Successful Treatment With Selective and Transplenic Artery Embolization for Small-for-Size Syndrome: A Case Report

Abstract

Small-for-size graft or small-for-size syndrome (SFSS) has emerged as an important clinical problem. SFSS is associated with high morbidity and poor prognosis, and many questions remain unanswered regarding its pathogenesis and treatment of SFSS (1–5). We report a liver graft recipient who developed clinical evidence of prolonged cholestasis and intractable ascites after a small-for-size right lobe living donor liver transplantation (LDLT) and who was successfully treated with a new procedure: selective splenic artery embolization using an interventional approach. The liver graft weighed 846 g, which was 56% of the recipient’s standard liver graft, and 0.90% of his body weight. After LDLT, serum total bilirubin remained at a high level, and the daily ascitic fluid volume increased to more than 2000 mL. The patient was initially treated with a steroid pulse therapy for possible acute rejection. However, a liver biopsy demonstrated no histologic features of acute rejection. A computed tomography scan showed congestion of liver segments of V and VIII, and both Doppler ultrasonography and a venacavography revealed lack of patency of the anastomosis between V5/V8 and interior vena cava indicating an outflow block of the segment V and VIII anastomosis. The Doppler ultrasonogram also showed that the portal vein system was dilated and with a very high flow velocity in the portal vein (60–70 cm/s), indicating portal overperfusion. The liver biopsy was also consistent with portal overperfusion liver injury. Our new procedure, selective and transsplenic artery embolization (TSAE) by interventional technique reduced promptly the flow velocity of portal vein from 60–70 cm/s to 20 cm/s. Serum total bilirubin level decreased from 242 μmol/L to 69.7umol/L by 2 weeks and to 30.2 μmol/L at 1 month after TSAE; the daily ascites fluid volume decreased dramatically to less than 500 mL 2 weeks after TSAE. We suggest that selective splenic artery embolization is a technically simple procedure for the treatment of portal overperfusion injury in SFSS. LuNan Yan ZheYu Chen Wentao Wang Wusheng Lu Qiang Lu Weixia Cheng Tianfu Wen Mingqing Xu Jiayin Yang Liver Transplantation Division Department of Surgery West China Hospital Sichuan University Medical School Chengdu, China