Successful minimally invasive management of late portal vein thrombosis after splenectomy due to splenic artery steal syndrome following liver transplantation: a case report

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.

Splenic artery steal syndrome after liver transplantation - prophylaxis or treatment?: A case report and literature review

Splenic artery steal syndrome (SASS) is a cause of graft hypoperfusion leading to the development of biliary tract complications, graft failure, and in some cases to retransplantation. Its management is still controversial since there is no universal consensus about its prophylaxis and consequently treatment. We present a case of SASS that occurred 48 hours after orthotopic liver transplantation (OLTx) in a 56-year-old male patient with alcoholic cirrhosis and severe portal hypertension, and who was successfully treated by splenic artery embolization. A literature search was performed using the PubMed database, and a total of 22 studies including 4,789 patients who underwent OLTx were relevant to this review. A prophylactic treatment was performed in 260 cases (6.2%) through splenic artery ligation in 98 patients (37.7%) and splenic artery banding in 102 (39.2%). In the patients who did not receive prophylaxis, SASS occurred after OLTx in 266 (5.5%) and was mainly treated by splenic artery embolization (78.9%). Splenic artery ligation and splenectomies were performed, respectively, in 6 and 20 patients (2.3% and 7.5%). The higher rate of complications registered was represented by biliary tract complications (9.7% in patients who received prophylaxis and 11.6% in patients who developed SASS), portal vein thrombosis (respectively, 7.3% and 6.9%), splenectomy (4.8% and 20.9%), and death from sepsis (4.8% and 30.2%). Whenever possible, prevention is the best way to approach SASS, considering all the potential damage arising from an arterial graft hypoperfusion. Where clinical conditions do not permit prophylaxis, an accurate risk assessment and postoperative monitoring are mandatory.

The Management of Portal Vein Thrombosis after Adult Liver Transplantation: A Case Series and Review of the Literature

Background: Portal vein thrombosis (PVT) after adult liver transplantation (LT) is a rare but serious complication with no consensus on the ideal treatment. We report a case series and a comprehensive review of the literature on PVT after LT to discuss the therapeutic options. Methods: The clinical data of 360 adult patients (≥18 years of age) who underwent LT from January 2017 to January 2020 were reviewed, and a comprehensive search of PubMed and Web of Science was conducted. Patients diagnosed with PVT after LT were identified, and relevant risk factors and therapies were analyzed. Results: Among the 360 patients, 7 (1.94%) developed PVT after LT. Onset of PVT within one week after LT was found in six patients (85.71%). Four of the seven patients with PVT received systemic anticoagulation (low molecular weight heparin and warfarin) therapy. Minimally invasive interventional therapies combined with systemic anticoagulation (heparin and warfarin) were applied for three patients, two of whom died because of severe abdominal hemorrhage and liver failure. Of the 33 cases reported in the literature, minimally invasive interventional therapy combined with systematic anticoagulation or sclerotherapy were the most-used methods (20/33). Systemic anticoagulation was administered to four patients, and surgical operation (thrombectomy; portosystemic shunt and retransplantation) was performed for nine patients. Among these 33 patients, 4 eventually died. Conclusions: Interventional therapy combined with systemic anticoagulation is a good choice for the management of PVT after LT, and in our experience, systemic anticoagulation alone can also have a positive effect for early PVT patients.

Portal vein thrombosis in a noncirrhotic patient after hemihepatectomy: A case report and review of literature

BACKGROUND

Portal vein thrombosis (PVT) is a condition caused by hemodynamic disorders. It may be noted in the portal vein system when there is an inflammatory stimulus in the abdominal cavity. However, PVT is rarely reported after hepatectomy. At present, related guidelines and major expert opinions tend to consider vitamin K antagonists or low-molecular weight heparin (LMWH) as the standard treatment. But based on research, direct oral anticoagulants may be more effective and safe for noncirrhotic PVT and are also beneficial by reducing the recurrence rate of PVT.

CASE SUMMARY

A 51-year-old woman without any history of disease felt discomfort in her right upper abdomen for 20 d, with worsening for 7 d. Contrast-enhanced computed tomography (CECT) of the upper abdomen showed right liver intrahepatic cholangiocarcinoma with multiple intrahepatic metastases but not to the left liver. Therefore, she underwent right hepatic and caudate lobectomy. One week after surgery, the patient underwent a CECT scan, due to nausea, vomiting, and abdominal distension. Thrombosis in the left branch and main trunk of the portal vein and near the confluence of the splenic vein was found. After using LMWH for 22 d, CECT showed no filling defect in the portal vein system.

CONCLUSION

Although PVT after hepatectomy is rare, it needs to be prevented during the perioperative period.

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.

Percutaneous treatment of portal vein thrombosis in a child who has undergone splenectomy

Thrombosis of the portal venous system is a well-recognized and potentially lethal complication after open or laparoscopic splenectomy. A 7-year-old girl with idiopathic thrombocytopenic purpura developed a portal vein thrombosis after open splenectomy. The portal vein thrombosis was diagnosed by color Doppler sonography. A percutaneous transhepatic thromboaspiration of the acute thrombus was done on the third postoperative day. Anticoagulation was continued for 6 months. The presented patient is the youngest patient to undergo percutaneous thromboaspiration of an acute thrombus via the transhepatic route. Percutaneous thromboaspiration via the transhepatic route is an effective means of treating a portal vein thrombosis.

Protective effect of resveratrol, a red wine constituent polyphenol, on rats subjected to portal vein thrombosis

This experimental study investigated the prophylactic effects of the antioxidant and antiaggregant compound resveratrol (R) on portal vein thrombosis (PVT) in rats. Thirty rats weighing 200- 250 g were distributed in 3 groups: Group A (n = 10) and underwent PVT+R, Group B (n = 10) PVT alone, and Group C (n = 10) were subjected to a sham operation. Group A rats received R (60 mg/d per naso-gastric tube) for 10 days before PVT. Concerning antioxidant status, statistically significant increases in both tissue and plasma levels of reduced glutathione (GSH) and decrease in malondialdehyde (MDA) levels were observed in the PVT+R group compared with the PVT group (P < .001 for all). Comparison of these parameters with those of the sham group revealed significantly higher tissue and plasma levels of GSH and low MDA levels among the sham-operated group when compared with to the PVT+R or PVT groups (P < .001 for all). Concerning the antiaggregant status, significant increases of c-AMP levels were detected in rats treated with R before experiencing PVT (P < .001). Cyclic AMP levels in the sham group were significantly higher than those of either the PVT or PVT+R groups (P < .001). One may advise patients undergoing liver transplantation and carrying certain cardiovascular disease risk factors to ingest foods containing R to minimize PVT.