Successful Treatment of Refractory Ascites after Liver Transplantation with Splenic Artery Embolization

Abstract

Introduction: Refractory ascites after orthotopic liver transplantation is rare. While secondary precipitating causes can be identified in a sizable number, a small proportion of the patients with post-transplantation ascites have no identifiable cause. Splenic artery embolization has recently been reported as an effective method of treating refractory ascites in such cases. We present a case of successful treatment of refractory ascites after liver transplantation with partial splenic artery embolization. Case: A 52-year-old Caucasian male had received an orthotopic liver transplant in March, 2011 for hepatocellular carcinoma and chronic hepatitis C induced liver cirrhosis. The patient developed refractory ascites 2 months after transplantation requiring repetitive therapeutic paracenteses. Liver biopsy and echocardiography showed no evidence of rejection or recurrent hepatitis and congestive heart failure, respectively. Transjugular hepatic venogram and pressure evaluation showed a kink at the anastomosis of right hepatic vein and inferior vena cava which was successfully stented with resolution of pressure gradient post intervention. The patient continued to have refractory ascites despite these measures and underwent partial splenic artery embolization (SAE) to decrease the inflow of blood to the portal circulation. After SAE, the patient had significant reduction in ascites with decreased need for paracentesis, improved renal function and reduced diuretic requirement. Discussion: Refractory ascites (RA) is an uncommon complication of orthotopic liver transplantation which poses a serious challenge to the clinician. It is associated with increased risk of renal failure and peritoneal infections, increased hospital stay and shortened survival. In majority of patients with RA, treatment of secondary causes including right sided heart failure, acute or chronic graft rejection and hepatic inflow or outflow obstruction, leads to resolution of ascites. In the patients with no identifiable cause, treatment of ascites is challenging. Transjugular intrahepatic portosystemic shunting has shown mixed results as a treatment strategy. Splenic artery embolization leading to decreased splenic inflow and decreased portal hypertension has shown encouraging results in the recent years. Conclusion: Owing to its effectiveness in decreasing portal hypertension and low complication risk, splenic artery embolization appears to an attractive treatment option for the challenging problem of refractory ascites after liver transplantation.