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

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.

Understanding Local Hemodynamic Changes After Liver Transplant: Different Entities or Simply Different Sides to the Same Coin?

Liver transplantation is an extremely complex procedure performed in an extremely complex patient. With a successful technique and acceptable long-term survival, a new challenge arose: overcoming donor shortage. Thus, living donor liver transplant and other techniques were developed. Aiming for donor safety, many liver transplant units attempted to push the viable limits in terms of size, retrieving smaller and smaller grafts for adult recipients. With these smaller grafts came numerous problems, concepts, and definitions. The spotlight is now aimed at the mirage of hemodynamic changes derived from the recipients prior alterations. This article focuses on the numerous hemodynamic syndromes, their definitions, causes, and management and interconnection with each other. The aim is to aid the physician in their recognition and treatment to improve liver transplantation success.

Small-For-Size Syndrome and Graft Inflow Modulation Techniques in Liver Transplantation

BACKGROUND

Partial liver transplantation has recently been proposed to alleviate organ shortages. However, transplantation of a small-for-size graft is associated with an increased risk of posttransplant hepatic dysfunction, commonly referred to as small-for-size syndrome (SFSS). This review describes the etiology, pathological features, clinical manifestations, and diagnostic criteria of SFSS. Moreover, we summarize strategies to improve graft function, focusing on graft inflow modulation techniques. Finally, unmet needs and future perspectives are discussed.

SUMMARY

In fact, posttransplant SFSS can be attributed to various factors such as preoperative status of the recipients, surgical techniques, donor age, and graft quality, except for graft size. With targeted improvement measures, satisfactory clinical outcomes can be achieved in recipients at increased risk of SFSS. Given the critical role of relative portal hyperperfusion in the pathogenesis of SFSS, various pharmacological and surgical treatments have been established to reduce or partially divert excessive portal inflow, and recipients will benefit from individualized therapeutic regimens after careful evaluation of benefits against potential risks. However, there remain unmet needs for further research into different aspects of SFSS to better understand the correlation between portal hemodynamics and patient outcomes.

KEY MESSAGES

Contemporary transplant surgeons should consider various donor and recipient factors and develop case-specific prevention and treatment strategies to improve graft and recipient survival rates.

Multimodality Imaging after Liver Transplant: Top 10 Important Complications

Patients who have undergone liver transplant are now regularly seen in day-to-day radiology practice. All surgical techniques for liver transplant require arterial, portal venous, hepatic venous and caval, and biliary anastomoses. This review is focused on the 10 "not to be missed" complications of liver transplant that affect the health and life of the graft and graft recipient. Arterial complications are the most common and devastating. Early hepatic artery thrombosis may be catastrophic because the biliary tree is solely dependent on the hepatic artery after transplant and collateral vessels have not yet formed. In contrast, delayed hepatic artery thrombosis may be more insidious as collateral arteries develop. US findings of delayed hepatic artery thrombosis may be similar to those of hepatic artery stenosis and celiac artery stenosis. Splenic artery steal syndrome is an increasingly recognized cause of graft ischemia. Venous complications are much less common. Hepatic venous and caval complications are notable for their increased incidence in living-donor and pediatric transplants. Biliary complications often result from arterial ischemia. Biliary cast syndrome is a notable example in which ischemic biliary mucosa sloughs into and obstructs the duct lumens. Neoplasms also may occur within the hepatic graft and may be due to recurrent malignancy, posttransplant lymphoproliferative disorder, or metastases. US is the initial imaging modality of choice, particularly in the acute postoperative setting. Further evaluation with contrast-enhanced US, CT, or MRI; catheter angiography; endoscopic retrograde cholangiopancreatography; and/or nuclear medicine studies is performed as needed. An invited commentary by Bhargava is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Recurrent graft failure secondary to portal vein steal syndrome: a case report with an unusual indication for a third liver transplant

Background

Portal vein shunt is common in chronic hepatic diseases and after a liver transplant. Ensuring a satisfactory portal flow is essential to support a rapid liver recovery, of paramount importance to meet the recipient’s metabolic needs.

Case presentation

We report the case of a 32-year-old female undergoing a third liver transplant due to recurrence of graft failure secondary to portosystemic shunting. The patient, affected with biliary atresia, was first transplanted in 2009 with a right split liver graft. The clinical course was complicated by biliary stenosis of the Roux-en-Y anastomosis and multiple episodes of acute rejection treated with steroid boluses, plastic dilation of the biliary anastomosis, and biliary catheter placement. Unfortunately, in 2017 a liver biopsy showed an autoimmunity with histological evidence of ANA 1:80 (granular and nucleolar pattern). This was a contributing factor of liver function impairment, leading to the need to perform a second liver transplant, complicated by an acute rejection, with only a partial response to steroid therapy. Due to the further worsening of the liver function (MELD: 40, Child–Pugh: C11), the patient was relisted for a liver transplant. After five days, she received her third liver transplant, with an entire graft of an AB0 identical group. Intraoperative exploration revealed multiple collaterals and large splenocaval shunts, with a significant alteration of the portal flow and hypertension, isolated and closed with a vascular stapler to restore the graft's regular portal vein flow.

