Splenic artery steal syndrome after liver transplantation - prophylaxis or treatment?: A case report and literature review

Abstract

Splenic artery steal syndrome (SASS) is a cause of graft hypoperfusion leading to the development of biliary tract complications, graft failure, and in some cases to retransplantation. Its management is still controversial since there is no universal consensus about its prophylaxis and consequently treatment. We present a case of SASS that occurred 48 hours after orthotopic liver transplantation (OLTx) in a 56-year-old male patient with alcoholic cirrhosis and severe portal hypertension, and who was successfully treated by splenic artery embolization. A literature search was performed using the PubMed database, and a total of 22 studies including 4,789 patients who underwent OLTx were relevant to this review. A prophylactic treatment was performed in 260 cases (6.2%) through splenic artery ligation in 98 patients (37.7%) and splenic artery banding in 102 (39.2%). In the patients who did not receive prophylaxis, SASS occurred after OLTx in 266 (5.5%) and was mainly treated by splenic artery embolization (78.9%). Splenic artery ligation and splenectomies were performed, respectively, in 6 and 20 patients (2.3% and 7.5%). The higher rate of complications registered was represented by biliary tract complications (9.7% in patients who received prophylaxis and 11.6% in patients who developed SASS), portal vein thrombosis (respectively, 7.3% and 6.9%), splenectomy (4.8% and 20.9%), and death from sepsis (4.8% and 30.2%). Whenever possible, prevention is the best way to approach SASS, considering all the potential damage arising from an arterial graft hypoperfusion. Where clinical conditions do not permit prophylaxis, an accurate risk assessment and postoperative monitoring are mandatory.

Keywords: Graft hypoperfusion; Nonocclusive hepatic artery hypoperfusion; Splenic artery steal syndrome; Steal syndrome.

Fig. 1

The contrast-enhanced abdominal computed tomography performed between Doppler ultrasounds and angiography.

Fig. 2

Angiography before splenic artery embolization. A diversion of blood flow into the splenic artery is shown, and the hepatic artery is not correctly visualized.

Fig. 3

Angiography before splenic artery embolization. Selective access to the hepatic artery origin, visualizing arterial anastomosis and the subsequent branches.

Fig. 4

Splenic artery coil embolization and hepatic artery blood flow regained after the procedure.