J Korean Soc Transplant.  2017 Jun;31(2):82-86. 10.4285/jkstn.2017.31.2.82.

Lessons Learned from Inappropriate Ligation of the Left Renal Vein for a Large Splenorenal Shunt in Living Donor Liver Transplantation

• Han YS

• KMID: 2385533
• DOI: http://doi.org/10.4285/jkstn.2017.31.2.82

Abstract

During living donor liver transplantation, a large spontaneous splenorenal shunt (SRS) should be addressed to obtain adequate portal inflow. Various procedures such as direct ligation of the SRS, splenectomy, left renal vein ligation (LRVL), and renoportal anastomosis can be applied to treat a large SRS according to the hemodynamics of the portal flow and anatomic conditions. Of these surgical procedures, LRVL is a simple and effective solution for treatment of a large SRS. However, to perform a LRVL, rigorous evaluation of the recipient's anatomic and hemodynamic variations is mandatory. In the present case, we ligated the left renal vein to treat a large SRS, which resulted in an unexpected thrombosis of the left renal vein and remaining portal vein stenosis in the SRS. Therefore, we revised our decisions regarding whether the LRVL was properly applied.

Keyword

Large splenorenal shunt; Left renal vein ligation; Renal vein thrombosis

MeSH Terms

Constriction, Pathologic
Hemodynamics
Humans
Ligation*
Liver Transplantation*
Liver*
Living Donors*
Portal Vein
Renal Veins*
Splenectomy
Splenorenal Shunt, Surgical*
Thrombosis

Figure

• 

  Fig. 1 Abdominal computed tomography performed 2 months before living donor liver transplantation showed a new hepatic mass, intrahepatic duct (IHD) stones, a large splenorenal shunt (SRS), and obliterated portal vein. (A) A new 4 cm diameter hepatic mass compatible with hepatocellular carcinoma (arrow). (B) Multiple IHD stones in both hemilivers (arrows). (C) Axial view: a large SRS (arrow). (D) Coronal view: obliterated portal vein with diameter of 6 mm (arrow) and a large SRS (arrowhead).

• 

  Fig. 2 On follow-up abdominal dynamic computed tomography, the left renal vein and a splenorenal shunt filled with thrombus, preserving the left gonadal vein patency. In addition, portal vein stenosis was observed. (A) Axial view: left renal vein thrombus (arrow) and a splenorenal shunt thrombus (arrowhead). (B) Coronal view: left renal vein thrombus (arrow) and a splenorenal shunt thrombus (arrowhead). (C) Coronal view: patent left gonadal vein (arrow) and portal vein stenosis (arrowhead).

Reference

1. Lee SG, Moon DB, Ahn CS, Kim KH, Hwang S, Park KM, et al. Ligation of left renal vein for large spontaneous splenorenal shunt to prevent portal flow steal in adult living donor liver transplantation. Transpl Int. 2007; 20:45–50.

2. Slater RR, Jabbour N, Abbass AA, Patil V, Hundley J, Kazimi M, et al. Left renal vein ligation: a technique to mitigate low portal flow from splenic vein siphon during liver transplantation. Am J Transplant. 2011; 11:1743–1747.

3. Samson RH, Lepore MR Jr, Showalter DP, Nair DG, Lanoue JB. Long-term safety of left renal vein division and ligation to expedite complex abdominal aortic surgery. J Vasc Surg. 2009; 50:500–504.

4. Elsharawy MA, Cheatle TR, Clarke JM, Colin JF. Effect of left renal vein division during aortic surgery on renal function. Ann R Coll Surg Engl. 2000; 82:417–420.

5. Baptista-Silva JC, Verissimo MJ, Castro MJ, Camara AL, Pestana JO. Anatomical study of the renal veins observed during 342 living-donor nephrectomies. Sao Paulo Med J. 1997; 115:1456–1459.

6. Satyapal KS, Kalideen JM, Haffejee AA, Singh B, Robbs JV. Left renal vein variations. Surg Radiol Anat. 1999; 21:77–81.

7. Moon DB, Lee SG, Hwang S, Kim KH, Ahn CS, Ha TY, et al. Ligation of left renal vein for splenorenal collateral shunt to prevent portal flow steal in adult living donor liver transplantation. J Korean Soc Transplant. 2005; 19:182–191.

8. Golse N, Bucur PO, Faitot F, Bekheit M, Pittau G, Ciacio O, et al. Spontaneous splenorenal shunt in liver transplantation: results of left renal vein ligation versus renoportal anastomosis. Transplantation. 2015; 99:2576–2585.

9. Moon DB, Lee SG, Ahn C, Hwang S, Kim KH, Ha T, et al. Application of intraoperative cine-portogram to detect spontaneous portosystemic collaterals missed by intraoperative doppler exam in adult living donor liver transplantation. Liver Transpl. 2007; 13:1279–1284.

10. Genzini T, Trevizol AP, Yamashita ET, Noujaim HM, Dos Santos RG, de Oliveira Gaboardi MT, et al. Left renal vein ligation during liver transplantation in a recipient with a single kidney. Liver Transpl. 2013; 19:563–564.

11. Asghar M, Ahmed K, Shah SS, Siddique MK, Dasgupta P, Khan MS. Renal vein thrombosis. Eur J Vasc Endovasc Surg. 2007; 34:217–223.