleeding after successful tae .
one patient did not show any clinical improvement , because of recurrent arterial bleeding of the same focus .
this patient had been treated by anti - coagulation therapy due to cerebral infarction , resulting in a severe iatrogenic bleeding tendency , and died of multifocal hemorrhage including cerebral hemorrhage several days after tae .
the overall technical and clinical success rates for the 30 sessions of tae were 21 ( 70% ) and 20 ( 67% ) , respectively .
these relatively low success rates can be ascribed to the three bleeding foci ( hepatic resection margins , hepatic artery anastomotic sites and hepaticojejunostomy sites ) , in which embolization was either incomplete or impossible . in the case of the three bleeding foci ,
if these bleeding foci were excluded , the overall technical and clinical success rates were 19 ( 100% ) and 18 ( 95% ) out of 19 sessions .
six ( 19% ) patients underwent two or three sessions of arteriography , because of recurrent arterial bleeding .
however , different bleeding foci were treated in each session of arteriography conducted for the same patient . recurrent bleeding at the same foci was present in only one patient , as described above . on the other hand
these cases were managed either by surgery ( 6 patients ) or close clinical observation ( 5 patients ) with transfusion , depending on the patient 's condition . in three of the former six patients ,
surgery allowed the discovery of active arterial bleeding at the hepatic artery anastomotic site ( n=1 ) , hepatic resection margin ( n=1 ) , and venous oozing ( n=1 ) at the anastomosis of the hepatic vein and vena cava .
however , a retrospective review of the selective angiographic images of these patients did not demonstrate the presence of any bleeding focus . in the remaining three patients ,
surgery did not lead to the discovery of any bleeding focus , and they only underwent hematoma evacuation .
after either conservative or surgical management , the signs of active bleeding ameliorated in all 11 patients . during the 6 month follow - up period after ldlt , there were no major tae - related complications .
conventional arteriography demonstrated 42 bleeding foci of arterial origin in 30 sessions ( 23 patients ) .
the number of bleeding foci detected were one in 22 sessions ( 15 patients ) , two in six sessions ( 6 patients ) , and more than three in two sessions ( 2 patients ) .
the bleeding foci originated most frequently from the hepatic artery ( 14/42 , 33% ) and intercostal artery ( 11/42 , 26% ) .
based on a complete review of the clinical , interventional and surgical data , the bleeding foci were classified into 4 categories corresponding to the most likely causes of arterial bleeding ( table 2 ) . in this way
, it was demonstrated that , in addition to surgical bleeding ( 36% ) , iatrogenic bleeding ( 40% ) was also a major cause of arterial bleeding after ldlt .
tae was technically successful in 33 of the 42 foci of active arterial bleeding ( table 1 ) ( figs . 1 , 2 )
. however , tae failed in the remaining 9 foci of active arterial bleeding , due to technically difficult superselection of the corresponding bleeding artery or the potential high risk associated with tae ( fig .
3 ) . these bleeding foci consisted of hepatic artery anastomotic sites ( n=2 ) , hepatic resection margins ( n=4 ) and hepaticojejunostomies ( n=3 ) , and they were treated by surgery .
however , in three sessions , additional immediate surgery had to be conducted following successful tae for the evacuation of hematoma .
however , there was no evidence of active arterial bleeding in the operation field in any of these cases . in 20 of the 21 sessions , the patients showed a clinical improvement in the active arterial bleeding after successful tae .
one patient did not show any clinical improvement , because of recurrent arterial bleeding of the same focus .
this patient had been treated by anti - coagulation therapy due to cerebral infarction , resulting in a severe iatrogenic bleeding tendency , and died of multifocal hemorrhage including cerebral hemorrhage several days after tae .
the overall technical and clinical success rates for the 30 sessions of tae were 21 ( 70% ) and 20 ( 67% ) , respectively .
these relatively low success rates can be ascribed to the three bleeding foci ( hepatic resection margins , hepatic artery anastomotic sites and hepaticojejunostomy sites ) , in which embolization was either incomplete or impossible . in the case of the three bleeding foci ,
the technical success rate was only 2 ( 18% ) out of 11 sessions . if these bleeding foci were excluded , the overall technical and clinical success rates were 19 ( 100% ) and 18 ( 95% ) out of 19 sessions .
six ( 19% ) patients underwent two or three sessions of arteriography , because of recurrent arterial bleeding .
however , different bleeding foci were treated in each session of arteriography conducted for the same patient .
recurrent bleeding at the same foci was present in only one patient , as described above .
on the other hand , arteriography showed no active bleeding focus in 12 sessions ( 11 patients ) .
these cases were managed either by surgery ( 6 patients ) or close clinical observation ( 5 patients ) with transfusion , depending on the patient 's condition . in three of the former six patients ,
surgery allowed the discovery of active arterial bleeding at the hepatic artery anastomotic site ( n=1 ) , hepatic resection margin ( n=1 ) , and venous oozing ( n=1 ) at the anastomosis of the hepatic vein and vena cava .
however , a retrospective review of the selective angiographic images of these patients did not demonstrate the presence of any bleeding focus . in the remaining three patients ,
surgery did not lead to the discovery of any bleeding focus , and they only underwent hematoma evacuation .
after either conservative or surgical management , the signs of active bleeding ameliorated in all 11 patients . during the 6 month follow - up period after ldlt , there were no major tae - related complications .
according to our results , arterial bleeding after ldlt was not confined to surgical causes .
surgical bleeding was one of the most common causes of bleeding after ldlt , however , iatrogenic bleeding was even more common than surgical bleeding in our retrospective study .
