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.
References:
1. Geissler I, Lamesch P, Witzigmann H, Jost U, Hauss J, Fangmann J. Splenohepatic arterial steal syndrome in liver transplantation: clinical features and management. Transpl Int. 2002;15(2-3):139-141. doi:10.1007/s00147-002-0386-0
2. Saad W EA. Philadelphia, PA: Lippincott Williams & Wilkins; Liver transplant-related vascular disease.
3. Uflacker R, Selby JB, Chavin K, Rogers J, Baliga P. Transcatheter splenic artery occlusion for treatment of splenic artery steal syndrome after orthotopic liver transplantation. Cardiovasc Intervent Radiol. 2002;25(4):300-306. doi:10.1007/s00270-002-2614-5
4. 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(3):374-379. doi:10.1002/lt.21386
5. Mogl MT, Nüssler NC, Presser SJ, et al. Evolving experience with prevention and treatment of splenic artery syndrome after orthotopic liver transplantation. Transpl Int. 2010;23(8):831-841. doi:10.1111/j.1432-2277.2010.01062.x
6. Dokmak S, Aussilhou B, Belghiti J. Liver transplantation and splenic artery steal syndrome: the diagnosis should be established preoperatively. Liver Transpl. 2013 Jun;19(6):667-8.
7. Kirbas I, Ulu EM, Ozturk A, et al. Multidetector computed tomographic angiography findings of splenic artery steal syndrome in liver transplantation. Transplant Proc. 2007;39(4):1178-1180. doi:10.1016/j.transproceed.2007.02.024
8. Grieser C, Denecke T, Steffen IG, et al. Multidetector computed tomography for preoperative assessment of hepatic vasculature and prediction of splenic artery steal syndrome in patients with liver cirrhosis before transplantation. Eur Radiol. 2010;20(1):108-117. doi:10.1007/s00330-009-1535-y
9. Presser N, Quintini C, Tom C, Wang W, Liu Q, Diago-Uso T, Fujiki M, Winans C, Kelly D, Aucejo F, Hashimoto K, Eghtesad B, Miller C. Safety and efficacy of splenic artery embolization for portal hyperperfusion in liver transplant recipients: a 5-year experience. Liver Transpl. 2015 Apr;21(4):435-41.
10. Nüssler NC, Settmacher U, Haase R, Stange B, Heise M, Neuhaus P. Diagnosis and treatment of arterial steal syndromes in liver transplant recipients. Liver Transpl. 2003;9(6):596-602. doi:10.1053/jlts.2003.50080
11. Pérez J, Grande LG, Achécar L, et al. Case report of splenic artery steal syndrome: demonstration of portal hyperflow mechanism by anatomic variant of the splenic artery and correlation with Doppler rates. Transplant Proc. 2011;43(6):2269-2271. doi:10.1016/j.transproceed.2011.05.022
12. Sainz-Barriga M, Baccarani U, Risaliti A, Gasparini D, Sponza M, Adani GL, Toniutto PL, Avellini C, Ramacciato G, Bresadola F. Successful minimally invasive management of late portal vein thrombosis after splenectomy due to splenic artery steal syndrome following liver transplantation: a case report. Transplant Proc. 2004 Apr;36(3):558-9.
13. De Carlis L, Sansalone CV, Rondinara GF, Belli LS, Rimoldi P, Romani F, Puttini M, Meroni A, Riolo F, Rossetti O, et al. Splenic artery steal syndrome after orthotopic liver transplantation: diagnosis and treatment. Transplant Proc. 1993 Aug;25(4):2594-6.
14. Song JY, Shi BY, Zhu ZD, et al. New strategies for prevention and treatment of splenic artery steal syndrome after liver transplantation. World J Gastroenterol. 2014;20(41):15367-15373. doi:10.3748/wjg.v20.i41.15367
15. Sevmis S, Boyvat F, Aytekin C, et al. Arterial steal syndrome after orthotopic liver transplantation. Transplant Proc. 2006;38(10):3651-3655. doi:10.1016/j.transproceed.2006.10.145
16. Sanyal R, Shah SN. Role of imaging in the management of splenic artery steal syndrome. J Ultrasound Med. 2009;28(4):471-477. doi:10.7863/jum.2009.28.4.471
17. Umeda Y, Yagi T, Sadamori H, et al. Preoperative proximal splenic artery embolization: a safe and efficacious portal decompression technique that improves the outcome of live donor liver transplantation. Transpl Int. 2007;20(11):947-955. doi:10.1111/j.1432-2277.2007.00513.x
18. Uzochukwu LN, Bluth EI, Smetherman DH, Troxclair LA, Loss GE Jr, Cohen A, Eason JD. Early postoperative hepatic sonography as a predictor of vascular and biliary complications in adult orthotopic liver transplant patients. AJR Am J Roentgenol. 2005 Dec;185(6):1558-70.
