Safety and efficacy of splenic artery embolization for portal hyperperfusion in liver transplant recipients: a 5-year experience

Prediction and management of small-for-size syndrome in living donor liver transplantation

Small-for-size syndrome (SFSS) remains a critical challenge in living donor liver transplantation (LDLT), characterized by graft insufficiency due to inadequate liver volume, leading to significant postoperative morbidity and mortality. As the global adoption of LDLT increases, the ability to predict and manage SFSS has become paramount in optimizing recipient outcomes. This review provides a comprehensive examination of the pathophysiology, risk factors, and strategies for managing SFSS across the pre-, intra-, and postoperative phases. The pathophysiology of SFSS has evolved from being solely volume-based to incorporating portal hemodynamics, now recognized as small-for-flow syndrome. Key risk factors include donor-related parameters like age and graft volume, recipient-related factors such as MELD score and portal hypertension, and intraoperative factors related to venous outflow and portal inflow modulation. Current strategies to mitigate SFSS include careful graft selection based on graft-to-recipient weight ratio and liver volumetry, surgical techniques to optimize portal hemodynamics, and novel interventions such as splenic artery ligation and hemiportocaval shunts. Pharmacological agents like somatostatin and terlipressin have also shown promise in modulating portal pressure. Advances in 3D imaging and artificial intelligence-based volumetry further aid in preoperative planning. This review emphasizes the importance of a multifaceted approach to prevent and manage SFSS, advocating for standardized definitions and grading systems. Through an integrated approach to surgical techniques, hemodynamic monitoring, and perioperative management, significant strides can be made in improving the outcomes of LDLT recipients. Further research is necessary to refine these strategies and expand the application of LDLT, especially in challenging cases involving small-for-size grafts.

Splenic artery steal syndrome after liver transplantation: A case series and review of literature

Splenic steal syndrome (SASS) represents a challenge to interventional radiologists after orthotopic liver transplantation. In this case series, we present three cases of patients who developed SASS after their liver transplants.

Hepatic artery stenosis following adult liver transplantation: evaluation of different endovascular treatment approaches

PURPOSE

To evaluate the efficacy and safety of hepatic artery interventions (HAI) versus extra-hepatic arterial interventions (EHAI) when managing clinically significant hepatic artery stenosis (HAS) after adult orthotopic liver transplantation.

MATERIALS AND METHODS

A single-center retrospective cohort analysis was conducted on liver transplant patients who underwent intervention for clinically significant HAS from September 2012 to September 2021. The HAI treatment arm included hepatic artery angioplasty and/or stent placement while the EHAI treatment arm comprised of non-hepatic visceral artery embolization. Primary outcomes included peri-procedural complications and 1-year liver-related deaths. Secondary outcomes included biliary ischemic events, longitudinal trends in liver enzymes and ultrasound parameters pre-and post-intervention.

RESULTS

The HAI arm included 21 procedures in 18 patients and the EHAI arm included 27 procedures in 22 patients. There were increased 1-year liver-related deaths (10% [2/21] vs 0% [0/27], p = 0.10) and complications (29% [6/21] vs 4% [1/27], p = 0.015) in the HAI group compared to the EHAI group. Both HAI and EHAI groups exhibited similar improvements in transaminitis including changes of ALT (-72 U/L vs -112.5 U/L, p = 0.60) and AST (-58 U/L vs -48 U/L, p = 0.56) at 1-month post-procedure. Both treatment arms demonstrated increases in post-procedural peak systolic velocity of the hepatic artery distal to the stenosis, while the HAI group also showed significant improvement in resistive indices following the intervention.

CONCLUSION

Direct hepatic artery interventions remain the definitive treatment for clinically significant hepatic artery stenosis; however, non-hepatic visceral artery embolization can be considered a safe alternative intervention in cases of unfavorable hepatic anatomy.

