Awad Nadia, Horrow Mindy M, Parsikia Afshin, Brady Paul, Zaki Radi, Fishman Michael D C, Ortiz Jorge
Department of Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA.
Exp Clin Transplant. 2012 Oct;10(5):475-81. doi: 10.6002/ect.2011.0201. Epub 2012 Aug 11.
Spontaneous splenorenal shunts cause significant vascular steal from the liver. There is no accepted algorithm for treating spontaneous splenorenal shunts before, during, or after liver transplant, and evidence for efficacy of treatments remains limited.
We reviewed the literature, and our institution's experience regarding spontaneous splenorenal shunts, including a case series of 6 patients with spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts, a case of intraoperative ligation of a large spontaneous splenorenal shunts during transplant, and 1 patient requiring multiple endovascular interventions to embolize recurrent spontaneous splenorenal shunts after orthotopic liver transplant.
Small spontaneous splenorenal shunts may not need intervention, as involution after liver transplant is well known. Transjugular intrahepatic porto-systemic shunts may decrease the porto-systemic gradient in patients with large spontaneous splenorenal shunts, as shown in our review of 6 patients with large spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts. We have demonstrated re-establishment of physiologic flow after ligation of a large spontaneous splenorenal shunt at the time of transplant, supporting operative ligation may be justified if intraoperative compression of the spontaneous splenorenal shunts demonstrates significant improvement of allograft portal venous flow. Ligation of the left renal vein for large spontaneous splenorenal shunts is a safe and effective method of preventing portal venous steal. For concomitant spontaneous splenorenal shunts and portal vein thrombosis, renoportal anastomosis can be performed. We report transient success with endovascular embolization of large spontaneous splenorenal shunts in a patient posttransplant who required multiple interventions.
Experience in the approach to and treatment of spontaneous splenorenal shunts in liver transplant recipients is limited. Further investigation into the best approach to treat spontaneous splenorenal shunts is warranted as the presence and persistence of spontaneous splenorenal shunts can lead to allograft dysfunction and possible allograft loss.
自发性脾肾分流会导致肝脏显著的血管窃血。目前尚无公认的在肝移植前、肝移植期间或肝移植后治疗自发性脾肾分流的方案，且治疗效果的证据仍然有限。
我们回顾了相关文献以及本机构关于自发性脾肾分流的经验，包括6例接受经颈静脉肝内门体分流术的自发性脾肾分流患者的病例系列、1例肝移植术中结扎大型自发性脾肾分流的病例以及1例原位肝移植后需要多次血管内介入栓塞复发性自发性脾肾分流的患者。
小型自发性脾肾分流可能无需干预，因为肝移植后其会自行消退，这是众所周知的。经颈静脉肝内门体分流术可能会降低大型自发性脾肾分流患者的门体压力梯度，如我们对6例接受经颈静脉肝内门体分流术的大型自发性脾肾分流患者的回顾所示。我们已经证明，在移植时结扎大型自发性脾肾分流后可重新建立生理性血流，这支持了如果术中对自发性脾肾分流进行压迫能显著改善移植肝门静脉血流，则手术结扎可能是合理的。对于大型自发性脾肾分流，结扎左肾静脉是预防门静脉窃血的一种安全有效的方法。对于合并自发性脾肾分流和门静脉血栓形成的情况，可进行肾门静脉吻合术。我们报告了1例移植后需要多次干预的患者，其大型自发性脾肾分流的血管内栓塞取得了短暂成功。
肝移植受者自发性脾肾分流的处理和治疗经验有限。鉴于自发性脾肾分流的存在和持续存在可能导致移植肝功能障碍甚至可能导致移植肝丧失，因此有必要进一步研究治疗自发性脾肾分流的最佳方法。
