Introduction:
Hypoperfusion of the hepatic artery includes two subtypes, which are SASS and gastroduodenal steal syndrome. It is a nonocclusive disease of the hepatic artery that often presents within 60 days of liver transplantation (1). In addition to hypoperfusion of the hepatic artery, SASS presents with blood flow being diverted to splenic parenchyma through the splenic artery, and this syndrome may be an under-recognized contributor to graft ischemia (2). Although most cases of SASS are discovered within 60 days of liver transplantation, SASS can present up to 5.5 years post-transplantation (3). The incidence of SASS ranges from 0.6% to 10.1% in liver transplant recipients (4). This wide range in incidence is due to no fixed objective diagnostic criteria (4). It is mainly a diagnosis of exclusion, and two important alternate diagnoses often considered are hepatic artery stenosis and hepatic artery thrombosis. Some studies have placed importance on pre-transplant evaluation for risk factors and potential subsequent intervention to reduce the risk of SASS (5,6). However, studies that have sought out potential risk factors such as spleen-liver ratio, splenomegaly, and pre-transplant splenic and hepatic artery size have had mixed results (7,8,9).