Surgical Versus Image-Guided Interventions in the Management of Complications After Liver Transplantation

Liver transplantation is a technically demanding surgical procedure with known complications, and the optimal approach to addressing vascular and biliary complications requires a coordinated effort between surgical and interventional radiology teams. Vascular complications involving the hepatic artery, portal vein, or hepatic veins can be characterized by their mechanism, chronicity, and timing of presentation. These factors help determine whether the optimal therapeutic approach is surgical or endovascular. Very early presentation in the perioperative period favors surgical revision, while later presentation is best addressed endovascularly. Biliary complications can be categorized as leaks or strictures, and coordinated surgical, endoscopic, and percutaneous management is needed to address these types of complications. Through advances in technique and the management of complications, outcomes after liver transplantation continue to improve.

Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.

Refractory Ascites After Liver Transplantation Treated With Splenic Artery Embolization: A Case Report and Literature Review

After orthotopic liver transplantation, several complications can arise, such as arterial or venous thrombosis, stenosis, biliary leakage, ischemia, or ascites. Although refractory ascites are not a common complication, they can have a significant impact on patients' prognosis and quality of life. This condition can be caused by multiple mechanisms, both intrahepatic and extrahepatic, and one of them is the splenic artery steal syndrome. In this article, we present the case of a patient with advanced cirrhosis who developed refractory ascites following liver transplantation. Despite management with diuretics and paracentesis, the ascites did not respond to conventional treatment. The diagnosis of splenic artery steal syndrome was confirmed through angiography, and subsequent embolization of the splenic artery resulted in symptom resolution.

Splenic Artery Embolism in Liver Transplant Patients: A Single-Center Experience

BACKGROUND

Hypersplenism, portal hypertension, and ascites have been seen after liver transplants. Patients are usually treated medically with refractory patients potentially undergoing splenectomy. Splenic artery embolism (SAE) is an alternative that can be performed to limit the surgical intervention that may have the benefit of improving portal hypertension. Few studies have studied the effect on main portal vein (MPV) velocities and hepatic artery resistive indices (HARIs) which may be beneficial as markers of portal hypertension.

PURPOSE

This study aims to evaluate the efficacy and safety of interventional radiology (IR)-guided SAE for the management of portal hypertension in patients who have had liver transplants.

METHODS

A retrospective analysis was conducted on liver transplant patients who had undergone IR-guided SAE post-transplant at a single tertiary transplant center from 2012 to 2022. The primary outcome of intervention efficacy was quantified by peak HARIs and MPV velocities. Ultrasound with Doppler obtained before and after the intervention was reviewed for these parameters. Secondary outcomes included adverse events at the time of the procedure and within one year of the procedure, the need for splenectomy, and spleen size.

RESULTS

Twenty-eight patients met the criteria for inclusion. The mean age of patients was 52.5 years (21-71 years) and the time after transplant was 149.5 days (2-1588 days). About 96.4% of SAEs were technically successful (n=27). Twenty-one patients had MPV velocities available, and 24 had peak HARIs available. In these patients, HARIs decreased by an average of 0.063 (95% CI 0.014-0.112) after SAE. MPV velocity decreased by an average of 47.2 cm/s (95% CI 27.3-67.1) after SAE. About 10.4% of patients (n=3) developed a procedure-related complication, all of which were femoral access site aneurysms. No (0) patients suffered from bleeding, infections, or abscesses after the procedure. About 10.7% of patients (n=3) required splenectomy after SAE: one splenectomy was due to technical failure and two were due to refractory symptoms.

CONCLUSION

We performed one of the first analyses on MPV and RI and showed that our patients saw an improvement post-embolization with a theoretical improvement in portal hypertension. The complication rate and risk of infection seem to be acceptable risks, making SAE a feasible option for management.

Open Thoracic Drainage Followed by Proximal Splenic Artery Embolization for Massive Hydrothorax Before Living Donor Liver Transplantation

BACKGROUND

Hepatic hydrothorax is associated with postoperative infectious complications and mortality in patients undergoing living-donor liver transplantation (LDLT). Thus, preoperative management of massive hepatic hydrothorax is essential for improving the outcomes of LDLT. This study aimed to demonstrate our successful cases and strategy for treating massive hepatic hydrothorax.

