We report a case of recovered portal flow by ligation of the left renal vein on the first postoperative day after orthotopic liver transplantation of a 54-year-old female with alcoholic liver cirrhosis, chronic kidney failure, and spontaneous splenorenal shunt. After reperfusion, Doppler ultrasonography showed almost total diversion of the portal flow into the existing splenorenal shunt, but because of severe coagulopathy and diffuse bleeding, ligation of the shunt was not attempted. A programmed relaparotomy was performed on the first postoperative day, and the left renal vein was ligated just to the left of the inferior vena cava. Portal flows subsequently increased to 37？cm/sec, and the patient presented a good and stable liver function. We conclude that patients with known preoperative splenorenal shunts should be closely monitored, and if the portal flow becomes insufficient, ligation of the left renal vein should be attempted in order to optimize the portal perfusion of the liver. 1. Introduction In cirrhotic patients with portal hypertension, collateral vessels into systemic circulation are well known. The amount of collateral flow depends on the stage of portal hypertension. In advanced stages, the development of a reversal hepatofugal portal flow may lead to a portal steal syndrome [1]. After orthotopic liver transplantation, usually the portal flow and pressure normalize and, providing that there is an adequate-sized graft, collateral vessels collapse and obliterate [2–4]. Low portal vein flows after orthotopic liver transplantation, due to persisting splenorenal shunt, are associated with hepatic hypoperfusion and poor allograft survival [2]. Splenorenal shunts are present in cirrhotic patients from nearly 14% up to 21%, and several studies have suggested that spontaneous portosystemic shunts should be treated in order to recover the portal flow of the liver graft [5, 6]. Beside direct division of the shunt vessels with or without splenectomy, the ligation of the left renal vein is described to be an effective technique and has been reported to be safe in adult liver transplant patients with large splenorenal shunts [7–9]. 2. Case Report The patient is a 54-year-old female with alcoholic liver cirrhosis and chronic kidney failure, listed for liver and sequential renal transplantation. The patient underwent a percutaneous ethanol injection therapy for a solitary hepatocellular carcinoma in 2009. At the timepoint of transplantation the MELD score was 37. The preoperatively conducted abdominal computed tomographic (CT) scan showed severe
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