Splenic Artery Steal Syndrome Post Liver Transplant Causing Ischemic Biliary Stricture

Abstract

Introduction: Splenic artery steal syndrome post liver transplant is rare. If present, there can be significant graft dysfunction and potential graft loss. We present a case of a patient with decompensated cirrhosis secondary to Wilson's disease who underwent orthotopic liver transplant complicated by splenic artery steal syndrome. Case: A 47 yo male was diagnosed with Wilson's disease as a teenager. Thirty years later, he presented with ascites, upper GI bleed, MELD of 40, and transferred to our Transplant Center. He underwent orthotopic liver transplant from a 49 yo healthy O +, Hbcab Igm + donor. Cold ischemic time was 8 hours and 50 minutes and warm ischemic time was 55 minutes. He was given HbIg intraoperatively, started on empiric Entecavir, and given additional HbIg during the first week post-transplant. Liver function tests (LFT's) were noted to be elevated with an ALT 365, AST 576, Total Bilirubin (TB) 21, and INR 2.46 on POD#3. Abdominal doppler showed diminished hepatic arterial flow with a resistive index (RI) of 1.0. Coil embolization of the gastroduodenal artery was done on POD#3 to help improve hepatic perfusion. Post embolization, he was noted to have continued bilirubin elevation (TB 18-20) through POD#6. Repeat abdominal ultrasound showed decreased diastolic flow in the main hepatic artery (RI of 0.79). Diagnostic ERCP showed an anastomotic biliary stricture treated with biliary stenting. His bilirubin trended downward from 18 to 14. Hepatic artery angiogram then showed a large diameter splenic artery with diversion of blood away from the liver. Splenic artery coil embolization was done on POD#9. His LFT's continued to trend downward thereaft er: ALT 132, AST 80, TB 6, INR 1.02. Repeat ERCP at 6 weeks showed an improved anastomotic stricture. Abdominal ultrasound 7 weeks post initial transplant showed adequate hepatic arterial flow (RI of 0.59) with normalization of LFT's. Discussion: Within the first week post-transplant, survival of the liver graft is dependent on adequate arterial oxygen supply. This patient showed signs of splenic arterial steal syndrome, manifested by his elevated liver enzymes. Arterial hypoperfusion of the graft as a result of shift in blood flow into the splenic or gastroduodenal arteries causes hepatic hypoperfusion and potential allograft dysfunction. Timely diagnosis and management with ERCP and IR embolization helped prevent postoperative morbidity and graft loss.