Splenic artery embolization for the treatment of refractory ascites after liver transplantation

Quintini, Cristiano; D’Amico, Giuseppe; Brown, Chase R.; Aucejo, Federico; Hashimoto, Koji; Kelly, D. G.; Eghtesad, Bijan; Sands, Mark; Fung, John J.; Miller, Charles M.

doi:10.1002/lt.22280

Cited by 46 publications

(65 citation statements)

References 31 publications

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“…Clearly, the authors and their colleagues in interventional radiology have developed significant expertise in optimizing the intrahepatic hemodynamics after orthotopic liver transplantation and are facile with spleen-preserving proximal splenic artery embolization (SAE). 2,3 The authors also reinforce the evidence supporting 2 risk factors for PHP: the spleen volume and the spleen/liver volume ratio.Although the current study is an important starting point for discussion, it suffers from some design flaws that make the data difficult to extrapolate for use by a wider audience. A lack of randomization and the absence of standardized indications for SAE limit the generalizability of the data.…”

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confidence: 60%

The safety and efficacy of proximal splenic artery embolization after liver transplantation are still not clearly defined

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Muiesan

2015

Liver Transpl

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In this issue of Liver Transplantation, Presser et al. 1 present an elegant description of their results from embolizing the proximal splenic artery in recipients after whole organ liver transplantation. They recount how empirical observations relating hepatic artery thrombosis to early arterial insufficiency were expanded to the treatment of portal hyperperfusion (PHP) and recurrent ascites. PHP and the importance of the hepatic artery buffer response are essential areas of research in the transplantation of whole and partial liver grafts. Clearly, the authors and their colleagues in interventional radiology have developed significant expertise in optimizing the intrahepatic hemodynamics after orthotopic liver transplantation and are facile with spleen-preserving proximal splenic artery embolization (SAE). 2,3 The authors also reinforce the evidence supporting 2 risk factors for PHP: the spleen volume and the spleen/liver volume ratio.Although the current study is an important starting point for discussion, it suffers from some design flaws that make the data difficult to extrapolate for use by a wider audience. A lack of randomization and the absence of standardized indications for SAE limit the generalizability of the data. The primary outcome of the study is the improvement of intrahepatic arterial flow and the reduction of portal venous flow. There is no doubt that this is a theoretically important result, but it would be helpful to demonstrate that proximal SAE produced a clinical effect such as a reduction in the rate of development of intractable ascites or that the volume of ascites was reduced after SAE. Along that line of thinking, the authors treated all recipients who had an elevated resistive index (RI) with SAE, but 12 patients still went on to develop intractable ascites. If all patients with elevated RIs were captured and an elevated RI led to intractable ascites, then how did these 12 patients progress to intractable ascites? These patients were shown to have a lower RI than those with elevated RIs, but where is the evidence that this was due to poor compliance of the liver graft? Moreover, the RI is affected by numerous factors, including blood volume, pressure, and heart rate, and to confuse matters further, it is also closely related to vascular compliance.Another issue with the design of the study is that the authors combine 2 different groups of patients into the study arm: those with high RIs and those with intractable postoperative ascites. These groups are undoubtedly different, and subsequently, attempting to draw conclusions from the data is difficult. The pathology of PHP in the first few days after transplantation is likely distinct from the pathophysiology in the weeks after transplantation, so treatment with proximal SAE is likely to have different consequences and effectiveness on day 3 versus day 88 after transplantation.The authors link a persistently elevated RI to the development of postoperative ascites, which mechanistically makes sense, but they have not provided a control...

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supporting

confidence: 60%

The safety and efficacy of proximal splenic artery embolization after liver transplantation are still not clearly defined

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Muiesan

2015

Liver Transpl

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“…(Evidence level C) Comment: Although PSE and splenectomy increase platelet and leukocyte counts, PSE allows preservation of adequate splenic tissue to safeguard against overwhelming infection [221]. Beneficial effects of PSE on refractory ascites after liver transplant were reported [222,223]. PSE reduced prothrombin time and increased serum albumin levels at 12 months [224].…”

Section: Portal Vein Thrombosismentioning

confidence: 99%

Evidence-based clinical practice guidelines for liver cirrhosis 2015

et al. 2016

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The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V 2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.

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“…Endovascular treatment options also play a limited role in nonvascular causes, such as recurrent infection or rejection needing medical treatment or liver transplant. 1,4,5 …”

Section: Diagnosis and Treatment Of Refractory Ascitesmentioning

confidence: 99%

“…33,31 Published reports on the use of splenic artery embolization in the treatment of RA after liver transplant are scarce. In the setting of liver transplant, Chang and associates, 34 Quintini and associates, 5 and Kim and associates 35 showed that splenic artery embolization was safe and effective in reducing the portal vein velocity immediately, translating into resolution of ascites in most of the patients. In contrast to distal embolization, a proximal embolization technique allows decreased splenic flow to produce the desired amount of ischemia while allowing distal revascularization, thereby preventing significant splenic infarct and complications.…”

Section: Transjugular Intrahepatic Portosystemic Shuntmentioning

confidence: 99%

“…In contrast to distal embolization, a proximal embolization technique allows decreased splenic flow to produce the desired amount of ischemia while allowing distal revascularization, thereby preventing significant splenic infarct and complications. 30,36,37 Although coils have been described for proximal splenic artery embolization, 5,38 some disadvantages of coil migration have been shown, with a need for multiple coils before complete occlusion is achieved.…”

Section: Transjugular Intrahepatic Portosystemic Shuntmentioning

confidence: 99%

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2015

Exp Clin Transplant

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Objectives: Recipients of liver transplant are surviving longer as both the surgical procedure and postsurgical care have improved. Despite improvements, serious complications from the procedure remain that significantly affect patient outcome and may result in retransplant. Refractory ascites is one complication, occurring in about 5.6% of transplant recipients. Management of refractory ascites after liver transplant presents a challenge to the multidisciplinary team caring for these patients. Materials and Methods:We discuss approaches to the diagnosis and treatment of refractory ascites after liver transplant, based on a literature review, with a primary focus on vascular causes. These approaches are illustrated by case examples highlighting our experiences at an academic tertiary medical center. We propose a clinical practice algorithm for optimal endovascular treatment of refractory ascites after liver transplant. Results: The cornerstone of refractory ascites care is diagnosis and treatment of the cause. Vascular causes are not infrequently encountered and, if not treated early, are associated with graft loss and high morbidity and mortality and are major indications for retransplant. For patients with recurrent disease or graft rejection needing large volume paracentesis, the use of a transjugular intrahepatic portosystemic shunt may serve as a bridge to more definitive treatment (retransplant), although it may not be as effective for managing ascites as splenic artery embolization, arguably underused, which is emerging as a potential alternative treatment option. Conclusions: A multidisciplinary strategy for the diagnosis and care of patients with refractory ascites after liver transplant is crucial, with endovascular treatment playing an important role. The aim is for this document to serve as a concise and informative reference to be used by those who may care for patients with this rare yet serious diagnosis.

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Splenic artery embolization for the treatment of refractory ascites after liver transplantation

Cited by 46 publications

References 31 publications

The safety and efficacy of proximal splenic artery embolization after liver transplantation are still not clearly defined

The safety and efficacy of proximal splenic artery embolization after liver transplantation are still not clearly defined

Evidence-based clinical practice guidelines for liver cirrhosis 2015

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