Hindawi Publishing Corporation
Case Reports in Transplantation
Volume 2013, Article ID 842538, 3 pages
Ligation of Left Renal Vein for Spontaneous
Splenorenal Shunt to Prevent Portal Hypoperfusion after
Orthotopic Liver Transplantation
Lampros Kousoulas,1Kristina Imeen Ringe,2Michael Winkler,1Frank Lehner,1
Nicolas Richter,1Juergen Klempnauer,1and Fabian Helfritz1
2Institute of Radiology, Hannover Medical School, Carl-Neuberg-Street 1, 30625 Hanover, Germany
Correspondence should be addressed to Lampros Kousoulas; email@example.com
Received 17 January 2013; Accepted 11 February 2013
Academic Editors: P. Boraschi, S. Faenza, and S. Pinney
Copyright © 2013 Lampros Kousoulas et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
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,
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 37cm/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.
In cirrhotic patients with portal hypertension, collateral
vessels into systemic circulation are well known. The amount
portal flow may lead to a portal steal syndrome . After
orthotopic liver transplantation, usually the portal flow and
pressure normalize and, providing that there is an adequate-
sized graft, collateral vessels collapse and obliterate [2–4].
Low portal vein flows after orthotopic liver transplan-
tation, due to persisting splenorenal shunt, are associated
with hepatic hypoperfusion and poor allograft survival .
Splenorenal shunts are present in cirrhotic patients from
nearly 14% up to 21%, and several studies have suggested that
ligation of the left renal vein is described to be an effective
technique and has been reported to be safe in adult liver
transplant patients with large splenorenal shunts [7–9].
2. Case Report
sis and chronic kidney failure, listed for liver and sequential
renal transplantation. The patient underwent a percutaneous
ethanol injection therapy for a solitary hepatocellular carci-
score was 37.
The preoperatively conducted abdominal computed
tomographic (CT) scan showed severe portal-systemic coll-
ateral vessels of the abdomen, including a splenorenal shunt
The patient underwent an orthotopic liver transplanta-
tion using a full-size organ. Donor age was 56 years, and
the organ quality was rated as “acceptable” by the explant
surgeon. Histopathological rating of steatosis was 25–30%.
2Case Reports in Transplantation
Figure 1: Preoperative CT imaging showing the splenorenal shunt
(arrow) and a splenomegaly (left renal vein = star).
Figure 2: Postoperative CT imaging (day 5) after the ligation of the
left renal vein. The arrow shows the point of ligation.
with replacement of the retrohepatic inferior vena cava and
time was 8 hours 47min.
diversion of the portal flow into the existing splenorenal
shunt, but because of severe coagulopathy and diffuse bleed-
ing, ligation of the shunt was not attempted. A programmed
relaparotomy was performed on the first postoperative day,
and the left renal vein was ligated at its confluence to the
inferior vena cava (Figure 2).
Portal flows subsequently increased to 37cm/sec. The
plasma or coagulation factors was not necessary. The post-
operative Doppler ultrasound examination showed normal
flows for both the hepatic artery and portal vein. The further
postoperative course was uncomplicated.
CT scan of the abdomen was performed, and progredient
thrombosis of the left renal vein was observed (Figures 3 and
4). Due to the preexisting chronic renal failure, this fact was
without any consequence for our patient, but it demonstrates
that the procedure of renal vein ligation bears the potential
risk of renal impairment. The patient currently enjoys good
allograft function with normal liver function tests.
Figure 3: Postoperative CT imaging (day 47) showing the throm-
bosis of the left renal vein at the point of ligation (arrow).
Figure 4: Postoperative CT imaging (day 47) showing in axial form
the thrombosis of the left renal vein (arrow).
with hepatic hypoperfusion and poor allograft survival [10,
11]. As an adequate portal venous inflow is critical for graft
function and survival, spontaneous or surgically created
portosystemic shunts have to be treated after the liver trans-
plantation in order to improve the portal flow to the allograft
. Direct ligation of a splenorenal shunt, with or without
a high risk of bleeding or of infection [13, 14]. Furthermore,
the portal flow. Therefore, the ligation of the left renal vein
at the inferior vena cava has been proposed as an alternative
therapeutic approach. Given the fact that the venous renal
blood flow accelerates the portal flow after the ligation of the
renal vein, this procedure can lead to sufficient portal flow.
Our case report shows that the ligation of the left renal
vein can be performed safely in order to optimize the flow
of the portal vein after the liver transplantation, but this
case, because of the chronic kidney failure of the patient, the
decision to ligate the left renal vein was easily made, but in
patients with normal kidney function, this aspect should be
taken into consideration.
Case Reports in Transplantation3
Thus, we conclude that patients with known preoperative
splenorenal shunt should be closely monitored after ortho-
topic liver transplantation, and if the portal flow becomes
of the left renal vein at the inferior vena cava should be
attempted in order to prevent portal flow steal and optimize
the portal perfusion of the liver. The selection of the method
performed should be based not only on the ability to identify
and ligate the shunt vessels, but also on the special character-
istics of the patient and on the experience of the surgeon.
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