title: An Approach to Diagnosis and Endovascular Treatment of Refractory Ascites in Liver Transplant: A Pictorial Essay and Clinical Practice Algorithm.
abstract: OBJECTIVE
  Recipients of liver transplant are surviving longer as both the surgical procedure and postsurgical care have improved. Despite improvements, serious complications from the procedure remain that significantly affect patient outcome and may result in retransplant. Refractory ascites is one complication, occurring in about 5.6% of transplant recipients. Management of refractory ascites after liver transplant presents a challenge to the multidisciplinary team caring for these patients.
  
  
  METHODS
  We discuss approaches to the diagnosis and treatment of refractory ascites after liver transplant, based on a literature review, with a primary focus on vascular causes. These approaches are illustrated by case examples highlighting our experiences at an academic tertiary medical center. We propose a clinical practice algorithm for optimal endovascular treatment of refractory ascites after liver transplant.
  
  
  RESULTS
  The cornerstone of refractory ascites care is diagnosis and treatment of the cause. Vascular causes are not infrequently encountered and, if not treated early, are associated with graft loss and high morbidity and mortality and are major indications for retransplant. For patients with recurrent disease or graft rejection needing large volume paracentesis, the use of a transjugular intrahepatic portosystemic shunt may serve as a bridge to more definitive treatment (retransplant), although it may not be as effective for managing ascites as splenic artery embolization, arguably underused, which is emerging as a potential alternative treatment option.
  
  
  CONCLUSIONS
  A multidisciplinary strategy for the diagnosis and care of patients with refractory ascites after liver transplant is crucial, with endovascular treatment playing an important role. The aim is for this document to serve as a concise and informative reference to be used by those who may care for patients with this rare yet serious diagnosis.
authors.affiliation: Department of Interventional Radiology, Jackson Memorial Hospital/University of Miami Hospital, Miami, Florida, USA.
authors.forename: Keith
authors.initials: K
authors.lastname: Pereira
authors.forename: Jason
authors.initials: J
authors.lastname: Salsamendi
authors.forename: Ji
authors.initials: J
authors.lastname: Fan
mesh_terms: D000465:Algorithms; D001201:Ascites / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D019091:Critical Pathways; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D011237:Predictive Value of Tests; D012307:Risk Factors; D016896:Treatment Outcome