Ligation of Left Renal Vein for Spontaneous Splenorenal Shunt to Prevent Portal Hypoperfusion after Orthotopic Liver Transplantation

Abstract

We report a case of recovered portal flow by ligation of the left renal vein on the first postoperative day after orthotopic liver transplantation of a 54-year-old female with alcoholic liver cirrhosis, chronic kidney failure, and spontaneous splenorenal shunt. After reperfusion, Doppler ultrasonography showed almost total diversion of the portal flow into the existing splenorenal shunt, but because of severe coagulopathy and diffuse bleeding, ligation of the shunt was not attempted. A programmed relaparotomy was performed on the first postoperative day, and the left renal vein was ligated just to the left of the inferior vena cava. Portal flows subsequently increased to 37 cm/sec, and the patient presented a good and stable liver function. We conclude that patients with known preoperative splenorenal shunts should be closely monitored, and if the portal flow becomes insufficient, ligation of the left renal vein should be attempted in order to optimize the portal perfusion of the liver.

Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation

“…Several maneuvers have been reported to improve inadequate portal flow to the allograft. Left RV ligation, splenectomy, renoportal anastomosis, ligation at the root of the SV, and selective SRS or splenic radiologic venous embolization or stent graft closure increase portal flow in cases of a large SRS.…”

“…PV thrombectomy is not enough to overcome this situation because of poor portal flow. There are several methods to increase portal flow in cases of large SRSs, including left renal vein (RV) ligation, splenectomy, and renoportal anastomosis . However, direct ligation of a large SRS is not widely used in clinical situations because it can be technically difficult and even dangerous …”

Radiologic evaluation of portal steal phenomenon in recipients of liver transplantation

“…While this trend of portal flow change is within the expected course of variation, if there is persistent or recurrent portosystemic shunts early after liver transplantation, portal flow velocity can be markedly decreased (Fig. 9), sometimes with bidirectional, hepatofugal, or no detectable flow (2,13,38). Collapse of portal vein and/ or hepatofugal flow in the shunting vessels can also be observed (2,13).…”