Discussion:
Currently, the treatments for SASS range from interventional
radiological ones to surgical ones such as splenic artery ligation,
proximal and distal embolization, banding and splenectomy
(13,14,21,22,23). Despite the wide range of possibilities, proximal
splenic artery embolization remains the most popular and preferred
intervention because it is less invasive than surgical options with less
risk of both intra and postoperative bleeding (11). It is also known
that proximal embolization is much more likely to maintain collateral
flow to the spleen than distal embolization (3). Table 1 summarizes the
most common methods for managing SASS. To explore hepatic artery
perfusion after embolization, an angiogram should be performed, and in
successful cases, this angiogram demonstrates increased, prompt flow in
the hepatic artery. In addition, it demonstrates increased enhancement
of the liver parenchyma during the late arterial phase (3).
Other treatments such as temporary splenic artery blockage have also
been reported in the literature (14,24,25). This method can lead to
decreased splenic artery flow without irreversible local ischemic
necrosis of the spleen. More studies are needed to investigate this
intervention. Nevertheless, it appears to be a promising therapeutic
intervention to SASS. Our case series highlights the fact that proximal
splenic artery embolization, either with coils or plugs, is the most
common treatment for SASS after orthotopic liver transplantation. It
also sheds light on relatively new and effective treatments such as
temporary blockade of splenic artery. Furthermore, it shows how imaging
modalities such as hepatic arteriogram and venograms with pressure
measurement can facilitate the diagnosis of this syndrome. Table 1 shows
most common treatments and their clinical outcome for SASS patients at
other institutions.
As research moves forward and more risk factors are found to be
associated with SASS, a greater importance may be placed upon
prophylactic treatment, such as pre-operative splenic artery
embolization. Mogl et al. demonstrated reduced risk of SASS
complications after SAS prophylaxis compared to post-operative treatment
(5). A randomized control trial by Umeda et al. also demonstrated that
preoperative embolization in patients who had severe portal hypertension
resulted in reduced hepatic hypoperfusion along with lower operative
time and blood loss (17). Other interventions such as splenic artery
ligation or banding are often used as prophylactic measures and can be
used if the diagnosis of SASS is made posttransplant (33).
Statement of funding:
There are no financial sources to disclose
Informed consent:
Written informed consent for publication of the case report was taken
from the participants
Authors contributions:
Assim Saad Eddin, MD: Original draft, review & editing
Abhiram Kamariju, MBBS: Original draft, review & editing
Umar Ramzan Bsc: Review & editing
Jay Yu, MD: Supervision, review & editing
Surbhi Dadwal, MBBS: Review & editing
Sandeep Laroia, MD: Conceptualization, Supervision, review & editing
Conflict of Interest statement:
The authors hereby agree that there are no conflicts of interest to
disclose.
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