Splenic artery steal syndrome in patients with orthotopic liver transplant: Where to embolize the splenic artery?

Florian N Fleckenstein,Willie M Luedemann,Timo A Auer,Gero Wieners,Julius Plewe,Rolf W Günther,Bernd Hamm,Ahmet Kücükkaya,Uli Fehrenbach,Bernhard Gebauer,Pavel Strnad

doi:10.1371/journal.pone.0263832

Abstract

This study compared proximal and distal embolization of the splenic artery (SA) in patients with splenic artery steal syndrome (SAS) after orthotopic liver transplantation (OLT) regarding post interventional changes of liver function to identify an ideal location of embolization. 85 patients with SAS after OLT treated with embolization of the SA between 2007 and 2017 were retrospectively reviewed. Periinterventional DSA was used to assess treatment success and to stratify patients according to the site of embolization. Liver function was assessed using following laboratory values: bilirubin, albumin, gamma-glutamyl transferase, glutamat-pyruvat-transaminase (GPT), glutamic-oxaloacetic transaminase (GOT), Alkaline Phosphatase (ALP), aPTT, prothrombin time and thrombocyte count. Descriptive statistics were used to summarize the data. Median laboratory values of pre, 1- and 3-days, as well as 1-week and 1-month post-embolization were compared between the respective embolization sites using linear mixed model regression analysis. All procedures were technically successful and showed an improved blood flow in the hepatic artery post-embolization. Ten Patients were excluded due to re -intervention or inconsistent image documentation. Pairwise comparison using linear mixed model regression analysis showed a significant difference between proximal and distal embolization for GPT (57.0 (IQR 107.5) vs. 118.0 (IQR 254.0) U/l, p = 0.002) and GOT (48.0 (IQR 48.0) vs. 81.0 (IQR 115.0) U/l, p = 0.008) 3-days after embolization as well as median thrombocyte counts 7-days after embolization (122 (IQR 108) vs. 83 (IQR 74) in thousands, p = 0.014). For all other laboratory values, no statistically significant difference could be shown with respect to the embolization site. We conclude that long-term outcomes after embolization of the SA in the scenario of SAS after OLT are irrespective of the site of embolization of the SA, whereas a proximal embolization potentially facilitates earlier normalization of liver function. Choice of technique should therefore be informed by anatomical conditions, safety considerations and preferences of the interventionalist.

Highlights

We conclude that long-term outcomes after embolization of the splenic artery (SA) in the scenario of steal syndrome (SAS) after orthotopic liver transplantation (OLT) are irrespective of the site of embolization of the SA, whereas a proximal embolization potentially facilitates earlier normalization of liver function
Choice of technique should be informed by anatomical conditions, safety considerations and preferences of the interventionalist
For patients suffering from complex liver diseases such as advanced stages of cirrhosis, certain stages of liver cancer and congenital or acquired abnormalities in anatomy or metabolism of the liver, orthotopic liver transplantation (OLT) is usually the only curative treatment option

Summary

Introduction

For patients suffering from complex liver diseases such as advanced stages of cirrhosis, certain stages of liver cancer and congenital or acquired abnormalities in anatomy or metabolism of the liver, orthotopic liver transplantation (OLT) is usually the only curative treatment option. In this context, splenic artery steal syndrome (SAS) is a frequently described vascular complication after OLT with incidences reported between 3 and 6% in the literature [1–5]. SAS is diagnosed by confirmation of an enlargement of the SA in combination with late enhancement of the hepatic artery territory [2, 9]

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Results

Conclusion