Refractory Ascites After Liver Transplantation due to Splenic Artery Steal Syndrome With Resolution After Splenectomy

Postliver transplant ascites occurs in 5%-7% of recipients. This report describes splenic artery steal syndrome, causing refractory post-transplant ascites and ischemic biliopathy requiring splenectomy. A 65-year-old man with alcohol-related cirrhosis underwent orthotopic liver transplantation (Model for End-Stage Liver Disease 12) with pretransplant splenomegaly and splenic-artery dilatation. Postoperatively, computed tomography demonstrated persistent ascites, splenic-to-hepatic artery ratio of 2.5, and reduced hepatic arterial perfusion. Endoscopic retrograde cholangiopancreatography identified an anastomotic stricture with intrahepatic biliopathy. Two splenic artery embolization procedures were unsuccessful. Salvage splenectomy achieved resolution of ascites, cholestasis, and biliopathy. Splenic artery steal syndrome is an under-recognized cause of refractory post-transplant ascites which may benefit from splenectomy after embolization failure.