Ligation of left renal vein for spontaneous splenorenal shunt to Download full-text
prevent portal hypoperfusion after orthotopic liver transplantation
Lampros Kousoulas1, Kristina Imeen Ringe2, Michael Winkler1, Frank Lehner1, Nicolas Richter1, Juergen Klempnauer1and Fabian Helfritz1
1 Department of General, Visceral and Transplant Surgery, Hanover Medical School, Hanover, Germany 2 Institute of Radiology, Hanover Medical School, Hanover Germany
Low portal vein flow after orthotopic liver transplantation due to
spontaneous splenorenal shunt is 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
spontaneous portosystemic shunts should be treated in order to
recover the portal flow of the liver graft.Ligation of the left renal
vein, prophylactic or as a salvage procedure after the
transplantation, is an effective technique and has been reported
to be safe in adult liver transplant patients with large
The patient is a 54-year-old female with alcoholic liver cirrhosis and chronic kidney failure. A preoperative
abdominal computed tomographic scan showed severe portal-systemic collateral vessels of the abdomen,
including a spleno-renal shunt. The patient underwent an orthotopic liver transplantation using a full-size
organ. After reperfusion portal flows were extremely low, but because of severe coagulopathy and diffuse
bleeding, ligation of the left renal vein was not attempted. A relaparotomy was performed on the first
postoperative day and the left renal vein was ligated at its confluence to the inferior vena cava. Portal flows
subsequently increased to 36.9 cm/sec and the patient presented a good and stable liver function. The
postoperative ultrasound of the hepatic artery and portal vein was normal. The patient currently enjoys good
allograft function with normal liver function tests.
Dr. med. Lampros Kousoulas
Hanover Medical School
Department of General, Visceral and Transplantsurgery
Carl-Neuberg-Straße 1, 30625 Hannover, Germany
Klinik für Allgemein-, Viszeral- und
Direktor Prof. Dr. med. J. Klempnauer
Picture 1. Preoperative CT imaging showing the spleno-renal
shunt (arrow) and a splenomegaly.
Picture 3. Postoperative CT imaging (day 47) showing the
thrombosis of the left renal vein at the point of ligation (star).
Picture 2. Postoperative CT imaging after the ligation of the left
renal vein. The new thrombosis of the renal vein is shown (arrow).
Picture 4. Postoperative CT imaging (day 47) showing the
thrombosis of the left renal vein (star).
Patients with known preoperative splenorenal shunt should be closely monitored after orthotopic liver Transplantation and if the portal flow becomes insufficient,
ligation or stapling of the left renal vein should be attempted to prevent portal flow steal and optimize the portal perfusion of the liver.
Tarantino G, et al. What are the implications of the spontaneuous spleno-renal shunts in liver cirrhosis? BMC Gastroenterol. 2009 Nov 24; 9: 89
Zardi EM, et al. Portosystemic shunts in a large cohort of patients with liver cirrholsis: detection rate and clinical relevance. J Gastroenterol. 2009; 44 (1): 76 – 83
Slater RR, et. al. Left renal vein ligation: A technique to mitigate low portal flow from splenic vein siphon during liver transplantation. Am J Transplant. 2011 Aug; 11 (8): 1743 – 7
Cho SY, et al. Ligation of left renal vein as a salvage procedure for splenorenal shunt after living donor liver transplantation: A case report. Transplant Proc. 2009 Dec; 41 (10): 4243 – 5
Castillo-Suescun F, et al. Hemodynamic Consequences of spontaneous splenorenal shunts in deceased donor liver transplantation. Liver Transpl. 2011 Aug; 17 (8): 891 – 5