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Digestive Disease Interventions
DOI: 10.1055/s-0044-1791775
Review Article

Splenic Artery Embolization for Post-Liver Transplant Ascites

Giuseppe D'Amico
1   Abdominal Transplantation Unit, University of Gothenburg, Gothenburg, Sweden
,
Luca Del Prete
2   General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
3   Department of Health Sciences, PhD School in Translational Medicine, University of Milan, Milan, Italy
,
Teresa Diago
4   Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
,
Sasan Partovi
5   Department of Interventional Radiology, Imaging Institute at Cleveland Clinic, Cleveland, Ohio
,
Sameer Gadani
5   Department of Interventional Radiology, Imaging Institute at Cleveland Clinic, Cleveland, Ohio
,
Cristiano Quintini
4   Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Abstract

Orthotopic liver transplantation (OLT) is the treatment of choice for end-stage liver disease. However, OLT may be associated with certain postoperative management challenges. Though refractory ascites (RA) is not a common complication post-OLT, it can have a significant impact on patient outcomes and quality of life. RA post-OLT can be caused by portal hyperperfusion. In this article, a systematic review of the literature was pursued to analyze the effectiveness of splenic artery embolization (SAE) with RA after OLT. Data sources included MEDLINE, EMBASE, and CENTRAL from inception to March 2024. Studies reporting on patients treated with SAE for the management of RA following OLT, from inception to March 2024, were included. Morbidity, mortality, and clinical resolution were synthesized through a narrative review. A total of eight articles were identified, including 80 patients. In the majority of the patients, the SAE was performed using a vascular plug. After SAE, no cases associated with mortality were reported. Severe complications (Clavien III) occurred in 2.5% (n = 2) of patients. The success rate, with clinical resolution of symptomatology (ascites), ranged in these articles between 97 and 100%. The approach to the management of RA post-OLT should focus on identifying the underlying cause. If the RA is associated with portal hyperperfusion, it can be managed with SAE. Particularly proximal SAE seems to be highly effective for the resolution of ascites and the procedure is associated with a low complication rate.

Keywords

liver transplant - splenic artery embolization - portal hyper flow - refractory ascites


