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. 2021 Apr 4;5(5):599-606.
doi: 10.1002/jgh3.12540. eCollection 2021 May.

Endovascular management of portal steal syndrome due to portosystemic shunts after living donor liver transplantation

Surabhi Jajodia  1   2 , Anubhav H Khandelwal  2 , Rohit Khandelwal  2 , Abhay K Kapoor  2 , Sanjay S Baijal  2
Affiliations

Endovascular management of portal steal syndrome due to portosystemic shunts after living donor liver transplantation

Surabhi Jajodia et al. JGH Open. .

Abstract

Background and aim: After liver transplant, pre-existent porto-systemic shunts (PSS) may persist, causing "portal steal," leading to graft dysfunction, hepatic encephalopathy (HE), and eventual rejection. In recipients of small-for-size transplant liver grafts, shunts may be created intraoperatively, facilitating diversion of portal flow to systemic circulation to avoid ill-effects of portal overperfusion. These iatrogenic shunts may also subsequently lead to portal steal. We aim to evaluate safety and efficacy of endovascular techniques in management of portal steal due to PSSs in living donor liver transplantation (LDLT) recipients.

Methods: Between 2013 and 2020, we encountered five LDLT recipients with large PSS, who presented with graft dysfunction and/or HE. One patient had a surgically created shunt and four had spontaneous shunts, not surgically ligated during transplant. Endovascular techniques including plug-assisted or balloon-occluded retrograde transvenous obliteration (PARTO/BRTO) or covered inferior vena cava (IVC) stent grafts were to occlude these PSS and counter the portal steal in all patients. Technical success and clinical outcomes at 1-year-follow-up were assessed.

Results: Imaging showed large PSS causing portal steal syndrome in all five patients. IVC stent graft was used to isolate the shunt in two patients and PARTO/BARTO was performed in three patients. One patient had guarded prognosis due to multiple organ dysfunction and died 5 days after endovascular procedure. At 1-year follow up, graft functions normalized in four patients with no recurrence of HE. No procedure-related complications were seen.

Conclusion: Endovascular techniques can be safely and effectively used to counter portal steal syndrome in LDLT recipients, thus avoiding surgical re-exploration in these patients.

Keywords: hepatic encephalopathy; living donor liver transplantation; portal steal; stent graft; vascular plugs.

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Figures

Figure 1
Figure 1
(a, b) Coronal and sagittal Maximum Intensity Projection CECT images showing a surgically created hemi‐portocaval shunt (orange triangle) between the IVC (*) and the right portal vein (blue arrow). Reformatted CT images were used to estimate the relation of the hepatic venous outflow and the Portocaval shunt outflow into the IVC to guide the IVC stent deployment. (c) Combined hepatic and IVC venogram was done to assess the landmarks for IVC stent placement and correlate it with pre‐defined CT measurements. (d, e) Metallic IVC stent graft deployed over a guidewire to obliterate the portocaval shunt. IVC, inferior vena cava.
Figure 2
Figure 2
(a, b) Axial and coronal CECT images in a living donor liver transplantation recipient showing large portosystemic shunt with gastro‐splenorenal (blue triangle) and meso‐renal components. (c) Cannulation of shunt using C1 catheter with venogram demonstrating the tortuous collateral channel. (d) Vascular plugs used to occlude the shunt. (e) Post‐plug assisted retrograde transvenous obliteration venogram demonstrates no further retrograde flow into the shunt.
Figure 3
Figure 3
Suggested protocol for management of post‐living donor liver transplantation patients with deranged liver function test.
See this image and copyright information in PMC

References

    1. Zhou HY, Chen TW, Zhang XM, Jing ZL, Zeng NL, Zhai ZH. Patterns of portosystemic collaterals and diameters of portal venous system in cirrhotic patients with hepatitis B on magnetic resonance imaging: association with Child‐Pugh classifications. Clin. Res. Hepatol. Gastroenterol. 2015; 39: 351–8. - PubMed
    1. Elshobary M, Shehta A, Salah T et al. Ligation of huge spontaneous porto‐systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: a case‐report. Int. J. Surg. Case Rep. 2017; 31: 214–17. - PMC - PubMed
    1. Kim SH, Lee JM, Choi JY et al. Changes of portosystemic collaterals and splenic volume on CT after liver transplantation and factors influencing those changes. AJR Am. J. Roentgenol. 2008; 191: W8–W16. - PubMed
    1. Kita Y, Harihara Y, Sano K et al. Reversible hepatofugal portal flow after liver transplantation using a small‐for‐size graft from a living donor. Transpl. Int. 2001; 14: 217–22. - PubMed
    1. Ikegami T, Shirabe K, Nakagawara H et al. Obstructing spontaneous major shunt vessels is mandatory to keep adequate portal inflow in living‐donor liver transplantation. Transplantation. 2013; 95: 1270–7. - PubMed

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