*Purpose: Hepatic artery stenosis (HAS) is a recognized vascular complication of liver transplant (LT) which can result in significant morbidity and mortality. Despite that there is paucity of literature investigating early diagnosis and evaluating patient outcomes. Purpose of this study was to investigate long term vasculobiliary complications, interventions, patient and graft outcomes associated with HAS.

*Methods: This is a retrospective analysis involving all DBD first grafts performed between January 2007 and December 2017 at our liver unit. Diagnosis of HAS was made by CT angiography (CTA). Clinical data were collated from electronic clinical database.

*Results: A total of 1225 first graft DBD LT were performed. 44 patients (3.6%) had confirmed diagnosis of HAS based on CTA. These were subdivided based on timing of HAS diagnosis post LT-early (diagnosis <90d n=23, 1.9%) and late (diagnosis >90d n=21, 1.7%) from LT. Higher incidence of “complex” arterial reconstructions (multiple anastomosis, retrieval injuries) were seen in early HAS (14/23, 61%) vs late HAS (9/21, 43% p>0.05) but this was significant when compared early HAS with no HAS (controls) (32/101, 32% p<0.05). Majority of biliary complications in HAS and no HAS were anastomotic strictures (AS) however etiology of these is likely different in these groups. In no HAS, 76% (77/101) of biliary complications were AS and majority of these were rescued with dilatation and stenting (47/77, 61%) where as in early HAS majority required dilatation/stenting followed by RouxenY or RouxenY without prior intervention. Based on CTA findings, grading scale to categorize HAS was devised. Mild stenosis was categorized as short anatomical kink with preserved flow, moderate as short segment narrowing with one additional element (cholangitis/liver infarct/upstream dilatation) while severe consisted of multiple areas of stenosis with flow limitation or long stenosis >5mm length. At <30d from HAS diagnosis, all patients within severe grade (2/2) required relisting of which one died; in the moderate group one was listed (1/4) and two had biliary complications requiring RouxenY (2/4) where as in the mild group majority had no complications (6/10). In the intermediate group (60-90d from HAS diagnosis), with severe stenosis, majority had vascular interventions (3/5) with no (2/5) or minimal biliary morbidity and interventions (3/5) with no graft or patient loss. With late HAS diagnosis (>90d from LT), severe grade with presence of collateralization, majority had no (4/7) or minimal (3/7) biliary complications with no patient or graft loss.

*Conclusions: While mild stenosis was associated with none to minimal morbidity, moderate to severe stenosis was associated with significant morbidity and mortality at diagnosis <30d from LT. Collateralization over time can help mitigate biliary complications. This work lays the foundation for practical tools to diagnose HAS at an early stage, provides a grading scale and management strategy that is long overdue.

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