Skip to main content
SpringerLink
Log in

Proximal Splenic Artery Embolization for Refractory Ascites and Hydrothorax Post-Liver Transplant

  • Clinical Investigation
  • Embolisation (arterial)
  • Published:
CardioVascular and Interventional Radiology Aims and scope Submit manuscript

Abstract

Purpose

Proximal splenic artery embolization (pSAE) has been advocated as a valuable tool to ameliorate portal hyper-perfusion (PHP). The purpose of this study was to determine the safety and efficacy of pSAE to treat refractory ascites (RA) and/or refractory hydrothorax (RH) in the setting of PHP post-liver transplant.

Material and Methods

A total of 30 patients who underwent pSAE for RA and/or RH after liver transplantation (LT) between January 2007 and December 2017 were analyzed retrospectively. The patients were divided into groups according to the time frame from pSAE to clinical resolution in order to identify predictors of RA/RH response to the procedure.

Results

Twenty-four (80%) patients responded to pSAE within three months, whereas 6 (20%) still required additional treatments for RA/RH at three months post-pSAE. In all cases clinical symptoms resolved within six months. Complications after pSAE were as follows: 2 cases of splenic infarction (6.6%), one case of post-splenic embolization syndrome (3.3%), one case of hepatic artery thrombosis (3.3%) and one case of portal vein (PV) thrombosis (3.3%). Increased intraoperative PV flow volume and increased pre-pSAE PV velocity, as well as higher estimated glomerular filtration rate were associated with early RA/RH resolution.

Conclusion

pSAE is safe and effective in treating RA and RH due to PHP after LT. This study suggests that clinical parameters indicating more severe PHP and better kidney function are possible predictors for early response to pSAE.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Abbreviations

eGFR:

Estimated glomerular filtration rate

HABR:

Hepatic artery buffer response

LT:

Liver transplantation

MELD:

Model for end stage liver disease

PHP:

Portal hyper-perfusion

pSAE:

Proximal splenic artery embolization

PV:

Portal vein

RA:

Refractory ascites

RH:

Refractory hydrothorax

US:

Ultrasound

References

  1. Ostojic A, Petrovic I, Silovski H, Kosuta I, Sremac M, Mrzljak A. Approach to persistent ascites after liver transplantation. World J Hepatol. 2022;14(9):1739–46.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: an update and review of the literature. WJH. 2017;9(31):1197–204.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Nishida S, Gaynor JJ, Nakamura N, Butt F, Illanes HG, Kadono J, et al. Refractory ascites after liver transplantation: an analysis of 1058 liver transplant patients at a single center. Am J Transplant. 2006;6(1):140–9.

    Article  CAS  PubMed  Google Scholar 

  4. Siqueira F, Kelly T, Saab S. Refractory ascites: pathogenesis, clinical impact, and management. Gastroenterol Hepatol. 2009;5(9):647–56.

    Google Scholar 

  5. Quintini C, Hirose K, Hashimoto K, Diago T, Aucejo F, Eghtesad B, et al. “Splenic artery steal syndrome” is a misnomer: the cause is portal hyperperfusion, not arterial siphon. Liver Transpl. 2008;14(3):374–9.

    Article  PubMed  Google Scholar 

  6. Quintini C, D’Amico G, Brown C, Aucejo F, Hashimoto K, Kelly DM, et al. Splenic artery embolization for the treatment of refractory ascites after liver transplantation. Liver Transpl. 2011;17(6):668–73.

    Article  PubMed  Google Scholar 

  7. Kelly DM, Miller C. Understanding the splenic contribution to portal flow: the role of splenic artery ligation as inflow modification in living donor liver transplantation. Liver Transpl. 2006;12(8):1186–8.

    Article  PubMed  Google Scholar 

  8. Hiraki Y, Uchida K, Nishida S, Levi DM, Selvaggi G, Tekin A, et al. A case report of severe hepatic artery vasospasm induced by hepatic arterial buffer response after liver transplantation. Transpl Proc. 2016;48(9):3167–70.

    Article  CAS  Google Scholar 

  9. Sanada Y, Mizuta K, Urahashi T, Ihara Y, Wakiya T, Okada N, et al. Hepatic arterial buffer response after pediatric living donor liver transplantation: report of a case. Transpl Proc. 2011;43(10):4019–24.

    Article  CAS  Google Scholar 

  10. Spitzer AL, Dick AAS, Bakthavatsalam R, Halldorson JB, Salvalaggio PR, Reyes JD, et al. Intraoperative portal vein blood flow predicts allograft and patient survival following liver transplantation. HPB. 2010;12(3):166–73.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Anisa-Nutu O, Justo-Alonso I, Marcacuzco-Quinto AA, Calvo-Pulido J, Jiménez-Romero LC. Complete splenic embolization for the treatment of refractory ascites after liver transplantation. Rev Esp Enferm Dig. 2018;3:257–9.

