The treatments for a spontaneous splenorenal shunt (SRS) include splenectomy and direct SRS ligation. However, both are major, technically complicated procedures that are associated with significant bleeding risks.[1, 2] To achieve the same outcome and avoid SRS manipulation in a region with significant collateral circulation, the surgeon may perform left renal vein ligation (LRVL). This procedure restores the appropriate portal flow to the liver graft by reversing the blood flow from the left renal vein to the portal vein through the SRS.
We report a case of LRVL that was performed during liver transplantation (LT) for a female recipient with only a single (left) kidney. The patient was a 61-year-old woman with hepatitis B, hepatic cirrhosis, and portal hypertension. She had tense ascites, jaundice (total bilirubin level = 3.8 mg/dL), and encephalopathy with a Model for End-Stage Liver Disease score of 21 and a Child-Pugh score of 12. Color Doppler ultrasonography indicated a patent portal vein with a hepatofugal, monophasic flow and a diverted flow to the upper mesenteric veins, gastric veins, and splenorenal shunts. During LT, the recipient portal vein flows were low after reperfusion. Dissection and clamping of the left renal vein were followed by a significant increase in the portal vein flow; LRVL was subsequently performed. Postoperative creatinine levels varied between 1.4 and 2.4 mg/dL. There was no damage to renal function attributable to this maneuver, with creatinine levels remaining at 1.4 mg/dL at the 1-year follow-up examination. Post-LT angioresonance indicated left kidney venous drainage through the gonadal vein to the iliac vessels and through the perisplenic veins to the portal vein (Fig. 1). A 2-year follow-up Doppler ultrasound examination showed increased portal vein flow approximately 3 times greater than the normal with a homogeneous echotexture of the hepatic parenchyma.
Adequate portal perfusion is essential for a graft's continued viability after LT. Portal flow diversion through a SRS occurs in nearly 19% of patients with cirrhosis and results in hepatofugal flow and compromised hepatic graft reperfusion.[4, 5] When it is necessary, a SRS can be surgically treated during LT through direct ligation of the splenorenal collateral veins with or without splenectomy. However, these procedures are dangerous because they are associated with a significant bleeding risk and may even result in death. As a simpler alternative to direct SRS ligation, LRVL has been proposed to avoid surgical manipulation in a region comprising innumerable collateral veins with portal hypertension. LRVL causes flow reversal from the left renal vein and, consequently, from the SRS in the direction of the portal vein, and thus the portal flow is safely adapted during hepatic reperfusion.
The LRVL technique has been determined to be safe during LT because it does not cause significant kidney injury, preserves renal function, and increases portal vein flow and thus prevents or reduces the risk of poor perfusion or portal vein thrombosis in the transplanted liver.[3, 6] In the present case, LRVL was the best alternative therapy for SRS even though the recipient had only 1 kidney. The safety of the procedure was confirmed by normal renal function and creatinine levels that were expected for the patient's age and follow-up duration.
Tércio Genzini, M.D.
Alisson Paulino Trevizol, M.D.
Eduardo Tomohissa Yamashita, M.D.
Huda Maria Noujaim, M.D.
Regina Gomes dos Santos, M.D.
Marilia Tavares Campos de Oliveira Gaboardi, M.D.
Leonardo Toledo Mota, M.D.
Juan Raphael Brañez Pereira, M.D.
Leonardo Ogawa Oliveira, M.D.
Marcelo Perosa, M.D.
HEPATO Group Bandeirantes Hospital São Paulo, Brazil