METHODS

Our strategy for hepatic hydrothorax includes (a) mini-thoracotomy under general anesthesia for the drainage of hydrothorax, (b) preoperative hepatic inflow modulation by proximal splenic arterial embolization, and (c) nutritional and physical intervention to improve the general condition.

RESULTS

Two patients with massive hepatic hydrothorax were treated with our strategy. Both patients had end-stage liver disease secondary to primary biliary cholangitis. Their performance status deteriorated due to massive hydrothorax. After the intervention, their performance status significantly improved. After that, LDLTs with right lobe grafts were performed. The duration of the operation was 440 and 343 minutes, with an intraoperative blood loss of 1,700 and 1,600 g, respectively. Their postoperative courses were uneventful, and they were discharged on postoperative days 16 and 14.

CONCLUSION

Our pre-LDLT multimodal management strategy for massive hepatic hydrothorax, including preoperative open thoracic drainage, pre-LDLT portal inflow modulation, and nutritional intervention, improved the preoperative condition of patients undergoing LDLT, resulting in successful outcomes.

Proximal Splenic Artery Embolization for Refractory Ascites and Hydrothorax Post-Liver Transplant

PURPOSE

Proximal splenic artery embolization (pSAE) has been advocated as a valuable tool to ameliorate portal hyper-perfusion (PHP). The purpose of this study was to determine the safety and efficacy of pSAE to treat refractory ascites (RA) and/or refractory hydrothorax (RH) in the setting of PHP post-liver transplant.

MATERIAL AND METHODS

A total of 30 patients who underwent pSAE for RA and/or RH after liver transplantation (LT) between January 2007 and December 2017 were analyzed retrospectively. The patients were divided into groups according to the time frame from pSAE to clinical resolution in order to identify predictors of RA/RH response to the procedure.

RESULTS

Twenty-four (80%) patients responded to pSAE within three months, whereas 6 (20%) still required additional treatments for RA/RH at three months post-pSAE. In all cases clinical symptoms resolved within six months. Complications after pSAE were as follows: 2 cases of splenic infarction (6.6%), one case of post-splenic embolization syndrome (3.3%), one case of hepatic artery thrombosis (3.3%) and one case of portal vein (PV) thrombosis (3.3%). Increased intraoperative PV flow volume and increased pre-pSAE PV velocity, as well as higher estimated glomerular filtration rate were associated with early RA/RH resolution.

CONCLUSION

pSAE is safe and effective in treating RA and RH due to PHP after LT. This study suggests that clinical parameters indicating more severe PHP and better kidney function are possible predictors for early response to pSAE.

Approach to persistent ascites after liver transplantation

Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.

Splenectomy ameliorates portal pressure and anemia in animal models of cirrhotic and non-cirrhotic portal hypertension

PURPOSE

Portal hypertension (PH)-associated splenomegaly is caused by portal venous congestion and splanchnic hyperemia. This can trigger hypersplenism, which favors the development of cytopenia. We investigated the time-dependent impact of splenectomy on portal pressure and blood cell counts in animal models of non-cirrhotic and cirrhotic PH.

MATERIALS AND METHODS

Ninety-six rats underwent either partial portal vein ligation (PPVL), bile duct ligation (BDL), or sham operation (SO), with subgroups undergoing additional splenectomy. Portal pressure, mean arterial pressure, heart rate, blood cell counts and hemoglobin concentrations were evaluated throughout 5 weeks following surgery.

RESULTS

Following PPVL or BDL surgery, the animals presented a progressive rise in portal pressure, paralleled by decreased mean arterial pressure and accelerated heart rate. Splenectomy curbed the development of PH in both models (PPVL: 16.25 vs. 17.93 ​mmHg, p ​= ​0.083; BDL: 13.55 vs. 15.23 ​mmHg, p ​= ​0.028), increased mean arterial pressure (PPVL: +7%; BDL: +9%), and reduced heart rate (PPVL: -10%; BDL: -13%). Accordingly, splenectomized rats had lower von Willebrand factor plasma levels (PPVL: -22%; BDL: -25%). Splenectomy resulted in higher hemoglobin levels in PPVL (14.15 vs. 13.08 ​g/dL, p ​< ​0.001) and BDL (13.20 vs. 12.39 ​g/dL, p ​= ​0.097) animals, and significantly increased mean corpuscular hemoglobin concentrations (PPVL: +9%; BDL: +15%). Thrombocytopenia only developed in the PPVL model and was alleviated in the splenectomized subgroup. Conversely, BDL rats presented with thrombocytosis, which was not affected by splenectomy.

