Evaluation of a deceased donor liver allograft from a COVID-positive donor

A 41-year-old female presented to the ER with shortness of breath after a diagnosis of COVID-19 ten days prior. She had a BMI of 32 and a history of hypertension. She was started on therapeutic-dose Lovenox on hospital day two. Seven days into her admission, the patient suffered an extensive right ischemic stroke with herniation. She was declared brain dead one day later and authorized for organ donation. Liver function tests (LFTs) peaked at aspartate aminotransferase 259 u/L, alanine aminotransferase 158 u/L, alkaline phosphatase 73 u/L, and total bilirubin 0.6 mg/dL. Liver enzymes acutely rose and then fell two days prior to donation. Terminal LFTs were aspartate aminotransferase 19 u/L, alanine aminotransferase 34 u/L, alkaline phosphatase 73 u/L, and total bilirubin 0.6 mg/dL. Peak and trough platelet and INR levels were 282 × 10^9/L, 117 × 10^9/L, and 1.1, 1.2, respectively. The patient was hemodynamically stable with no documented vasopressor use or tachyarrhythmias. During the donor operation, the liver was congested initially but improved after diuresis. Biopsy revealed 20% macrosteatosis. There was an accessory/replaced right hepatic artery. The liver flushed well in situ and on the back-table via the portal vein. Both kidneys were procured and transplanted. At the recipient center, the hepatic artery was dissected to the gastroduodenal artery (GDA) to perform reconstruction of the accessory/replaced right hepatic artery. The hepatic artery distal to the GDA appeared discolored ( Figure 1) and dissection was continued up to the bifurcation for further evaluation.

FIGURE 1.

Low (A) and high magnification (B) photographs of the bifurcation of the common hepatic artery, the GDA, and the right and left hepatic arteries. Distal to the GDA, a distinct purple hue is visibly appreciated through the arterial walls that demonstrated resistance to arterial flushing on the back-table

1. QUESTIONS

• 1What is the most probable diagnosis based on the findings in Figure1A and BandFigure2?
  • a
    Hepatic artery dissection
  • b
    Hepatic artery thrombosis (HAT)
  • c
    Intramural hematoma of the hepatic artery
  • d
    Portal venous thrombosis
  • e
    Ischemic cholangiopathy
• 2 What pre-donation modality can best be used to evaluate liver allografts in the setting of COVID-positive donors with a history of thrombosis or elevated liver function tests (LFTs)?
  • a
    No additional investigation is required
  • b
    Arteriogram with interventional radiology
  • c
    CT angiogram abdomen with or without delayed images
  • d
    Non-Contrast CT of the abdomen
  • e
    Duplex ultrasound of the liver
• 3Given the finding during the back table preparation of this donor liver, how should COVID-positive donor livers with a history of thrombosis or elevated LFTs be evaluated during and after recovery?
  • a
    Early, thorough back table evaluation of the vessels
  • b
    Intra-operative angiography
  • c
    Back-bench hepatic arterial vasculature methylene blue infusion
  • d
    Retrograde hepatic vein flushing
  • e
    Visual assessment of liver flush quality
• 4 If unable to satisfactorily evaluate the extent of thrombosis, what is the safest next step?
  • a
    Split the liver and then use the less affected side for transplant
  • b
    Liver biopsy
  • c
    Decline the organ and cancel the transplant
  • d
    Proceed with transplantation and use intra-arterial tPA
  • e
    Attempt to re-flush the hepatic artery and portal vein and proceed with transplantation

FIGURE 2.

Thrombi extracted from the right and left hepatic arteries with a subacute appearance and firmness to tactile sensation