肝移植术后脾动脉盗血综合征治疗选择及安全性评价(附5例报告)

Evaluation on outcomes and reliability of treatment options for splenic arterial steal syndrome after orthotopic liver transplantation:A report of 5 patients

目的：分析肝移植术后脾动脉盗血综合征（SASS）不同时机治疗方式选择的临床效果，评价脾动脉栓塞的疗效及其安全性。方法回顾性分析2004年1月至2013年12月武警总医院191例肝硬化、脾脏增大，术前脾动脉直径/肝动脉直径≥1.5、但术中肝动脉血流≥30 cm/s的肝移植病人SASS发生率及临床表现。根据确诊时机和程度分别采取脾动脉栓塞、肝动脉与脾动脉或腹主动脉重新吻合、脾动脉结扎或脾脏切除，比较4种处理方式的临床效果及安全性。结果17例（8.9%）病人确诊为SASS，绝大多数（16/17，94.1%）发生在术后15 d内。5例急诊行脾动脉栓塞后肝总动脉血流[栓塞前（16.6±3.0）cm/s vs.栓塞后（39.3±7.7）cm/s，P＜0.001]立即改善，阻力指数全部恢复到正常水平（0.5～0.8），未观察到相关并发症。12例继发肝动脉血栓形成病人取出血栓或溶栓后行肝动脉与腹主动脉吻合（4例）、脾动脉结扎（3例）或脾切除（5例）；其中3例接受再次肝移植；2例因肝功能衰竭死亡。结论 SASS是肝移植术后严重并发症，及时诊断并行脾动脉栓塞是有效的补救措施，具有可靠的疗效和安全性。

Objective To evaluate the clinical outcomes and reliability of treatment options based on diagnostic timing for splenic artery steal syndrome （SASS） in recipients underwent orthotopic liver transplantation （OLT）, and to compare splenic artery coil-embolization （SAE） with other options by efficacy and reliability. Methods The incidence and clinical manifestation of SASS in 191 consecutive patients performed OLT between January 2004 and December 2013 in the General Hospital of Chinese People’s Armed Police Force were analyzed retrospectively. Those patients were suffered from liver cirrhosis combined with splenomegaly, with the ratio of pre-OLT splenic artery （SA） diameter to common hepatic artery （SA/CHA） diameter ≥1.5, but intra-OLT peak systolic velocity （PSV）≥30 cm/s. SAE, re-anastomosis HA to aorta （HTA, SA or abdominal aorta）, splenic artery ligation （SAL） or splenectomy （SPT） were performed to cope with SASS depending on occurring time and aftermath of SASS. SAE with other treatments were compared by clinical outcomes and reliability. Results A total of 17 cases out of 191 patients （8.90%） were identified as SASS, and the overwhelming majority of whom （16/17, 94.11%） were detected in 15d early after OLT. The sluggish and dim PSV of the patency hepatic artery increased immediately in the mean PSV from 16.55±2.97 cm/s to 39.34±7.67 cm/s （P〈0.001）, and resistivity index （RI） of HA rehabilitated to reasonable level（0.5~0.8） after SAE, without any related complication detected. A total of 12 patients with hepatic artery thrombosis secondary to SASS were performed embolectomy or thrombolysis followed by HTA （4 patients）, SAligation （SAL, 3 patients）, or splenectomy （SPT, 5 patients）, while 3 of them developed requiring re-OLT. All the patients obtained satisfactory results by the salvage strategies, except 2 out of 12 patients died from liver failure. Conclusion SASS is a severe complication after OLT. As an effective salvage intervention to prevent from devastating consequence, coil-emblization of SA shortly after early diagnosis is deserved to be introduced for satisfactory results and reasonable safety.