CONCLUSIONS

Splenectomy improves both cirrhotic and non-cirrhotic PH, and ameliorates the hyperdynamic circulation. Hypersplenism related anemia and thrombocytopenia were only significantly improved in the non-cirrhotic PH model.

Refractory Ascites with Intrahepatic Portal Thrombosis after Living Donor Liver Transplantation Successfully Treated by Splenic Artery Embolization and Apixaban (Case Report)

Refractory ascites is a rare complication after liver transplantation, and its incidence ranges from 5% to 7%. A 56-yearold man diagnosed with HBV-LC with massive ascites underwent living donor liver transplantation. After transplantation, more than 1000 ml/day of ascites was steadily drained until two weeks after LT. CT showed intrahepatic Rt. portal vein thrombosis and many remnant collaterals with splenomegaly. We decided to embolize the proximal splenic artery and use apixaban to reduce portal flow and resolve the intrahepatic portal thrombosis. One day after splenic artery embolization, the patient's ascites dramatically decreased. Three days later, he was discharged from the hospital. Three months later, a follow-up liver CT showed resolution of thrombosis and no ascites. Splenic artery embolization was an effective and safe procedure for portal flow modulation in portal hyertension. Apixaban was effective for partial portal vein thrombosis in a liver transplant recipient.

Long term outcomes and complications of reno-portal anastomosis in liver transplantation: results from a propensity score-based outcome analysis

Diffuse splanchnic vein thrombosis (DSVT) remains a serious challenge in liver transplantation (LT). Reno-portal anastomosis (RPA) has previously been reported as a valid option for management of patients with DSVT during LT. The aim of this study was to evaluate post-transplant renal function and surgical outcomes of patients with DSVT who underwent RPA during LT. Between January 2005 and December 2017, 1270 patients underwent LT at our institution, including 16 with DSVT managed with RPA (RPA group). We compared renal function and surgical outcomes in these patients to outcomes in 48 propensity score (PS)-matched patients without thrombosis (control group), using a 1:3 matching model. The two groups had similar rates of postoperative portal vein thrombosis (PVT), renal dysfunction as measured by estimated glomerular filtration rate (eGFR), and overall postoperative complications (Clavien grade III), although the RPA group had a higher incidence of postoperative upper gastrointestinal (GI) bleeding (31.3% vs 4.2%; P = 0.009) that had no clinical consequence. There were no significant differences in five-year graft and patient survival rates between the groups (P = 0.133 and P = 0.166, respectively). RPA is an established technique in the management of patients with DSVT during LT, with comparable outcomes to patients without thrombosis. Our report is the first to demonstrate similar surgical outcomes, including long-term renal function, in LT recipients with or without RPA.

The Application of Interventional Radiology in Living-Donor Liver Transplantation

Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.

Treatment on the Spleen Prevents the Progression of Secondary Sarcopenia in Patients With Liver Cirrhosis

