Invited Commentary: Splenic Artery Embolization: Practical Overview of a Commonly Encountered Procedure.

ObjectiveThis retrospective study reports our experience using splenic arterial particle embolization and coil embolization for the treatment of sinistral portal hypertension (SPH) in patients with and without gastric bleeding.MethodsFrom August 2009 to May 2012, 14 patients with SPH due to pancreatic disease were diagnosed and treated with splenic arterial embolization. Two different embolization strategies were applied; either combined distal splenic bed particle embolization and proximal splenic artery coil embolization in the same procedure for acute hemorrhage (1-step) or interval staged distal embolization and proximal embolization in the stable patient (2-step). The patients were clinically followed.ResultsIn 14 patients, splenic arterial embolization was successful. The one-step method was performed in three patients suffering from massive gastric bleeding, and the bleeding was relieved after embolization. The two-step method was used in 11 patients, who had chronic gastric variceal bleeding or gastric varices only. The gastric varices disappeared in the enhanced CT scan and the patients had no gastric bleeding during follow-up.ConclusionsSplenic arterial embolization, particularly the two-step method, proved feasible and effective for the treatment of SPH patients with gastric varices or gastric variceal bleeding.

Intra-arterial ampicillin and gentamicin and the incidence of splenic abscesses following splenic artery embolization: A 20-year case control study

Various minimally invasive, surgical, and laparoscopic interventions are performed for treatment and management of splenic artery steal syndrome in liver transplant and cirrhotic patients. Common approaches include splenic artery banding, ligation, stenting, and embolization to increase hepatic arterial flow. Splenic artery embolization has undergone further development to facilitate timely diagnosis, increase efficacy, decrease adverse outcomes, and improve patient selection. We review the current diagnostic modalities and technical advancements of splenic artery embolization to improve hepatic arterial perfusion in patients with splenic artery steal syndrome.

No. 117: Non-Operative Management of Blunt Spleen Trauma BST

Objective To compare clinical outcomes of superior versus inferior splenic artery embolization in partial splenic embolization (PSE) and identify predictors of major complications. Material and methods This retrospective case-control study included 73 patients who underwent PSE between May 2005 and April 2021. They were divided into two groups: the superior and middle splenic artery embolization group (Group A, n = 37) and the inferior and middle splenic artery embolization group (Group B, n = 36). Outcome differences and major complications between the groups were assessed. Logistic regression was used to analyze potential predictors of major complications, and the optimal cutoff value for splenic embolization rates was determined using the Youden index. Results There were no significant differences in laboratory and radiological outcomes between the two groups. Group A had a significantly lower incidence of major complications than Group B (p = 0.049), a lower Visual Analog Scale (VAS) score for pain (p = 0.036), and a shorter hospital stay (p = 0.022). Independent risk factors for major complications included inferior and middle splenic artery embolization (odds ratio [OR] = 3.672; 95% confidence interval [CI] = 1.028-13.120; p = 0.045) and a higher spleen embolization rate (OR = 1.108; 95% CI = 1.003-1.224; p = 0.044). The optimal cutoff for spleen embolization rate to predict major complications was 59.93% (sensitivity 77.8%, specificity 63.6%). Conclusion Using 500-700 µm microspheres for PSE, targeting the middle and superior splenic artery yields similar effects to targeting the middle and inferior artery, but results in lower rates of major complications and shorter hospital stays. To effectively minimize the risk of major complications, the embolization rate should be kept below 59.93%, regardless of the target vessel.

BackgroundSplenic injury due to colonoscopy is rare, but has high mortality. While historically treated conservatively for low‐grade injuries or with splenectomy for high‐grade injuries, splenic artery embolisation is increasingly utilised, reflecting modern treatment guidelines for external blunt trauma. This systematic review evaluates outcomes of published cases of splenic injury due to colonoscopy treated with splenic artery embolisation.MethodsA systematic review was performed of published articles concerning splenic injury during colonoscopy treated primarily with splenic artery embolisation, splenectomy, or splenorrhaphy from 1977 to 2022. Datapoints included demographics, past surgical history, indication for colonoscopy, delay to diagnosis, treatment, grade of injury, splenic artery embolisation location, splenic preservation (salvage), and mortality.ResultsThe 30 patients treated with splenic artery embolisation were of mean age 65 (SD 9) years and 67% female, with 83% avoiding splenectomy and 6.7% mortality. Splenic artery embolisation was proximal to the splenic hilum in 81%. The 163 patients treated with splenectomy were of mean age 65 (SD 11) years and 66% female, with 5.5% mortality. Three patients treated with splenorrhaphy of median age 60 (range 59–70) years all avoided splenectomy with no mortality. There was no difference in mortality between splenic artery embolisation and splenectomy cohorts (p = 0.81).ConclusionsSplenic artery embolisation is an effective treatment option in splenic injury due to colonoscopy. Given the known benefits of splenic salvage compared to splenectomy, including preserved immune function against encapsulated organisms, low cost, and shorter hospital length of stay, embolisation should be incorporated into treatment pathways for splenic injury due to colonoscopy in suitable patients.