    Google Scholar 

  12. Eipel C, Abshagen K, Vollmar B. Regulation of hepatic blood flow: The hepatic arterial buffer response revisited. World J Gastroenterol. 2010;16(48):6046–57.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Pinto S, Reddy SN, Horrow MM, Ortiz J. Splenic artery syndrome after orthotopic liver transplantation: a review. Int J Surg. 2014;12(11):1228–34.

    Article  PubMed  Google Scholar 

  14. Piano S, Tonon M, Angeli P. Management of ascites and hepatorenal syndrome. Hepatol Int. 2018;12(S1):122–34.

    Article  PubMed  Google Scholar 

  15. Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, et al. The management of ascites in cirrhosis: report on the consensus conference of the international ascites club. Hepatology. 2003;38(1):258–66.

    Article  PubMed  Google Scholar 

  16. Porcel JM. Management of refractory hepatic hydrothorax: current opinion in pulmonary medicine. Curr Opin Pulm Med. 2014;20(4):352–7.

    Article  PubMed  Google Scholar 

  17. Hadduck TA, McWilliams JP. Partial splenic artery embolization in cirrhotic patients. World J Radiol. 2014;6(5):160–8.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Pereira K, Salsamendi J, Fan J. An approach to diagnosis and endovascular treatment of refractory ascites in liver transplant: a pictorial essay and clinical practice algorithm. Exp Clin Transpl. 2015;13(5):387–93.

    Google Scholar 

  19. Cheng YF, Huang TL, Chen TY, Concejero A, Tsang LLC, Wang CC, et al. Liver graft-to-recipient spleen size ratio as a novel predictor of portal hyperperfusion syndrome in living donor liver transplantation. Am J Transpl. 2006;6(12):2994–9.

    Article  CAS  Google Scholar 

  20. Presser N, Quintini C, Tom C, Wang W, Liu Q, Diago-Uso T, et al. Safety and efficacy of splenic artery embolization for portal hyperperfusion in liver transplant recipients: a 5-year experience: SAE for portal hyperperfusion. Liver Transpl. 2015;21(4):435–41.

    Article  PubMed  Google Scholar 

  21. Meighani A, Jafri SMR, Raoufi M, Salgia R. Splenic artery embolization for treatment of refractory ascites after liver transplantation: ACG case reports journal. ACG Case Rep J. 2016;3(2):136–8.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Pravisani R, Baccarani U, Adani G, Lorenzin D, Vit A, Cherchi V, et al. Splenic artery syndrome as a possible cause of late onset refractory ascites after liver transplantation: management with proximal splenic artery embolization. Transpl Proc. 2016;48(2):377–9.

    Article  CAS  Google Scholar 

  23. Koconis KG, Singh H, Soares G. Partial splenic embolization in the treatment of patients with portal hypertension: a review of the English language literature. J Vasc Interv Radiol. 2007;18(4):463–81.

    Article  PubMed  Google Scholar 

  24. Ekeh AP, Kauffman S. Complications arising from splenic artery embolization: a review of an 11-year experience. Am J Surg. 2013;205(3):5.

    Article  Google Scholar 

  25. Madoff DC, Denys A, Wallace MJ, Murthy R, Gupta S, Pillsbury EP, et al. Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications. Radiographics. 2005;25(Suppl_1):S191-211.

    Article  PubMed  Google Scholar 

  26. Zhang L, Zhang ZG, Long X, Liu FL, Zhang WG. Severe complications after splenic artery embolization for portal hypertension due to hepatic cirrhosis. Risk Manag Healthc Policy. 2020;13:135–40.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kim H, Suh KS, Jeon YM, Park MS, Choi Y, Mori S, et al. Partial splenic artery embolization for thrombocytopenia and uncontrolled massive ascites after liver transplantation. Transpl Proc. 2012;44(3):755–6.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

None.

Funding

There were no external funding resources.

Author information

Authors and Affiliations

  1. Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA

    Giuseppe D’Amico, Luca Del Prete, Hajime Matsushima, Teresa Diago-Uso, Koji Hashimoto, Bijan Eghtesad, Masato Fujiki, Federico Aucejo, Choon Hyuck David Kwon, Charles Miller & Cristiano Quintini

  2. Department of Interventional Radiology, Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Sasan Partovi & Sameer Gadani

  3. General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy

    Luca Del Prete

  4. Department of Health Sciences, PhD School in Translational Medicine, University of Milan, 20142, Milan, Italy

    Luca Del Prete

  5. Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan

    Hajime Matsushima

Authors
  1. Giuseppe D’Amico
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sasan Partovi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Luca Del Prete
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hajime Matsushima
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Teresa Diago-Uso
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Koji Hashimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Bijan Eghtesad
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Masato Fujiki
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Federico Aucejo
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Choon Hyuck David Kwon
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Charles Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Sameer Gadani
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Cristiano Quintini
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sasan Partovi.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study consent for publication is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

D’Amico, G., Partovi, S., Del Prete, L. et al. Proximal Splenic Artery Embolization for Refractory Ascites and Hydrothorax Post-Liver Transplant. Cardiovasc Intervent Radiol 46, 470–479 (2023). https://doi.org/10.1007/s00270-023-03376-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00270-023-03376-3

Keywords

Search

Navigation