Liver & intrahepatic bile ducts

Liver transplantation

Early onset graft injury

Transplantation - surgical / vascular complications

Editorial Board Member: Monika Vyas, M.D.
Rui Caetano Oliveira, M.D., Ph.D.

Last staff update: 20 February 2023 (update in progress)

Copyright: 2022-2023,, Inc.

PubMed Search: Liver transplantation complications

Rui Caetano Oliveira, M.D., Ph.D.
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Cite this page: Oliveira RC. Transplantation - surgical / vascular complications. website. Accessed April 2nd, 2023.
Definition / general
  • Complications after liver transplantation
  • Biliary and vascular complications are common
  • Important cause of posttransplant morbidity
Essential features
  • Biliary and vascular complications are common events after liver transplantation
  • These events have implication on overall survival and quality of life of patients
  • Retransplantation may be necessary
  • Post liver transplantation biliary complications include:
    • Anastomotic strictures
    • Nonanastomotic strictures
    • Bile leaks
    • Bile duct stones
    • Bilomas
    • Sphincter of Oddi dysfunction
    • Ischemic cholangiopathy
  • Thrombosis
ICD coding
  • ICD-10: T86.4 - complications of liver transplant
  • Liver
  • Bile ducts
  • Hepatic artery
  • Portal vein
  • Bile injury is the result of a multifactorial process involving the bile duct
  • Cold / warm ischemia, perfusion injury, bile salt toxicity and immune mediated lesions have been described as causative (Virchows Arch 2012;461:41)
  • Lesions of the peribiliary vascular plexus and deep biliary glands are thought to be the main cause of nonanastomotic strictures (J Hepatol 2014;60:1172)
  • Graft injury, with prolonged cold (> 12 hours) and warm (> 90 minutes) ischemia time (Clin Liver Dis (Hoboken) 2016;7:73)
  • Donor quality (affected by donor age, steatosis > 30%, hypotension, small for size allograft) (Clin Liver Dis (Hoboken) 2016;7:73)
  • Ischemia
  • Inflammation
  • Infection
  • Surgery complications
  • Rejection
Clinical features
  • Abdominal pain
  • Fatigue
  • Fever (if infection)
  • Jaundice
  • Usually by a combination of clinical, laboratory and radiologic findings
  • Liver enzyme increase, namely aspartate aminotransferase (AST)
  • International normalized ratio (INR) increase
  • Acidosis
  • Alkaline phosphatase, gamma glutamyl transferase, total bilirubin and conjugated bilirubin, especially in biliary complication (Ann Hepatobiliary Pancreat Surg 2022;26:76)
Radiology description
Radiology images

Contributed by Ricardo Martins, M.D.

Portal vein thrombosis

Hepatic artery thrombosis

Acute portal vein thrombosis

Nonanastomotic strictures

Prognostic factors
Case reports
Gross description
  • Biliary complications
    • Liver explant with biliary obstruction / fibrosis of the bile duct; on cut section, it shows a mild to moderate fibrous tissue with bile casts and green tone
  • Vascular complications
    • Liver explant with hepatic artery / portal vein thrombosis, with complete / partial occlusion; on cut section, the liver is hemorrhagic and congestive
Gross images

Contributed by Rui Caetano Oliveira, M.D., Ph.D.

Bile casts in cholangiopathy

Liver necrosis

Liver necrosis cut section

Liver necrosis cut section

Liver thrombosis

Microscopic (histologic) description
  • Biliary cirrhosis is common after cholangiopathies or at least moderate to severe fibrosis
  • Ductular reaction in cases of bile duct obstruction, associated with portal tract edema
  • Copper stains may be positive in cases of chronic cholestasis as well as hepatocyte biliary metaplasia
  • Sinusoidal dilation and congestion are common in venous drainage complications
  • Ischemic necrosis is common in thrombosis
  • Reference: Diagn Histopathol 2018;24:508
Microscopic (histologic) images

Contributed by Rui Caetano Oliveira, M.D., Ph.D. and @RaulSGonzalezMD on Twitter

Ischemic cholangiopathy

Sinusoidal dilation


Foci of necrosis

Severe necrosis

Extensive necrosis

Extensive liver necrosis

Venous portal tract thrombosis

Major portal branch thrombosis

Bile duct ulceration

Extensive ulceration

Bile duct necrosis

Lipopeliosis following liver transplantation

Lipopeliosis following liver transplantation

Biliary cirrhosis

Ductular reaction and biliary metaplasia

Copper accumulation

Positive stains
  • CK7 may be useful in demonstrating ductular reaction and hepatocyte biliary metaplasia in cases of biliary obstruction
  • Rhodanine stain usually demonstrates copper deposits in periportal hepatocyte in cases of biliary obstruction
Sample pathology report
  • Liver, retransplant:
    • Biliary cirrhosis due to ischemic cholangiopathy (see comment)
    • Comment: There is ulceration of the right biliary duct, with severe inflammation consisting of neutrophils and foamy histiocytes round bile pigment. Hepatic parenchyma exhibits architectural changes, with bridge forming cirrhosis in a jigsaw pattern. CK7 demonstrates a ductular reaction and there is copper accumulation in the periseptal hepatocytes.
Differential diagnosis
Board review style question #1

Liver retransplantation is performed and the image above shows the gross examination. Which of the following is the probable cause?

  1. Acute rejection
  2. Biliary complications
  3. Portal thrombosis
  4. Primary no function
Board review style answer #1
Board review style question #2
Which of the following is thought to be the main cause of nonanastomotic strictures?

  1. Cytomegalovirus infection
  2. Lesions of the peribiliary vascular plexus and deep biliary glands
  3. Liver size
  4. Rejection
Board review style answer #2
B. Lesions of the peribiliary vascular plexus and deep biliary glands

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Reference: Transplantation - surgical / vascular complications
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