Splenic Artery Syndrome as a Possible Cause of Late Onset Refractory Ascites After Liver Transplantation: Management With Proximal Splenic Artery Embolization.
BACKGROUND
Portal hyperperfusion (PHP) is a hemodynamic condition which may develop after liver transplantation and cause refractory ascites (RA). The diagnosis is established by exclusion of other causes of increased sinusoidal pressure/resistance such as cellular rejection or toxicity and outflow obstruction. PHP as part of the pathogenesis of the splenic artery syndrome (SAS) can be treated with splenic artery embolization (SAE).


METHODS
This is a retrospective study on a cohort of first-time whole-size liver transplant recipients diagnosed with RA due to PHP and treated by proximal SAE (pSAE) at the Liver Transplant Unit of the University Hospital of Udine between 2004 and 2014.


RESULTS
For this study, 23 patients were identified (prevalence 8%) and treated. Preliminary clinical workup to diagnose SAS was based on exclusion of other possible causes of RA with graft biopsy, cavogram with hepatic venous pressure measurement, computed tomography scan, and angiography. The pSAE was performed 110 ± 61 days after transplantation, and no procedure-related complications occurred. pSAE resulted in a significant decrease of portal vein velocity (P = .01) and wedge hepatic venous pressure (P = .03). The diameter of the spleen showed a slightly significant reduction (P = .047); no modification of hepatic artery resistive index were encountered (P = .34). Moreover, pSAE determined the resolution of RA in all cases.


CONCLUSIONS
pSAE is a safe and effective procedure to modulate the hepatic inflow and thus to treat RA secondary to SAS, with a low incidence of complications and a high rate of clinical response.
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
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R
Pravisani
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy. Electronic address: umberto.baccarani@uniud.it.
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U
Baccarani
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
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G
Adani
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
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D
Lorenzin
Division of Interventional Radiology, University Hospital of Udine, Udine, Italy.
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A
Vit
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
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V
Cherchi
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
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S
Calandra
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
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I
Rispoli
Department of Medicine and Pathology Clinical and Experimental, Medical Liver Transplantation Unit, Internal Medicine, University of Udine, Udine, Italy.
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P
Toniutto
Division of Interventional Radiology, University Hospital of Udine, Udine, Italy.
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M
Sponza
General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
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Risaliti
D000368:Aged; D001201:Ascites / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D001783:Blood Flow Velocity; D015331:Cohort Studies; D019468:Disease Management; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006439:Hemodynamics; D006499:Hepatic Artery; D006801:Humans; D008099:Liver; D008102:Liver Circulation / Q000502:physiology*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D017082:Portal Pressure; D011168:Portal System / Q000503:physiopathology*; D011169:Portal Vein; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D013154:Spleen; D013157:Splenic Artery; D013577:Syndrome; D014652:Vascular Diseases / Q000150:complications / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*