Effect of splenic artery embolization for splenic artery steal syndrome in liver transplant recipients: estimation at computed tomography based on changes in caliber of related arteries

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.

Diagnostic Value of Color Doppler Ultrasound and Contrast-Enhanced Ultrasound in the Artery Steal Syndrome After Orthotopic Liver Transplantation

Purpose

This study aimed to investigate the application of color Doppler ultrasound (CDU) and contrast-enhanced ultrasound (CEU) in the early diagnosis of arterial steal syndrome (ASS) after orthotopic liver transplantation (OLT).

Patients and Methods

A total of 1827 patients received OLT in our department between January 2007 and December 2021, and CDU and CEU were performed after surgery. Ultrasonographic data were collected and further analyzed. ASS was confirmed by digital subtraction angiography (DSA), and the use of splenic artery embolization was dependent on the DSA findings and clinical conditions. The ultrasonographic data were collected before and after embolization.

Results

ASS was found in 23 patients (23/1827; 1.26%). CDU: the portal vein velocity was higher than normal in 17 patients (52.83±21.74 cm/s); the hepatic artery flow signals disappeared in 7 patients; the hepatic artery velocity was 13.57±5.85 cm/s in 16 patients. In 23 patients, the spleen artery velocity was 170.12±32.04 cm/s. CEU: the hepatic artery was observed in 7 patients without hepatic artery flow signals on CDU; in 23 patients, the contrast agent reached the portal vein at the presence of contrast in the hepatic artery or earlier (difference: 2.21±1.09 s). Splenic artery embolization was done in 17 of 23 patients with ASS. The hepatic artery flow velocity, hepatic artery resistance index, splenic artery velocity and time to the presence of contrast were significantly improved after embolization (P<0.05).

Conclusion

CDU and CEU are the preferred, effective tools in the diagnosis of ASS. Reduced peak hepatic artery velocity, increased spleen artery velocity and reduced time difference in the contrast reaching the portal vein and hepatic artery are indicative of ASS.

Splenic artery steal syndrome in patients with orthotopic liver transplant: Where to embolize the splenic artery?

Purpose

This study compared proximal and distal embolization of the splenic artery (SA) in patients with splenic artery steal syndrome (SAS) after orthotopic liver transplantation (OLT) regarding post interventional changes of liver function to identify an ideal location of embolization.

Methods and materials

85 patients with SAS after OLT treated with embolization of the SA between 2007 and 2017 were retrospectively reviewed. Periinterventional DSA was used to assess treatment success and to stratify patients according to the site of embolization. Liver function was assessed using following laboratory values: bilirubin, albumin, gamma-glutamyl transferase, glutamat-pyruvat-transaminase (GPT), glutamic-oxaloacetic transaminase (GOT), Alkaline Phosphatase (ALP), aPTT, prothrombin time and thrombocyte count. Descriptive statistics were used to summarize the data. Median laboratory values of pre, 1- and 3-days, as well as 1-week and 1-month post-embolization were compared between the respective embolization sites using linear mixed model regression analysis.

Results

All procedures were technically successful and showed an improved blood flow in the hepatic artery post-embolization. Ten Patients were excluded due to re -intervention or inconsistent image documentation. Pairwise comparison using linear mixed model regression analysis showed a significant difference between proximal and distal embolization for GPT (57.0 (IQR 107.5) vs. 118.0 (IQR 254.0) U/l, p = 0.002) and GOT (48.0 (IQR 48.0) vs. 81.0 (IQR 115.0) U/l, p = 0.008) 3-days after embolization as well as median thrombocyte counts 7-days after embolization (122 (IQR 108) vs. 83 (IQR 74) in thousands, p = 0.014). For all other laboratory values, no statistically significant difference could be shown with respect to the embolization site.

Conclusion

We conclude that long-term outcomes after embolization of the SA in the scenario of SAS after OLT are irrespective of the site of embolization of the SA, whereas a proximal embolization potentially facilitates earlier normalization of liver function. Choice of technique should therefore be informed by anatomical conditions, safety considerations and preferences of the interventionalist.

Splenic artery embolization with detachable balloons for hypersplenism

Objective

This study was performed to investigate the efficacy of proximal splenic artery embolization using detachable balloons for patients with hypersplenism and portal hypertension.

Methods

Twelve patients diagnosed with hypersplenism with thrombocytopenia or leukocytopenia caused by portal hypertension were treated by proximal splenic artery embolization with detachable balloons and metallic fibered coils. All patients were followed for up to 6 months. Blood parameters, coagulation factors, and liver function indicators were measured. Enhanced computed tomography and abdominal ultrasonography examinations were also performed in advance to confirm the infarction area and evaluate the changes in spleen size.

Results

Postoperative angiography demonstrated complete embolization of the proximal splenic artery in all 12 patients. Thrombocyte and leukocyte counts rose significantly in all patients in 2 weeks and stayed significantly higher than those before embolization throughout the 6-month follow-up. The total bilirubin concentration and prothrombin activity recovered significantly and returned to normal levels 6 months later. Computed tomography revealed partial infarction and liquefaction of the splenic parenchyma in nine patients.

Conclusions

Proximal splenic artery embolization using detachable balloons could be considered a safe and effective therapeutic modality in alleviating hypersplenism secondary to portal hypertension.

Advantages of time-resolved contrast-enhanced 4D MR angiography in splenic arterial steal syndrome

Splenic artery steal syndrome (SASS) is a severe complication affecting up to 10% of orthotopic liver transplant (OLT) patients. In this case report, we present a 35-year-old male with OLT secondary to liver failure due to hemochromatosis, who developed SASS. We describe potential application of different imaging techniques for diagnosis of SASS with focus on the value of time-resolved contrast enhanced 4D magnetic resonance angiography (MRA).

