Endovascular management of portal steal syndrome due to portosystemic shunts after living donor liver transplantation

BACKGROUND AND AIM: After liver transplant, pre‐existent porto‐systemic shunts (PSS) may persist, causing “portal steal,” leading to graft dysfunction, hepatic encephalopathy (HE), and eventual rejection. In recipients of small‐for‐size transplant liver grafts, shunts may be created intraoperatively, facilitating diversion of portal flow to systemic circulation to avoid ill‐effects of portal overperfusion. These iatrogenic shunts may also subsequently lead to portal steal. We aim to evaluate safety and efficacy of endovascular techniques in management of portal steal due to PSSs in living donor liver transplantation (LDLT) recipients. METHODS: Between 2013 and 2020, we encountered five LDLT recipients with large PSS, who presented with graft dysfunction and/or HE. One patient had a surgically created shunt and four had spontaneous shunts, not surgically ligated during transplant. Endovascular techniques including plug‐assisted or balloon‐occluded retrograde transvenous obliteration (PARTO/BRTO) or covered inferior vena cava (IVC) stent grafts were to occlude these PSS and counter the portal steal in all patients. Technical success and clinical outcomes at 1‐year‐follow‐up were assessed. RESULTS: Imaging showed large PSS causing portal steal syndrome in all five patients. IVC stent graft was used to isolate the shunt in two patients and PARTO/BARTO was performed in three patients. One patient had guarded prognosis due to multiple organ dysfunction and died 5 days after endovascular procedure. At 1‐year follow up, graft functions normalized in four patients with no recurrence of HE. No procedure‐related complications were seen. CONCLUSION: Endovascular techniques can be safely and effectively used to counter portal steal syndrome in LDLT recipients, thus avoiding surgical re‐exploration in these patients.