The relevance of the order of revascularization in liver grafting

Abstract A study was conducted comparing the effects of initial arterialization vs. initial portal revascularization in unstored warm ischemic (for 30 min) livers, livers stored for 4 hr at 0° C in Collins solution and livers rendered warm ischemic for 1 hr before removal and replacement as autografts. All livers that received initial arterialization showed uniform diffuse perfusion, whereas those with initial portal perfusion were patchy and well perfused only in the right lobe. In the experimental animal, initial arterialization using an end‐to‐end method was much casier and required less retraction. The energy charge and ATP levels dropped sharply during brief warm ischemia but returned rapidly to normal on revascularization. Although the decline in energy charge was less in stored livers, the return to normal was slower and incomplete. Plasma levels of AST indicated much greater damage in the stored livers and were lowest in recipients in unstored livers that were arterialized first. After longer warm ischemia, energy charge values declined and only completely returned to 60% of preoperative values within 2 hr of grafting. Despite this, the survival rate of these animals was very poor and only one survived overnight. Seven of the 12 survived the procedure, but in five death occurred within 30 min of full revascularization. In this group, AST levels rose sharply after revascularization to a mean level of 1,000 U. The resutls suggest that while initial arterizlization is beneficial if brief warm ischemia has occurred, it has no advantages other than improved subjective appearance of the liver and ease of performance after a 4‐hr period of cold storage. Neither order of revascularization reversed the damage caused by 1 hr definitive warm ischemia. Although the advantages were limited, there were no appearent detrimental effects of primary arterialization and thus this order could be undertaken if so desired.(H EPATOLOGY 1990;11:471–476.)