19. Nishida S, Kadono J, DeFaria W, et al. Gastroduodenal artery steal syndrome during liver transplantation: intraoperative diagnosis with Doppler ultrasound and management. Transpl Int. 2005;18(3):350-353. doi:10.1111/j.1432-2277.2004.00065.x
20. García-Criado A, Gilabert R, Bianchi L, Vilana R, Burrel M, Barrufet M, Oliveira R, García-Valdecasas JC, Brú C. Impact of contrast-enhanced ultrasound in the study of hepatic artery hypoperfusion shortly after liver transplantation: contribution to the diagnosis of artery steal syndrome. Eur Radiol. 2015 Jan;25(1):196-202.
21. Boyvat F, Aytekin C, Karakayali H, Ozyer U, Sevmis S, Emiroğlu R, Haberal M. Stent placement in pediatric patients with hepatic artery stenosis or thrombosis after liver transplantation. Transplant Proc. 2006 Dec;38(10):3656-60.
22. Alvarez D, Gerona S, Waisburg Z, Ciardullo M, de Santibanes E,Mastai R. Splanchnic hyperemia after liver transplantation inpatients with end-stage liver disease. Liver Transpl Surg 1998;4:300-303.
23. Manner M, Otto G, Senninger N, Kraus T, Goerich J, HerfarthC. Arterial steal: An usual cause for hepatic hypoperfusion after liver transplantation. Transplant Int 1991;4:122-124.
24. Kelly DM, Shiba H, Nakagawa S, et al. Hepatic blood flow plays an important role in ischemia-reperfusion injury. Liver Transpl. 2011;17(12):1448-1456. doi:10.1002/lt.22424
25. Brenner T, Fleming TH, Spranz D, et al. Reactive metabolites and AGE-RAGE-mediated inflammation in patients following liver transplantation. Mediators Inflamm. 2013;2013:501430. doi:10.1155/2013/501430
26-. Splenic artery syndrome after Orthotopic Liver Transplantation: A Review. International Journal of Surgery. https://www.sciencedirect.com/science/article/pii/S1743919114009121?via%3Dihub
27. Zhu XS, Gao YH, Wang SS, et al. Contrast-enhanced ultrasound diagnosis of splenic artery steal syndrome after orthotopic liver transplantation. Liver Transpl. 2012;18(8):966-971. doi:10.1002/lt.23453
28. Uslu N, Aslan H, Tore HG, et al. Doppler ultrasonography findings of splenic arterial steal syndrome after liver transplant. Exp Clin Transplant. 2012;10(4):363-367. doi:10.6002/ect.2012.0007
29. Grieser C, Denecke T, Steffen IG, et al. Multidetector computed tomography for preoperative assessment of hepatic vasculature and prediction of splenic artery steal syndrome in patients with liver cirrhosis before transplantation. Eur Radiol. 2010;20(1):108-117. doi:10.1007/s00330-009-1535-y
30. Li C, Quintini C, Hashimoto K, et al. Role of Doppler Sonography in Early Detection of Splenic Steal Syndrome. J Ultrasound Med. 2016;35(7):1393-1400. doi:10.7863/ultra.15.06072
31. Liu DY, Yi ZJ, Tang Y, Niu NN, Li JX. Three Case Reports of Splenic Artery Steal Syndrome After Liver Transplantation. Transplant Proc. 2015;47(10):2939-2943. doi:10.1016/j.transproceed.2015.10.037
32. Pérez J, Grande LG, Achécar L, et al. Case report of splenic artery steal syndrome: demonstration of portal hyperflow mechanism by anatomic variant of the splenic artery and correlation with Doppler rates. Transplant Proc. 2011;43(6):2269-2271. doi:10.1016/j.transproceed.2011.05.022
33. Vogl TJ, Pegios W, Balzer JO, Lobo M, Neuhaus P. Arterielles steal-syndrom bei patienten nach lebertransplantation: transarterielle embolisation von A. lienalis oder A. gastroduodenalis [Arterial steal syndrome in patients after liver transplantation: transarterial embolization of the splenic and gastroduodenal arteries]. Rofo. 2001;173(10):908-913. doi:10.1055/s-2001-17592