• Xiaodong Sun, Zhongqi Fan, Wei Qiu, Yuguo Chen, Chao Jiang, and Guoyue Lv.
• Department of Hepatobiliary & Pancreas Surgery, The First Hospital, Jilin University, Changchun, China.
• Medicine (Baltimore). 2018 Jun 1; 97 (25): e10947.

RationaleMedian arcuate ligament (MAL) may compress the coeliac trunk inducing median arcuate ligament syndrome (MALS). MALS is a risk factor for hepatic artery thrombosis (HAT) in liver transplant recipients.Patient ConcernsA thin female complained about upper abdominal pain for two months.DiagnosesThe patient was diagnosed as primary biliary cirrhosis.InterventionsThe patient received two liver transplantations. During the first liver transplantation, the hepatic artery (HA) pulsations were normal. Doppler B ultrasonography showed normal blood flow in the HA in the first week. A 4 cm hematoma was detected in the first porta hepatis. On the ninth day, the hematoma had increased to 9 cm along with development of HAT. Exploratory laparotomy was performed. Bleeding at the site of arterial anastomosis was considered to be the reason for the hematoma. Doppler imaging revealed no blood flow in the liver. Computed tomography angiography demonstrated MALS. Salvage liver transplantation combined with dissection of MAL was performed. The maximum velocity of HA increased to 87 cm/s.OutcomesThe patient was discharged from the hospital 17 days after the second transplantation. At discharge, the liver function was normal and Doppler showed good blood flow in the HA.LessonsMALS can cause HAT after liver transplantation. Before the liver transplantation, we should use Doppler B ultrasonography and sagittal CT imaging to judge whether the patient is with MALS. Also, before arterial anastomosis in liver transplantation is conducted, we should observe the impacts on the HA caused by pre-blocking gastroduodenal artery, which determines if we are supposed to do MAL dissection or bridge HA with aorta.

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