Conclusions

In patients listed for a liver transplant, portal steal syndrome should be identified prior to the transplant. Our recommendation is to consider intraoperative or perioperative closure of the portal collateral varices.

Endovascular thromboaspiration with neurointerventional devices for early hepatic artery thrombosis after split liver transplant

We report the case of a 38-year-old woman who underwent orthotopic 'split' liver transplant, complicated by hepatic artery thrombosis on the first postoperative day. The patient was successfully treated with an endovascular approach by mechanical thromboaspiration of the hepatic artery, using neurovascular devices, angioplasty and stenting at the site of the surgical anastomosis.

Time is of the essence: A single-center experience of hepatic arterial supply impairment management in pediatric liver transplant recipients

BACKGROUND

Impairment of hepatic arterial flow including hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), and splenic artery steal syndrome (SASS) is potentially life-threatening complications. The proposed early diagnosis and urgent treatment strategy of graft arterial flow reduction aim to decrease morbidity and mortality.

METHODS

Pediatric patients with known hepatic arterial flow impairment were retrospectively reviewed. Patients were grouped by occlusive (HAT) and non-occlusive (HAS/SASS) arterial flow reduction. Patients with HAT were further divided in two groups based on the estimated maximal hepatic artery occlusion time ≤8 and >8 hours.

RESULTS

Impairment of hepatic arterial flow developed in 32 of 416 pediatric liver transplant recipients. HAT, HAS, and SASS incidences were 4.1% (n = 17), 2.2% (n = 9), and 1.4% (n = 6), respectively. Neither graft loss nor death occurred in the non-occlusive group. The probabilities of sepsis (OR, 1.7; 95% CI, 1.14-2.53; P=.008) and graft loss or death (OR, 1.42; 95% CI, 1.04-1.92; P=.046) were higher in the occlusive group. Patients with estimated maximal duration of hepatic artery occlusion ≤ 8 hours (n = 7; 41.2%) did not have ischemic-type biliary lesions and sepsis (P=.044 and 0.010, respectively) but had excellent 3-year graft survival compared with > 8 hours group (100% vs 40%; P=.037). Multivariate analysis revealed HAT manifestation by fever was associated with increased chances of graft loss or death.

CONCLUSION

Occlusive arterial complications impose higher risks of graft loss and death. Thorough arterial supply monitoring by Doppler ultrasonography and urgent endovascular arterial flow restoration may salvage both graft and the recipient.

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.

The devil is in the detail: current management of perioperative surgical complications after liver transplantation

PURPOSE OF REVIEW

Despite advances in the field, perioperative morbidity is common after liver transplantation. This review examines the current literature to provide up-to-date management of common surgical complications associated with liver transplantation.

RECENT FINDINGS

Research focuses on problems with anastomoses of the vena cava, portal vein, hepatic artery, and bile ducts. Interventional endoscopic and radiological techniques are used more frequently to avoid reoperation.

SUMMARY

Advances in the management of perioperative surgical complications have focused on minimally invasive measures that successfully treat technical problems with implantation of liver allografts from both living and deceased donors.

The use of splenic artery embolization to maintain adequate hepatic arterial inflow after hepatic artery thrombosis in a split liver transplant recipient

INTRODUCTION

Split liver transplant is gaining increasing use in the current environment of growing organ shortage. It is associated with a higher risk of complications, owing to its complexity and technical challenges. Splenic artery steal syndrome, is a complication that can occur following liver transplant and cause inadequate hepatic arterial inflow, hepatic artery thrombosis and graft loss. We report a successful management of hepatic artery thrombosis and splenic artery steal syndrome after a split liver transplant by surgical thrombectomy followed by angiography and splenic artery embolization.

CASE

60-year old female, with liver cirrhosis, who underwent a deceased donor right lobe orthotopic liver transplant. The procedure was complicated by hepatic artery thrombosis, requiring re-exploration. However, despite anastomotic revision the patient had poor hepatic arterial inflow. Both angiography and ultrasonography demonstrated splenic artery steal syndrome. This was successfully managed by splenic artery embolization with improved hepatic artery flow on ultrasonography and angiography.

CONCLUSION

Splenic artery steal syndrome is a rare complication that can occur after a liver transplant. Experience with this phenomenon is limited in split liver transplantation.We demonstrated successful early management of splenic artery steal syndrome with coil embolization in a split liver transplant preventing further morbidity and graft loss.

Intraoperative Doppler sonogram in pediatric liver transplants: a pictorial review of intraoperative and early postoperative complications

A spectrum of vascular complications can be seen in pediatric liver transplant patients, including occlusion and hemodynamically significant narrowing of the vessels that provide inflow to or outflow from the graft. Intraoperative Doppler ultrasound (US) has the potential benefit of identifying vascular complications in pediatric liver transplant patients prior to abdominal closure. Importantly, intraoperative Doppler US can be used as a problem-solving tool in situations such as position-dependent kinking of the portal or hepatic veins, or in suspected vasospasm of the hepatic artery. Furthermore, this technique can be used for real-time reassessment after surgical correction of vascular complications. This pictorial review of intraoperative Doppler US in pediatric liver transplant patients illustrates normal findings and common vascular complications, including examples after surgical correction, in the perioperative period.