Splenic artery embolization for refractory ascites after liver transplantation: a single-center experience

Purpose: Refractory ascites (RA) is a rare but poorly understood complication following liver transplantation (LT). It is often associated with portal hyperperfusion, potentially driven by splenic hyperafflux. In such cases, splenic artery embolization (SAE) has been proposed as a minimally invasive and cost-effective therapeutic option to reduce splanchnic inflow and alleviate symptoms. Materials and methods: This retrospective study analyzed patients who underwent LT between August 2010 and September 2023 at IRCCS Azienda Ospedaliera-Universitaria di Bologna and were subsequently diagnosed with refractory ascites. Embolization of the splenic artery was performed using coils or plugs of variable caliber. Laboratory assessments included bilirubin, albumin, alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), and international normalized ratio (INR). Additionally, Child–Pugh and MELD scores were recorded. The severity and evolution of ascites were monitored through serial ultrasonographic follow-ups. Results: A total of 12 patients met the inclusion criteria. No severe complications related to the procedure were observed. Among them, 9 patients (75%) experienced complete resolution of ascites and normalization of liver function within 9 months post-procedure. Three patients (25%) died during follow-up due to transplant-related complications unrelated to SAE in the first month after the procedure. Conclusion: SAE is an effective treatment option for patients with refractory ascites following LT. The procedure resulted in significant improvement in ascites control and liver function in most patients. Good patient selection is essential for a good procedure outcome. Further research with larger patient cohorts and longer follow-up is needed to validate these results. Level of evidence: Level 3.