Splenic Artery Embolization for Non-Bleeding Gastric Varices and Hypersplenism Due to Isolated Splenic Vein Thrombosis

Abstract

Splenic artery embolization has been used with success for treatment of bleeding gastric varices secondary to splenic vein thrombosis. We present a case of isolated splenic vein thrombosis causing non-bleeding gastric varices and hypersplenism which was successfully treated with splenic artery embolization. A 56 year old man with hemachromatosis previously treated with phlebotomy presented with intermittent epigastric abdominal pain and thrombocytopenia. The subsequent workup included an evaluation for cirrhosis and portal hypertension including a liver biopsy and hepatic wedge pressure measurements which were normal. Further evaluation included a normal bone marrow biopsy. A CT scan and duplex ultrasound revealed an enlarged spleen of 15 cm as well as a suggestion of gastric varices and nonvisualization of the splenic vein. Splenic vein thrombosis was confirmed by MR venogram. Hematological evaluation revealed no hypercoagulable state and there was no history of pancreatitis or other explanation for the isolated finding of splenic vein thrombosis. Subsequently, an EGD revealed significant gastric varices. It was decided that a surgical splenectomy would be high risk due to multiple abdominal venous collaterals and that a medical splenectomy with splenic artery embolization is indicated to decompress venous collaterals prior to a planned surgical splenectomy. After the embolization, follow-up endoscopies have shown improvement in gastric varices and repeat laboratory evaluation has shown normalization of platelet counts even after ten months of follow-up. The decision was made not to proceed with surgical splenectomy at this time. There are only a few reported cases of isolated splenic vein thrombosis without a clear etiology. Splenic vein thrombosis is well known to cause hypersplenism and gastric varices. Splenic artery embolization has been described for 25 years and is mainly utilized in patients with bleeding gastric varices and hypersplenism, usually prior to splenectomy. This procedure is traditionally reserved for high risk surgical patients as it has been reported to have complications such as hematoma or splenic abscess. We suggest this procedure as an effective treatment modality while monitoring clinically for complications or evidence of splenic regeneration at which time surgical therapy could be considered.