Hyperammonemia is an important stimulator of myostatin expression, a negative regulator of muscle growth. After splenectomy or partial splenic artery embolization (PSE), hyperammonemia often improves. Thus, we investigated changes in skeletal muscle index (SMI) in patients following an operation on the spleen and in patients who did not undergo an operation on their spleen. The study was designed retrospectively, in which we analyzed data collected between January 2000 and December 2015. Patients were assigned to the splenectomy/PSE or nontreatment group. Changes in SMI (ΔSMI), ammonia (Δammonia), myostatin (Δmyostatin), irisin (Δirisin), and branched‐chain amino acids/tyrosine molar ratio (ΔBTR) were analyzed between baseline and 5‐year follow‐up both before and after inverse probability of treatment weighting adjustment (IPTW). Patients (102) were enrolled (splenectomy/PSE, n = 45; nontreatment group, n = 57) before IPTW adjustment: ΔSMI (2.6 cm²/m² vs. −8.8 cm²/m², respectively) (P < 0.001), Δmyostatin (−867 vs. −568, respectively) (P < 0.001), Δammonia (−34 and 16, respectively) (P < 0.001), and ΔBTR (0.89 and −0.665, respectively) (P < 0.001). There were no differences between splenectomy and PSE regarding these factors. Moreover, after IPTW adjustment, significant differences were observed between the splenectomy/PSE and nontreatment group for the median ΔBTR (0.89 and −0.64, respectively) (P < 0.001), Δammonia (−33 and 16, respectively) (P < 0.001), Δmyostatin (−894 and 504, respectively) (P < 0.001), and ΔSMI (1.8 cm²/m² and −8.2 cm²/m², respectively) (P < 0.001). Conclusions: Both splenectomy and PSE were associated with the prevention of secondary sarcopenia in patients with LC. Moreover, it can be expected that muscle volume loss is reduced by splenectomy or PSE in patients with hyperammonemia.

Post-transplant inflow modulation for early allograft dysfunction after living donor liver transplantation

Background

To treat small-for-size syndrome (SFSS) after living donor liver transplantation (LDLT), many procedures were described for portal flow modulation before, during, or after transplantation. The selection of the procedure as well as the best timing remains controversial.

Case presentation

A 43-year-old female with end-stage liver disease underwent LDLT with extended left with caudate lobe graft from her donor who was her 41-year-old brother (graft volume/standard liver volume (GV/SLV), 35.7%; graft to recipient weight ratio (GRWR), 0.67%). During the surgery, splenectomy could not be performed owing to severe peri-splenic adhesions to avoid the ruined bleedings. The splenic artery ligation was not also completely done because it was dorsal to the pancreas and difficult to be approached. Finally, adequate portal vein (PV) inflow was confirmed after portal venous thrombectomy. As having post-transplant optional procedures that are accessible for PV flow modulation, any other procedures for PV modulation during LDLT were not done until the postoperative assessment of the graft function and PV flow for possible postoperative modulation of the portal flow accordingly. Postoperative PV flow kept as high as 30 cm/s. By the end of the 1st week, there was a progressive deterioration of the total bilirubin profile (peak as 19.4 mg/dL) and ascitic fluid amount exceeded 1000 mL/day. Therefore, splenic artery embolization was done effectively and safely on the 10th postoperative day (POD) to reverse early allograft dysfunction as PV flow significantly decreased to keep within 20 cm/s and serum total bilirubin levels gradually declined with decreased amounts of ascites below 500 mL on POD 11 and thereafter. The patient was discharged on POD 28 with good condition.

Conclusions

SFSS can be prevented or reversed by the portal inflow modulation, even by post-transplant procedure. This case emphasizes that keeping accessible angiographic treatment options for PV modulation, such as splenic artery embolization, after LDLT is quite feasible.

Impact of imbalanced graft-to-spleen volume ratio on outcomes following living donor liver transplantation in an era when simultaneous splenectomy is not typically indicated

The impact of an imbalanced graft-to-spleen volume ratio (GSVR) on posttransplant outcomes other than postreperfusion portal hypertension remains unknown. The importance of GSVR might vary according to whether simultaneous splenectomy (SPX) is performed. This retrospective study divided 349 living donor liver transplantation (LDLT) recipients from 2006 to 2017 into 2 groups: low GSVR (≤0.70 g/mL) and normal GSVR (>0.70 g/mL). The cutoff value of GSVR was set based on the first quartile of the distributed data. Graft survival and associations with various clinical factors were investigated between the groups according to whether SPX was performed. Low GSVR did not affect outcomes when SPX was performed. In contrast, it was associated with an increased incidence of early graft loss (EGL) and poor graft survival by presenting posttransplant thrombocytopenia, cholestasis, coagulopathy, and massive ascites when the spleen was preserved. Among patients with a preserved spleen, the multivariable analysis results revealed that older donor age and low GSVR were independent risk factors for graft loss. In conclusion, low GSVR was an independent predictor of graft loss after LDLT when the spleen was preserved. Preserved spleen with extremely low GSVR may be related to persistent hypersplenism, impaired graft function, and consequent EGL.