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 Embolization in Patients After Orthotopic Liver Transplant

OBJECTIVES

Hypersplenism (thrombocytopenia, leukopenia, anemia) syndrome and ascites occur after orthotopic liver transplant. These conditions can be treated by open splenectomy. Splenic artery embolization has been practiced as an alternative surgical method.

MATERIALS AND METHODS

Between January 2013 and January 2015, twenty-one orthotopic liver transplants were performed at the National Scientific Medical Research Center, Astana, Kazakhstan. Of these patients, 3 subsequently received splenic artery embolization 12, 8, and 6 months after transplant: 2 patients who had been diagnosed with primary biliary cirrhosis and 1 patient with hepatitis B virus -related liver cirrhosis. Two patients received a right-lobe living orthotopic liver transplant, and 1 patient received a deceased donor transplant. Indications for splenic artery embolization (ascites, splenomegaly) were based on clinical and ultrasonographic investigation and laboratory findings (thrombocytopenia, platelet count < 60 × 109/L, leukocytopenia, and white blood cell count < 2 × 109/L). Two recipients had leukothrombocytopenia and refractory ascites, and 1 had only thrombocytopenia. Splenic artery embolization was performed via a percutaneous femoral artery approach under local anesthesia. Transcatheter splenic artery branch occlusion was performed by deploying occlusion material. Preoperative spleen size ranged from 17.5 × 8.0 cm to 22.0 × 12.5 cm; ascites volumes were > 1000 mL.

RESULTS

In all patients, ascites and platelet levels decreased after splenic artery embolization. In 1 patient with leukopenia, white blood cell count normalized. After embolization, 1 patient had severe abdominal pain requiring analgesia medication, and 2 patients had fever that lasted 3 days. Patients were discharged 6 to 9 days after embolization. One patient developed a perisplenic abscess without fever 1 month after discharge, and the abscess was drained using an ultrasound-guided percutaneous procedure.

CONCLUSIONS

Splenic artery embolization is a safe and effective minimally invasive method for treating hypersplenism and ascites in orthotopic liver transplant recipients and an alternative to open splenectomy.

New strategies for prevention and treatment of splenic artery steal syndrome after liver transplantation

AIM: To explore a prophylactic procedure to prevent splenic artery steal syndrome (SASS), as well as a therapeutic intervention to correct it.

METHODS: Forty-three liver transplant patients were enrolled in a non-randomized controlled trial, with the eligible criterion that the diameter of the splenic artery is more than 5 mm and/or 1.5 times of the diameter of the hepatic artery. The procedure of splenic artery banding was performed in 28 of the 43 patients, with the other 15 patients studied as a control group. SASS and other complications were compared between these two groups. A new therapeutic intervention, temporary incomplete blockade of the splenic artery with a balloon, was performed to treat SASS in this study.

RESULTS: The incidence of SASS was decreased by banding the splenic artery (0/28 vs 5/15, P = 0.006), and the same result was observed in total complications associated with prophylactic procedures (2/28 vs 6/15, P = 0.014). Five patients in the control group developed SASS within 5 d after OLT, 2 of whom were treated by coil embolization of the splenic artery, whereas the other 3 by temporary blockade of the splenic artery. Reappeared or better hepatic arteries with improved systolic amplitude and increased diastolic flow were detected by Doppler ultrasonography in all the 5 patients. Local splenic ischemic necrosis and nonanastomotic biliary stricture were diagnosed respectively in one patient treated by coil embolization, and no collateral complication was detected in patients treated by temporary blockade of the splenic artery.

CONCLUSION: SASS should be avoided during the operation by banding the splenic artery. Temporary blockade of the splenic artery is a new safe and effective intervention for SASS.

Contrast-enhanced ultrasound diagnosis of splenic artery steal syndrome after orthotopic liver transplantation

The aim of this study was to investigate the use of contrast-enhanced ultrasound (CEUS) for the detection of splenic artery steal syndrome (SASS) after orthotopic liver transplantation (OLT). Two hundred forty-seven patients underwent OLT. Blood tests and color Doppler flow imaging (CDFI) were performed at various time points after the operation. CEUS and celiac angiography were used for patients suspected of having SASS. If the diagnosis of SASS was confirmed, splenic artery embolization was performed to enhance hepatic artery flow. CEUS and angiography were performed for the assessment of postinterventional clinical outcomes. Three of the 247 patients died postoperatively, and 8 patients were suspected of having SASS because of elevated liver enzyme levels and slim or undetectable hepatic artery blood signals by CDFI at various points after the operation. In these 8 patients, CEUS showed a delayed and weak contrast-enhanced blood signal in the hepatic artery associated with a rapid and intense enhancement of the portal vein blood. No narrowing of the hyperintense signal was observed in the hepatic artery by CEUS. The 8 diagnoses of SASS were proven by celiac angiography, which showed delayed perfusion of the hepatic artery and rapid filling of the splenic artery. Immediately after the interventional procedure, CEUS demonstrated a significantly enlarged hyperintense blood signal in the hepatic artery. In conclusion, approximately 3.27% of SASS cases occur after OLT. SASS can be identified as a sluggish and weak hyperintense blood signal in the hepatic artery without the narrowing and interruption of the hypointense signal in CEUS imaging. CEUS is an effective imaging modality for the detection of SASS after OLT.