Maximally decreasing portal pressures with transjugular intrahepatic portosystemic shunt (TIPS) is associated with improved ascites control but also increased encephalopathy incidence. Since splenic venous flow contributes to portal hypertension, we assessed if combining small-diameter TIPS with splenic artery embolization could improve ascites while minimizing encephalopathy. Fifty-five patients underwent TIPS creation for refractory ascites. Subjects underwent creation of 8 mm TIPS followed by proximal splenic artery embolization (group A, n=8), or of 8 mm (group B, n=6) or 10 mm TIPS (group C, n=41) without splenic embolization. Data were retrospectively reviewed. In group A, median portosystemic gradient decreased from 19 mmHg to 9 mmHg after TIPS, and 8 mmHg after subsequent splenic artery embolization. In groups B and C, gradient decreased from 15 mmHg to 8 mmHg and 16 mmHg to 6 mmHg. All patients except for one in group A and two in C had greater than 50% reduction in the number of paracenteses in 3 months. Any postprocedural encephalopathy incidence was 62%, 50%, 83% in groups A, B, and C, respectively. Overall, 20% of subjects with 10 mm TIPS required TIPS reduction/closure compared to 7% of subjects with 8 mm TIPS. We found that 8 mm diameter TIPS provided similar ascites control compared to 10 mm TIPS regardless of splenic embolization. While more patients with 10 mm TIPS required reduction/closure for severe encephalopathy, the study was underpowered for definitive assessment. Splenic embolization might have the potential to further decrease portosystemic gradient and ascites as an alternative to dilation of TIPS to 10 mm minimizing the risk of encephalopathy, but larger studies are warranted.

The spleen is one of the most frequently injured organs in abdominal trauma and is often managed nonoperatively with low rates of failure. A common adjunct to nonoperative management (NOM) is splenic artery embolization (SAE) which is controversial in some patient groups. We hypothesized that SAE would confer no benefit in elderly trauma patients undergoing NOM. This retrospective cohort study included patients in years 2019 to 2022 of the Trauma Quality Improvement Program database presenting after splenic trauma stratified into adult (age, 15-64 years) and elderly (age ≥65 years) cohorts. A cox proportional hazards model was used to estimate the adjusted odds of in-hospital mortality, up to 30 days, associated with age and management strategy. An interaction term between age group and management strategy allowed for evaluation of differential associations between cohorts. Secondary analysis focused on identification of predictors of NOM failure and potential differences between the age cohorts examined. This study analyzed 65,421 adult and 11,813 elderly patients with splenic trauma. Age was a significant predictor of mortality with elderly patients having over triple the risk of mortality compared with adults; following age, SAE increased the mortality risk by 41%. Despite increasing overall mortality risk, in adults, SAE was protective against failure of NOM. This relationship was not seen in the elderly cohort, where SAE had no benefit for preventing failure of NOM. Splenic artery embolization was associated with an increased risk of mortality in both adult and elderly patients and, as such, may be a marker for a decompensating patient. In the adult patient, SAE was beneficial for avoiding operative intervention. However, in the elderly patient no such benefit was seen. We recommend that in the decompensating elderly patient after splenic trauma, trauma surgeons should consider operative intervention, rather than SAE, as second-line therapy. Therapeutic/Care Management; Level III.

Purpose: Spontaneous rupture of spleen (SRS) is a rare but fatal complication of Infectious Mononucleosis (IM) with a reported incidence of 0.1 - 0.5%. Management usually consists of splenectomy in hemodynamically unstable patients and non-operative surveillance in stable patients. We report the successful use of splenic artery embolization as an alternative treatment in an unstable patient. Case: A previously healthy 18-year-old male admitted to the hospital with the sudden onset of left sided abdominal pain and pre-syncope after 1 week of fever and sore throat. On examination, he had BP of 86/46 and HR of 112 with severe left upper quadrant tenderness. Blood work showed Hemoglobin (Hb) of 12.3 which dropped to 6.4 in 6 hours of presentation and he was transfused with 2 units of packed RBCs. Abdominal CT scan revealed a grade III splenic laceration with large amount of blood in peritoneal cavity (Figure 1). Splenic artery arteriography along with embolization of the main splenic artery was performed (Figure 2). After the procedure his Hb stabilized, abdominal pain improved and fever resolved. Subsequently Epstein-barr virus serology was positive with a titer >160 u/ml. Repeat CT scan in 4 days after the procedure showed multiple regions of splenic infarction but the majority of the spleen was preserved. His Hb stabilized and was discharged on day 6 of his hospitalization.Figure 1Figure 2Discussion: Splenic artery embolization has not been studied well in cases of SRS secondary to IM. The majority of the literature is on splenectomy in unstable patients or non-operative watchfulness in stable patients. This methodology preserves spleen and prevents the dreadful complication of overwhelming post splenectomy infection, risks of laparotomy and the consequent morbidity and mortality in apslenic patients.