coagulopathy after ldlt is inevitable for a certain period of time in most liver transplant recipients , until the graft 's function is normalized .
the risk of iatrogenic bleeding is also high in the early post - ldlt period .
thus , clinicians should make a particular effort to prevent iatrogenic bleeding during percutaneous procedures after ldlt . some amount of surgical bleeding from the hepatic artery at the hepatic arterial anastomotic site , hepatic resection margin or hepaticojejunostomy site is inevitable , because ldlt generates a liver graft with variable - sized cut surfaces and multiple anastomotic sites .
in fact , bleeding from the hepatic artery was the most common cause of bleeding in our study . however , performing tae in the case of bleeding from the hepatic artery following ldlt was virtually impossible , because of the difficulty involved in the superselection of the bleeding arteries , due to the existence of fine arterial feeders , hepatic arterial anastomotic stenosis , a tortuous arterial course or multifocal occurrences .
furthermore , performing tae of the hepatic artery runs the risk of hepatic infarction or failure following inadvertent diffuse proximal embolization ( 16 ) .
( 17 ) reported that three of nine patients with extrahepatic pseudoaneurysm following liver transplantation underwent effective coil embolization , however all patients subsequently underwent retransplantation due to graft ischemia .
accordingly , we achieved technical success in only four of the 14 foci involving bleeding from the hepatic arterial branches .
although tae can be performed in some patients with massive bleeding from the hepatic artery , we consider that surgical management is the treatment of choice for the management of surgically induced bleeding from the hepatic artery anastomotic site , hepatic resection margin or hepaticojejunostomy site .
the cause of bleeding from the intercostal artery was iatrogenic bleeding in most cases , resulting from either placement of a drain tube or central venous catheterization .
the cause of bleeding from the inferior phrenic artery was uncertain , however it might have been related to various causes , such as intraoperative retractor injury , chest tube insertion or spontaneous bleeding , and it must be routinely evaluated to rule out active bleeding . knowledge of the clinical symptoms or signs of arterial bleeding provided by the clinicians is very helpful prior to the performance of arteriography . a jp drain was the most common clinical clue to the presence of arterial bleeding after ldlt .
bleeding can occur from the hepatic , intercostal , inferior phrenic or pancreaticoduodenal arteries or from the jejunal branches of the superior mesenteric artery .
unusually , bleeding from the deep circumflex iliac and inferior epigastric arteries was manifested as jp bleeding in one case .
therefore , in our opinion , arteriograms of the inferior phrenic and intercostals arteries , as well as of the superior mesenteric and common hepatic arteries , should be surveyed in cases of jp drain bleeding .
in addition , those arteries supplying the lower thoracic and abdominal walls should also be considered as possible sources of arterial bleeding . as in the case of general surgical patients , ldlt recipients are also subject to bleeding from stress ulceration , peptic ulcer and angiodysplasia of the colon ( 4 , 6 , 18 ) .
not uncommonly , this bleeding tends to be resolved only by proper medical treatment ( 4 ) .
clinical observation may be sufficient whenever the patient 's condition tolerates it . in our study , four patients with hematochezia or melena showed negative outcomes on arteriography , but improved clinically without surgery or tae . in fact , tae was very effective in cases of positive arteriography , and all four patients with arteriographically proven gastrointestinal bleeding improved after only one session of tae . in the conventional arteriogram , a negative outcome does not always guarantee the absence of actual bleeding . in our study ,
surgery demonstrated active bleeding foci in three of six patients without active bleeding on selective arteriography .
this discrepancy seems to have been caused by minor or intermittent arterial bleeding or venous oozing .
in contrast , surgery did not lead to the detection of any bleeding focus in the three remaining patients . in conclusion ,
technical limitations were encountered when using tae for the management of hepatic arterial bleeding . however , in the other locations , tae seems to be effective and safe for the control of arterial bleeding after ldlt .
 objectiveto analyze the causes of arterial bleeding after living donor liver transplantation ( ldlt ) and to evaluate the efficacy of transcatheter arterial embolization ( tae).materials and methodsforty - two sessions of conventional arteriography were performed in 32 of the 195 patients who underwent ldlt during the past 2 years . 
 this was done in search of bleeding foci of arterial origin . 
 tae was performed with microcoils or gelatin sponge particles . 
 the causes of arterial bleeding , the technical and clinical success rates of tae and the complications were retrospectively evaluated.resultsforty-two bleeding foci of arterial origin were identified on 30 sessions of arteriography in 21 patients . 
 the most common cause of bleeding was percutaneous procedures in 40% of the patients ( 17 of the 42 bleeding foci ) followed by surgical procedures in 36% ( 15/42 ) . 
 the overall technical and clinical success rates of tae were 21 ( 70% ) and 20 ( 67% ) of the 30 sessions , respectively . 
 the overall technical success rate of tae for the treatment of bleeding from the hepatic resection margin , hepatic artery anastomotic site and hepaticojejunostomy was only 18% ( 2/11 ) , whereas for the treatment of bleeding in the other locations the technical and clinical success rates of tae were 100% and 95% , respectively . 
 no procedure - related major complications occurred.conclusionin the case of arterial bleeding after ldlt , percutaneous procedure - related hemorrhages were as common as surgery - related hemorrhages . 
 there were technical difficulties in using tae for the treatment of hepatic arterial bleeding . 
 however , in the other locations , tae seems to be safe and effective for the control of arterial bleeding in ldlt recipients . 
MATERIALS AND METHODS
Patient Population
Conventional Arteriography and Transcatheter Arterial Embolization
Analysis
RESULTS
Causes and Locations of Arterial Bleeding
Transcatheter Arterial Embolization
DISCUSSION