Double Versus Single Hepatic Artery Anastomosis in Pediatric Left Liver Grafts: A Reassessment of Outcomes.

BACKGROUND: The primary goal of hepatic artery reconstruction is to restore blood flow to the liver graft and its biliary system. Surgical approaches vary in the number of arterial anastomoses, magnification techniques, and anticoagulation strategies. This study analyzes the anatomical approaches used for arterial reconstruction, the incidence of HAT, and associated risk factors. METHOD: A retrospective study of 489 primary pediatric LDLT performed between January 2017 and July 2024. RESULTS: The incidence rates of HAT, early portal vein thrombosis (EPVT), late-PVT, biliary leak (BL), and biliary stricture (BS) were 1% (n = 5), 1.4% (n = 7), 4.3% (n = 21), 15% (n = 73), and 11.9% (n = 58), respectively. Double HA anastomosis was performed in 29.4% (119/405) of cases, with LHA-LHA + MHA-RHA being the most frequent combination. HAT occurred in four patients (1.4%) with single HA anastomosis and one patient (0.8%) in the double HA group (p = 1.00). The rates of BS and BL in the single HA group were 14.7% (n = 51) and 12.1% (n = 42), respectively, compared to 16% (n = 21) and 10.7% (n = 14) in the double HA group (BS: p = 0.72, BL: p = 0.66). Increasing age, CIT, and secondary abdominal closure were associated with higher HAT risk. The overall survival rate was 94.6%, with a median follow-up of 50.7 months (IQR: 21.1-73). CONCLUSION: This study showed a low HAT rate (1%) with increasing age, CIT, and secondary abdominal closure as risk factors. Double HA anastomosis did not reduce biliary complications. The most common HA graft-recipient combinations in this study were LHA-RHA for single HA reconstruction and LHA-LHA + MHA-RHA for double HA reconstruction.