Vascular steal of the portal vein after orthotopic liver transplant: intraoperative sonographic diagnosis.
Spontaneous splenorenal shunts (SSRSs) are portosystemic connections between the splenic vein and the left renal vein (LRV) that develop commonly in patients with portal hypertension. (1) They reportedly occur in 18% to 19% of patients evaluated for a liver transplant. (2),(3) As the liver become more cirrhotic, a major steal phenomenon may occur, whereby blood is shunted from the high-resistance venous bed of the liver to the lower systemic pressure of the LRV. (4) Not infrequently, an SSRS will go undetected during orthotopic liver transplantation because dissection is limited to the right upper quadrant. The importance of these shunts may be underappreciated preoperatively by the radiologist. Usually, if small, these shunts will involute without incident when the lower-resistance allograft is implanted. (5),(6) Larger varices, those greater than 10 mm at the level of transition into the LRV, are more likely to steal blood from the liver, causing allograft failure and possibly death. (4),(7),(8) It is therefore important to document on preoperative imaging the size and location of portosystemic varices in any patient being evaluated for liver transplantation. We present a case in which intraoperative sonography showed a large SSRS that impaired hepatic portal inflow after transplantation, ultimately resulting in the patient's death.
Horrow
Mindy M
MM
Departmentof Radiology, Albert Einstein Medical Center, Philadelphia, Pennsylvania 19141 USA. horrowm@einstein.edu
Phares
Matthew A
MA
Viswanadhan
Narayan
N
Zaki
Radi
R
Araya
Victor
V
Ortiz
Jorge
J
D006801:Humans; D016031:Liver Transplantation / Q000009:adverse effects* / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000002:abnormalities* / Q000000981:diagnostic imaging*; D018084:Ultrasonography, Interventional / Q000379:methods*