Hypersplenism (thrombocytopenia, leukopenia, anemia) syndrome and ascites occur after orthotopic liver transplant. These conditions can be treated by open splenectomy. Splenic artery embolization has been practiced as an alternative surgical method. Between January 2013 and January 2015, twenty-one orthotopic liver transplants were performed at the National Scientific Medical Research Center, Astana, Kazakhstan. Of these patients, 3 subsequently received splenic artery embolization 12, 8, and 6 months after transplant: 2 patients who had been diagnosed with primary biliary cirrhosis and 1 patient with hepatitis B virus -related liver cirrhosis. Two patients received a right-lobe living orthotopic liver transplant, and 1 patient received a deceased donor transplant. Indications for splenic artery embolization (ascites, splenomegaly) were based on clinical and ultrasonographic investigation and laboratory findings (thrombocytopenia, platelet count < 60 × 109/L, leukocytopenia, and white blood cell count < 2 × 109/L). Two recipients had leukothrombocytopenia and refractory ascites, and 1 had only thrombocytopenia. Splenic artery embolization was performed via a percutaneous femoral artery approach under local anesthesia. Transcatheter splenic artery branch occlusion was performed by deploying occlusion material. Preoperative spleen size ranged from 17.5 × 8.0 cm to 22.0 × 12.5 cm; ascites volumes were > 1000 mL. In all patients, ascites and platelet levels decreased after splenic artery embolization. In 1 patient with leukopenia, white blood cell count normalized. After embolization, 1 patient had severe abdominal pain requiring analgesia medication, and 2 patients had fever that lasted 3 days. Patients were discharged 6 to 9 days after embolization. One patient developed a perisplenic abscess without fever 1 month after discharge, and the abscess was drained using an ultrasound-guided percutaneous procedure. Splenic artery embolization is a safe and effective minimally invasive method for treating hypersplenism and ascites in orthotopic liver transplant recipients and an alternative to open splenectomy.

Objective To study the use of contrast-enhanced ultrasound in diagnosing splenic arterial steal syndrome (SASS) after liver transplantation, and to compare the curative effect, safety and follow-up results of the different embolization methods in the treatment of SASS after liver transplantation. Methods From January 2005 to December 2017, 41 patients after liver transplantation in our hospital developed splenic artery steal syndrome and were treated with splenic arterial embolization. All these patients underwent ultrasound, and in 19 patients contrast-enhanced ultrasonography was also done to detect the presence of splenic artery steal. The findings were confirmed by angiography. These patients then underwent splenic arterial embolization. In 32 patients coil embolization was done (group A) and in 9 patients embolization was assisted with Amplatzer occluders (group B). Results In all the 41 patients with SASS, angiography after splenic artery embolization showed the second and third order arterial branches in the liver increased in number and in diameter with good blood flow compared with those before treatment. The postoperative blood flow and pattern on ultrasound returned to normal. In group A, 12 patients (12/32, 37.5%) developed splenic infarction, including 11 patients with partial splenic infarction, and 1 patient developed a splenic abscess after complete splenic infarction. In group B, two patients developed partial splenic infarction (2/9, 22.2%). All the patients with splenic infarct had no clinical symptoms. No treatment was required except for the patient who developed splenic abscess after complete splenic infarction. The patient recovered well after treatment with antibiotics and splenic abscess drainage. There was no other complications. Conclusions Contrast-enhanced ultrasound provided early diagnosis of splenic artery steal after liver transplantation. Interventional splenic artery embolization was safe and effective to treat splenic arterial steal syndrome after liver transplantation. Coil embolization assisted with Amplatzer occluders was better than the traditional coil embolization with more accurate embolization site and fewer complications. Key words: Liver transplantation; Splenic artery steal syndrome; Contrast-enhanced ultrasound; Interventional treatment; Splenic arterial embolization

Background: Management of blunt spleen injuries has evolved from mandatory splenectomy to non-operative man-agement (NOM) allowing for splenic salvage, Splenic artery embolization (SAE) has been shown to be an effective treat-ment for hemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. Aim of Study: The aim of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma with splenic injury and to determine if the costs of an added, preventative procedure (SAE) early in management of blunt splenic injury would be offset by added utility by avoiding splenectomy. Patients and Methods: This study was a retrospective cohort study from a tertiary institution (50 patients in King Khaled Hospital Trauma Center, Hail, KSA and 9 patients in Al Hussein University Hospital, Cairo, Egypt). A total of 59 patients were treated with embolization in this period for blunt trauma, and however 39 cases were excluded given the presence of multiple concomitant injuries. Isolated splenic injury treated with SAE were identified in 20 patients and included for final analysis. Of these 10 patients, none required subsequent splenectomy following SAE. Results: The mean total angiography costs were 1837.94± 405.368 $, the costs of post-procedure management of patients including all hospital costs prior to discharge with associated length of stay. Conclusion: Splenic embolization is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our center was much lower than previously modelled data from overseas studies. Further research is advised to directly compare the cost of SAE and splenectomy in other countries.

04:12 PM Abstract No. 256 Splenic embolization for splenic arterial steal syndrome

Complications arising from splenic embolization after blunt splenic trauma

A nationwide Australian cross-sectional study assessing current management and infection prevention practices after Splenic Artery Embolisation (SAE) following trauma.