Complete splenic embolization for the treatment of refractory ascites after liver transplantation

Refractory ascites is an uncommon complication that may develop postoperatively after liver transplantation. The diagnosis and treatment of this condition is a real challenge. We report two cases of patients who underwent a transplant due to cryptogenic cirrhosis and developed refractory ascites during the immediate postoperative period. This is a serious complication associated with decreased survival by up to one year and a reduced quality of life. After ruling out the main causes of ascites, a portal hyperflow was a potential etiology. This condition perpetuates itself with splenic circulation and brings about a reduction in the hepatic arterial flow. Therefore, if arterial blood flow to the spleen is diminished, venous return and portal circulation will be reduced and arterial blood flow will improve. Splenic artery embolization is a procedure introduced many years ago for the management of splenic artery steal syndrome and small-for-size living donor liver transplantation. This procedure is performed in order to reduce portal hyperflow and consequently, ascites. In conclusion, splenic artery embolization is a therapeutic option for the treatment of refractory ascites after liver transplantation.

Proximal total splenic artery embolization for refractory hepatic encephalopathy

A Japanese woman with a history of Kasai operation for biliary atresia had living-donor liver transplantation at the age of 22. The first episode of refractory HE and late cellular rejection was treated by a high dose of methylprednisolone. The second episode of refractory HE was treated by balloon-occluded retrograde transvenous obliteration for a spleno-renal shunt. However, the third episode of refractory HE occurred 11 years after liver transplantation. The liver cirrhosis and hypersplenism were present with a Child-Pugh score of C-10. Although portal vein flow was hepatopetal, superior mesenteric vein flow regurgitated. We performed proximal total splenic artery embolization (TSAE). Superior mesenteric vein flow changed to a hepatopetal direction and she became clear. At a year after proximal TSAE, her spleen volume had decreased to 589 mL (20% decrease) on computed tomography. She is well and has a Child-Pugh score of 8 without overt HE. We report the first case of refractory HE treated by proximal TSAE that is a possible less invasive treatment option for a selected patient.

Interventional radiology in the management of the liver transplant patient

Liver transplantation (LT) is commonly used to treat patients with end-stage liver disease. The evolution of surgical techniques, endovascular methods, and medical care has led to a progressive decrease in posttransplant morbidity and mortality. Despite these improvements, a multidisciplinary approach to each patient remains essential as the early diagnosis and treatment of the complications of transplantation influence graft and patient survival. The critical role of interventional radiology in the collaborative approach to the care of the LT patient will be reviewed. Liver Transplantation 23 1328-1341 2017 AASLD.

Impact of Doppler Ultrasound on Diagnosis and Therapy Control of Lienalis Steal Syndrome After Liver Transplantation

Background

Lienalis steal syndrome is a rare complication after orthotopic liver transplantation leading to severe complications. Routine duplex sonography allows early and safe detection of lienalis steal syndrome and secondarily helps to monitor the outcome by evaluating the hemodynamics.

Material/Methods

This analysis included eight patients who after orthotopic liver transplantation needed splenic artery embolization due to lienalis steal syndrome. Lienalis steal syndrome was assumed in case of elevated transaminases, bilirubinemia or persistent ascites, and the absence of further pathologies. Diagnosis was supported by ultrasound, confirmed by digital subtraction angiography, and followed by splenic artery embolization for treatment. We analyzed blood levels and ultrasound findings before and after splenic artery embolization as well as during follow-up and evaluated for incidence of severe biliary complications and survival.

Results

Arterial resistive index (RI) significantly regularized after splenic artery embolization while the maximum arterial velocity increased. The portal venous flow volume and maximum velocity decrease. Laboratory parameters normalized. Two of eight patients developed ischemic-type biliary disease. Survival rate was 88% over a median follow-up of 33 months.

Conclusions

Beside unspecific clinical findings, bedside ultrasound examination enabled a quick verification of the diagnosis and allowed direct treatment to minimize further complications. Furthermore, ultrasound can immediately monitor the therapeutic effect of splenic artery embolization.