Publication History

Received: 26 June 2024

Accepted: 16 September 2024

Article published online:
25 November 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Ostojic A, Petrovic I, Silovski H, Kosuta I, Sremac M, Mrzljak A. Approach to persistent ascites after liver transplantation. World J Hepatol 2022; 14 (09) 1739-1746
    CrossrefPubMedSearch in Google Scholar
  • 2 Nishida S, Gaynor JJ, Nakamura N. et al. Refractory ascites after liver transplantation: an analysis of 1058 liver transplant patients at a single center. Am J Transplant 2006; 6 (01) 140-149
    CrossrefPubMedSearch in Google Scholar
  • 3 Kato T, Levi DM, DeFaria W, Nishida S, Tzakis AG. Liver transplantation with renoportal anastomosis after distal splenorenal shunt. Arch Surg 2000; 135 (12) 1401-1404
    CrossrefPubMedSearch in Google Scholar
  • 4 Siqueira F, Kelly T, Saab S. Refractory ascites: pathogenesis, clinical impact, and management. Gastroenterol Hepatol (N Y) 2009; 5 (09) 647-656
    PubMedSearch in Google Scholar
  • 5 D'Amico G, Partovi S, Del Prete L. et al. Proximal splenic artery embolization for refractory ascites and hydrothorax post-liver transplant. Cardiovasc Intervent Radiol 2023; 46 (04) 470-479
    CrossrefPubMedSearch in Google Scholar
  • 6 Quintini C, Hirose K, Hashimoto K. et al. “Splenic artery steal syndrome” is a misnomer: the cause is portal hyperperfusion, not arterial siphon. Liver Transpl 2008; 14 (03) 374-379
    CrossrefPubMedSearch in Google Scholar
  • 7 Quintini C, D'Amico G, Brown C. et al. Splenic artery embolization for the treatment of refractory ascites after liver transplantation. Liver Transpl 2011; 17 (06) 668-673
    CrossrefPubMedSearch in Google Scholar
  • 8 Kelly DM, Miller C. Understanding the splenic contribution to portal flow: the role of splenic artery ligation as inflow modification in living donor liver transplantation. Liver Transpl 2006; 12 (08) 1186-1188
    CrossrefPubMedSearch in Google Scholar
  • 9 Pinto S, Reddy SN, Horrow MM, Ortiz J. Splenic artery syndrome after orthotopic liver transplantation: a review. Int J Surg 2014; 12 (11) 1228-1234
    CrossrefPubMedSearch in Google Scholar
  • 10 Kim H, Suh KS, Jeon YM. et al. Partial splenic artery embolization for thrombocytopenia and uncontrolled massive ascites after liver transplantation. Transplant Proc 2012; 44 (03) 755-756
    CrossrefPubMedSearch in Google Scholar
  • 11 Lee CY, Lim WX, Chen CL. et al. Efficacy and safety of splenic artery embolization for intractable ascites using Amplatzer vascular plug versus coil after living donor liver transplantation. Diagn Interv Radiol 2022; 28 (05) 478-485
    CrossrefPubMedSearch in Google Scholar
  • 12 Maurer MH, Mogl MT, Podrabsky P. et al. Splenic artery syndrome after orthotopic liver transplantation: treatment with the Amplatzer vascular plug. Cardiovasc Intervent Radiol 2011; 34 (06) 1208-1213
    CrossrefPubMedSearch in Google Scholar
  • 13 Meighani A, Jafri SM, Raoufi M, Salgia R. Splenic artery embolization for treatment of refractory ascites after liver transplantation. ACG Case Rep J 2016; 3 (02) 136-138
    CrossrefPubMedSearch in Google Scholar
  • 14 Nutu OA, Justo Alonso I, Marcacuzco Quinto AA, Calvo Pulido J, Jiménez Romero LC. Complete splenic embolization for the treatment of refractory ascites after liver transplantation. Rev Esp Enferm Dig 2018; 110 (04) 257-259
    PubMedSearch in Google Scholar
  • 15 Pravisani R, Baccarani U, Adani G. et al. Splenic artery syndrome as a possible cause of late onset refractory ascites after liver transplantation: management with proximal splenic artery embolization. Transplant Proc 2016; 48 (02) 377-379
    CrossrefPubMedSearch in Google Scholar
  • 16 Rysmakhanov M, Doskali M, Taganova A. et al. Splenic artery embolization in patients after orthotopic liver transplant. Exp Clin Transplant 2015; 13 (Suppl. 03) 52-54
    PubMedSearch in Google Scholar
  • 17 Kim JJ, Dasika NL, Yu E, Fontana RJ. Transjugular intrahepatic portosystemic shunts in liver transplant recipients. Liver Int 2008; 28 (02) 240-248
    CrossrefPubMedSearch in Google Scholar
  • 18 Saad WE, Darwish WM, Davies MG, Waldman DL. Transjugular intrahepatic portosystemic shunts in liver transplant recipients for management of refractory ascites: clinical outcome. J Vasc Interv Radiol 2010; 21 (02) 218-223
    CrossrefPubMedSearch in Google Scholar
  • 19 N'Kontchou G, Seror O, Bourcier V. et al. Partial splenic embolization in patients with cirrhosis: efficacy, tolerance and long-term outcome in 32 patients. Eur J Gastroenterol Hepatol 2005; 17 (02) 179-184
    CrossrefPubMedSearch in Google Scholar
  • 20 Sockrider CS, Boykin KN, Green J. et al. Partial splenic embolization for hypersplenism before and after liver transplantation. Clin Transplant 2002; 16 (Suppl. 07) 59-61
    CrossrefPubMedSearch in Google Scholar
  • 21 Ou HY, Huang TL, Chen TY. et al. Emergency splenic arterial embolization for massive variceal bleeding in liver recipient with left-sided portal hypertension. Liver Transpl 2005; 11 (09) 1136-1139
    CrossrefPubMedSearch in Google Scholar
  • 22 Pålsson B, Hallén M, Forsberg AM, Alwmark A. Partial splenic embolization: long-term outcome. Langenbecks Arch Surg 2003; 387 (11-12): 421-426
    CrossrefPubMedSearch in Google Scholar
  • 23 Lautt WW. Mechanism and role of intrinsic regulation of hepatic arterial blood flow: hepatic arterial buffer response. Am J Physiol 1985; 249 (5, Pt 1): G549-G556
    PubMedSearch in Google Scholar
  • 24 Kelly DM, Zhu X, Shiba H. et al. Adenosine restores the hepatic artery buffer response and improves survival in a porcine model of small-for-size syndrome. Liver Transpl 2009; 15 (11) 1448-1457
    CrossrefPubMedSearch in Google Scholar
  • 25 Luca A, Miraglia R, Caruso S, Milazzo M, Gidelli B, Bosch J. Effects of splenic artery occlusion on portal pressure in patients with cirrhosis and portal hypertension. Liver Transpl 2006; 12 (08) 1237-1243
    CrossrefPubMedSearch in Google Scholar
  • 26 Madoff DC, Denys A, Wallace MJ. et al. Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications. Radiographics 2005; 25 (Suppl. 01) S191-S211
    CrossrefPubMedSearch in Google Scholar