Outcomes of hepatic artery thrombosis after paediatric liver transplantation (HEPATIC): an international, multicentre, retrospective registry study

Why clinicians should know about it

• Picked for Pediatric Surgery (paper of the day, 15 October 2026): Retrospective registry of hepatic artery thrombosis after pediatric liver transplant

Abstract

BACKGROUND: Hepatic artery thrombosis after paediatric liver transplantation is a severe complication that can lead to acute graft failure, often requiring urgent re-transplantation. We aimed to assess the 1-year incidence of graft loss and mortality and to evaluate outcomes according to the timing of hepatic artery thrombosis and the treatment approaches in patients with hepatic artery thrombosis after paediatric liver transplantation. METHODS: In this international, multicentre, retrospective study, the HEPATIC registry, which had 33 centres across 21 countries as of December, 2025, was used to identify patients who developed hepatic artery thrombosis at age younger than 18 years after paediatric liver transplantation between Jan 1, 2002, and Dec 31, 2021, and who either received a diagnosis of or received an intervention for hepatic artery thrombosis before Jan 1, 2023. Donor-related, recipient-related, and transplantation-related characteristics collected from local medical records were entered retrospectively into electronic case reports by participating centres, with centralised data quality control. Primary outcomes were 1-year graft loss and mortality after hepatic artery thrombosis diagnosis. The outcomes were examined based on when hepatic artery thrombosis occurred after paediatric liver transplantation (early [≤7 days] vs late [>7 days]), primary management strategy (conservative management, surgical revascularisation, endovascular therapy, or immediate listing for re-transplantation), and transplantation era (in 5-year intervals). The registry was registered with ClinicalTrials.gov, NCT05818644. FINDINGS: Hepatic artery thrombosis occurred in 415 patients, of whom 216 (52%) were female and 199 (48%) were male, and median age was 1·7 years (IQR 0·8-6·5). Median follow-up was 50·9 months (IQR 17·0-112·6). Graft loss occurred in 180 patients by 1 month (cumulative incidence 43% [95% CI 38-48]) and 222 by 1 year (54% [49-58]); 51 patients died by 1 month (12% [9-15]) and 77 by 1 year (19% [15-22]). Surgical revascularisation was the first-line treatment approach in 195 (47%) patients. Other strategies included listing for re-transplantation in 99 (24%), conservative management in 79 (19%), and endovascular therapy in 42 (10%). Treatment approaches changed over time, with increased use of conservative management and endovascular therapy and reduced listing for re-transplantation (p<0·0001), with no accompanying change in 1-year mortality across eras (p=0·14). Early (≤7 days) hepatic artery thrombosis occurred in 282 (68%) patients and was associated with higher 1-year graft loss than late (>7 days) hepatic artery thrombosis (cumulative incidence 57% [95% CI 51-63] vs 47% [37-55], log-rank p=0·010). Surgical revascularisation was used in 167 (59%) patients and listing for re-transplantation in 66 (23%) patients with early hepatic artery thrombosis, whereas conservative management was used in 51 (38%) patients and endovascular therapy in 21 (16%) patients with late hepatic artery thrombosis; however, 1-year mortality did not differ between treatment strategies among patients with early versus late hepatic artery thrombosis. INTERPRETATION: Hepatic artery thrombosis after paediatric liver transplantation is associated with notably high 1-year graft loss and mortality, particularly if hepatic artery thrombosis occurs within 7 days after the procedure. The management strategies for hepatic artery thrombosis differ according to the post-transplantation timing of hepatic artery thrombosis occurrence. Despite changes in management over the past 20 years, outcomes have remained poor, underscoring the need to improve therapeutic strategies for this complication. FUNDING: None.

Abstract as published, via PubMed.