Hemodynamic consequences of spontaneous splenorenal shunts in deceased donor liver transplantation

Abstract

The presence of large spontaneous splenorenal shunts (SSRSs) is a risk factor for poor portal vein flow and liver dysfunction. The disconnection of splenorenal shunts by left renal vein (LRV) ligation has been suggested as a potential solution for improving portal flow. We reviewed the hemodynamic consequences of splenorenal shunts in deceased donor liver transplantation and investigated the role of LRV ligation. In 10 patients who underwent liver transplantation at our institution between January 2006 and April 2010, an SSRS was diagnosed preoperatively. Intraoperative portal and hepatic artery flows were measured with a transit time flowmeter. The shunt was disconnected in 6 patients for whom the portal flow after reperfusion was less than or equal to 1200 mL/minute. LRV ligation resulted in significant increases in the portal flow. There were no differences in renal function for the patients who underwent renal vein ligation and the patients who did not undergo ligation. In conclusion, LRV ligation disconnects splenorenal shunts and modulates the portal inflow without any detrimental effects on renal function. Liver Portal hypertension leads to the development of an extensive network of portosystemic collateral vessels. In 5% to 12% of patients, these collaterals include spontaneous splenorenal shunts (SSRSs).

Perioperative Management of Spontaneous Splenorenal Shunts in Orthotopic Liver Transplant Patients

“…In that series, portal vein flow less than 1200 mL/min in the allograft after reperfusion raised concern for portal hypoperfusion, necessitating intervention. 4 Ligation of the LRV may be more appealing than ligation of the SRS itself, as the varix is very thin-walled and inadvertent damage could precipitate dramatic blood loss. Additionally, it has been well established that LRV ligation is a good surgical option and does not negatively affect renal function.…”

“…A spontaneous splenorenal shunt (SRS) forms between the splenic vein and the left renal vein ( Figures 1A and B) and has been noted in up to one-fifth of patients evaluated for liver transplant. [1][2][3][4] As the degree of cirrhosis progresses, higher resistance in the liver vascular bed can lead to considerable shunting of portal blood into the left renal vein. This causes the splenorenal shunt to become a high-flow collateral and ultimately can result in significant vascular steal from the transplanted liver.…”

Influence of splenorenal shunt on long-term outcomes in cirrhosis

“…A splenorenal shunt (SRS) is a collateral vessel detected at the splenic hilum in patients with portal hypertension [8]. It is one of several spontaneous shunts, which may be created by reopening the embryonic venous route [9].…”

Hepatic encephalopathy in a liver transplant recipient with stable liver function

“…Interestingly, it has been suggested that large splenorenal shunts may be a risk factor for PVT since its presence would decrease portal flow after LT and promote portal occlusion. 9,10 For that reason, if a large splenorenal shunt is present in an LT candidate, as in our case, its ligation could be beneficial. Shunt ligation is not associated with any detrimental effects on either hepatic or renal function.…”

“…Shunt ligation is not associated with any detrimental effects on either hepatic or renal function. 10 However, whether these shunts should be routinely closed during LT needs to be further studied.…”