By Introduction: Exentoration during multivisceral and small bowel transplantation is associated with significant blood loss that increases patient instability intra operatively and may affect the subsequent post operative course. This is particularly the case for multivisceral transplantation for portomesenteric thrombosis. Previous authors have described this technique either to facilitate graft enterectomy^[2] or full multivisceral transplants in the context of portomesenteric thrombosis^[1]. 

Methods: Embolisation was undertaken in theatre following anaesthesia and placement of lines. Arterial access via the femoral artery was achieved and Amplatzer arterial plugs (St Jude) were landed as appropriate. These were either type I (8mm in length) or type II (16-24 mm). In the case of full multivisceral transplants the plugs occluded both coeliac access and superior mesenteric arteries. In circumstances where the stomach was retained the SMA, hepatic and splenic arteries were occluded and the left gastric artery preserved. Arterial closure was achieved using a Cordis Exoseal device. Embolisation was undertaken with the patient on a carbon opperating table.

Results: We have utilised arterial embolisation to facilitate explants in 7 patients who have had either liver small bowel transplants, full multivisceral transplants or small bowel, pancreas and colon transplants.
Six of the 7 embolisations were undertaken prior to surgical start and one part way through the explant to limit bleeding.
By performing embolisation in the operating theatre there was minimal delay in the explant procedure and no increase in the cold ischaemic time. 
There was a reduction in intra operative blood loss, metabolic and haemodynamic instability. One patient undergoing a full multivisceral transplant for porto mesenteric thrombosis required no blood products intra operatively.
There were no complications associated with the embolisation procedure.

Conclusion: We believe that arterial embolisation is a very usefull technique to minimise the blood loss associated with bowel transplantation. It reduces operative time, blood loss and metabolic instability.
The use of arterial plugs substantially reduces the time required for embolisation and the selective occlusion of visceral arterial branches allows for the preservation of the stomach.

[1] Ceulmans L J, Jochmans I, Montbaliu D, Verhaegen M, Laleman W, Nevens F, Heye S, Maleux G, Pirenne J. Pre-operative arterial embolisation facilitates multivisceral transplantation for portomesenteric thrombosis. Am J Transplant 2015;15:2963-9
[2] Fan J, Tekin A, Nishida S, et al. Preoperative embolisation of the graft superior mesenteric artery assists graft enterecomy in intestinal transplant recipients. Transplantation 2012;84:89-91