Current understanding and management of splenic steal syndrome after liver transplant: A systematic review

BACKGROUND

Splenic steal syndrome (SSS) is a condition that can occur after orthotopic liver transplant (OLT). However, limited information is available about this condition.

METHODS

A systematic literature search of studies performed through May 2016 was conducted to identify reports of angiographically confirmed SSS and its variants. All of the factors relevant to this disorder were collected and analyzed.

RESULTS

A total of 219 cases of SSS and its variants were identified. The condition occurred in 4.7% of patients after OLT, and 93.7% of cases were diagnosed within the first 2 months after OLT. Conventional arteriography demonstrated nonocclusive hepatic artery hypoperfusion in all affected patients. Abnormal liver function was the most common clinical presentation, reported in 71.9% of cases. Less common presentations included thrombocytopenia, acute graft failure, and persistent ascites. On Doppler ultrasound, a high resistance index of the hepatic artery was present in 84.1% of patients. Increased spleen volume (≥829 mL) before OLT was suggestive of a potential risk for SSS. Splenic artery embolization (SAE) was performed in 94.7% of cases; this procedure immediately reversed flow abnormalities on Doppler ultrasound and improved liver function tests in 96.3% of cases.

CONCLUSIONS

The risk factors and potential etiologies of SSS remain largely unknown. Future studies should investigate the possible role of pre-OLT portal hypertension and portal hyperperfusion after OLT in the development of this syndrome. Collecting intraoperative hemodynamic data and performing Doppler ultrasound screening after OLT could potentially help clinicians to identify patients at high risk of arterial hypoperfusion and prevent potential complications from hepatic artery hypoperfusion.

Splenic Artery Syndrome as a Possible Cause of Late Onset Refractory Ascites After Liver Transplantation: Management With Proximal Splenic Artery Embolization

BACKGROUND

Portal hyperperfusion (PHP) is a hemodynamic condition which may develop after liver transplantation and cause refractory ascites (RA). The diagnosis is established by exclusion of other causes of increased sinusoidal pressure/resistance such as cellular rejection or toxicity and outflow obstruction. PHP as part of the pathogenesis of the splenic artery syndrome (SAS) can be treated with splenic artery embolization (SAE).

METHODS

This is a retrospective study on a cohort of first-time whole-size liver transplant recipients diagnosed with RA due to PHP and treated by proximal SAE (pSAE) at the Liver Transplant Unit of the University Hospital of Udine between 2004 and 2014.

RESULTS

For this study, 23 patients were identified (prevalence 8%) and treated. Preliminary clinical workup to diagnose SAS was based on exclusion of other possible causes of RA with graft biopsy, cavogram with hepatic venous pressure measurement, computed tomography scan, and angiography. The pSAE was performed 110 ± 61 days after transplantation, and no procedure-related complications occurred. pSAE resulted in a significant decrease of portal vein velocity (P = .01) and wedge hepatic venous pressure (P = .03). The diameter of the spleen showed a slightly significant reduction (P = .047); no modification of hepatic artery resistive index were encountered (P = .34). Moreover, pSAE determined the resolution of RA in all cases.

CONCLUSIONS

pSAE is a safe and effective procedure to modulate the hepatic inflow and thus to treat RA secondary to SAS, with a low incidence of complications and a high rate of clinical response.

Imaging panorama in postoperative complications after liver transplantation

The liver is the second most-often transplanted solid organ after the kidney, so it is clear that liver disease is a common and serious problem around the globe. With the advancements in surgical, oncological and imaging techniques, orthotopic liver transplantation has become the first-line treatment for many patients with end-stage liver disease. Ultrasound, and Doppler are the most economical and cost-effective imaging modalities for evaluating postoperative fluid collections and vascular complications. Computed tomography (CT) is used to confirm the findings of ultrasound and look for pulmonary complications. Magnetic resonance imaging (MRI) is used for the diagnosis of biliary complications, bile leaks and neurological complications. This article illustrates the imaging options for diagnosing the various complications that can be encountered in the postoperative period after liver transplantation.