The portal hyperperfusion, or small-for-size syndrome (SFSS), is a widely recognized clinical complication that may occur after segmental
liver transplantation. Several surgical strategies have been proposed to reduce portal blood inflow and portal pressure after partial
liver transplantation. In particular, splenic artery
ligation and
splenectomy have been used without a firm hemodynamic basis for these procedures. Our group recently demonstrated that, in patients with
cirrhosis and
portal hypertension, the occlusion of the splenic artery causes a significant reduction in the portal pressure gradient, which is directly related to the spleen volume and indirectly related to the liver volume. This concept is at the center of our strategy for performing early splenic artery embolization (SAE) for the treatment of SFSS after living-related
liver transplantation (LRLT). Six patients developed small-for-size syndrome, defined as: onset within the first week after LRLT of progressive
hyperbilirubinemia without mechanical cause; marked
cholestasis; centrilobular sinusoidal dilatation and hepatocyte
atrophy at liver biopsy; and refractory
ascites in the absence of vascular complications. All six patients who underwent SAE rapidly improved their clinical condition, with an evident decrease in the value of
bilirubin in the serum, in the production of
ascites, and improvement in condition of
pancytopenia. Coagulopathy expressed by the international normalized ratio value (INR) was not a reliable early marker of SFSS in this series; in fact a slight improvement in the result of this test was already present immediately after LRLT and before SAE. Because splenic flow clearly contributes to portal hyperperfusion, an early SAE can relieve the partial graft from the deleterious effect of this portal overflow.