Partial Splenic Artery Embolization Research Articles

Effects and complications of partial splenic artery embolization for portal hypertension

Effects and complications of partial splenic artery embolization for portal hypertension

Big spleens and hypersplenism: fix it or forget it?

Hypersplenism is a common manifestation of portal hypertension in the cirrhotic. More than half of cirrhotics will have low platelet counts, but neutropenia is much less common. Despite being common in the cirrhotic population, the presence of hypersplenism is of little clinical consequence. The presence of hypersplenism suggests more advanced liver disease and an increase in risk of complications, but there is no data showing that correcting the hypersplenism improves patient survival. In most series, the most common indications for treating the hypersplenism is to increase platelet and white blood cell counts to allow for use of drugs that suppress the bone marrow such as interferon alpha and chemotherapeutic agents. There are several approaches used to treat hypersplenism. Portosystemic shunts are of questionable benefit. Splenectomy, either open or laparoscopically, is the most effective but is associated with a significant risk of portal vein thrombosis. Partial splenic artery embolization and radiofrequency ablation are effective methods for treating hypersplenism, but counts tend to fall back to baseline long-term. Pharmacological agents are also effective in increasing platelet counts. Development of direct acting antivirals against hepatitis C will eliminate the most common indication for treatment. We lack controlled trials designed to determine if treating the hypersplenism has benefits other than raising the platelet and white blood cell counts. In the absence of such studies, hypersplenism in most patients should be considered a laboratory abnormality and not treated, in other words forget it.

Partial splenic artery embolization in cirrhotic patients.

Splenomegaly is a common sequela of cirrhosis, and is frequently associated with decreased hematologic indices including thrombocytopenia and leukopenia. Partial splenic artery embolization (PSE) has been demonstrated to effectively increase hematologic indices in cirrhotic patients with splenomegaly. This is particularly valuable amongst those cirrhotic patients who are not viable candidates for splenectomy. Although PSE was originally developed decades ago, it has recently received increased attention. Presently, PSE is being utilized to address a number of clinical concerns in the setting of cirrhosis, including: decreased hematologic indices, portal hypertension and its associated sequela, and splenic artery steal syndrome. Following PSE patients demonstrate significant increases in platelets and leukocytes. Though progressive decline of hematologic indices occur following PSE, they remain improved as compared to pre-procedural values over long-term follow-up. PSE, however, is not without risk and complications of the procedure may occur. The most common complication of PSE is post-embolization syndrome, which involves a constellation of symptoms including fever, pain, and nausea/vomiting. The rate of complications has been shown to increase as the percent of total splenic volume embolized increases. The purpose of this review is to explore the current literature in regards to PSE in cirrhotic patients and to highlight their techniques, and statistically summarize their results and associated complications.

Efficacy of partial splenic artery embolization for gastric varices with left-sided portal hypertension

We report the case of a 70-year-old man who was admitted to another hospital with a chief complaint of hematochezia. He had undergone total gastrectomy 15 years ago. Abdominal computed tomography (CT) showed complete obstruction of the splenic vein by a tumor in the head of the pancreas. He was then referred to our hospital for further management of anemia and the pancreatic tumor. Upper gastrointestinal endoscopy revealed isolated varices lacking the red color sign in the region of the gastric anastomosis. We made the diagnoses of pancreatic head cancer based on the findings on the cytological specimens obtained by endoscopic retrograde cholangiopancreatography, and left-sided portal hypertension due to splenic vein invasion of the tumor based on the CT findings. Because we could not conclude that the bleeding was caused by the varices, we started the patient on chemotherapy and kept her under observation. During the hospitalization, however, the hematochezia recurred repeatedly, and two blood transfusions were required. Upper gastrointestinal endoscopy performed a second time revealed enlarged and oozing varices, and we performed partial splenic artery embolization (PSE) to reduce the blood ooze from the site of bleeding. Well-developed collateral circulation was seen at the splenic hilum and we performed 80% embolization using Gelfoam and metallic coils. The PSE reduced the varices in the anastomosis, and nine months later, the varices had almost disappeared entirely. Left-sided portal hypertension complicated by pancreatic cancer is comparatively rare. In the present case, PSE was effective for stemming the bleeding from the gastric varices.

Obliterative Portal Venopathy: A Rare Cause of Pre-sinusoidal Portal Hypertension

Introduction: Making an etiologic diagnosis in patients with noncirrhotic portal hypertension can often be a formidable challenge for clinicians. We describe a rare case of pre-sinusoidal intrahepatic portal hypertension. Case: A 54-year-old man presented with an upper GI bleed. He had a longstanding history of fibrostenotic Crohn's disease s/p surgical resections and therapy with various immunomodulating agents. He had a history of massive splenomegaly and thrombocytopenia (platelets ˜40,000), for which he'd been followed by a hematologist without a definitive diagnosis, despite numerous tests including a bone marrow biopsy. An EGD revealed large, grade four esophageal varices, for which he underwent several variceal band ligation sessions. Initial CT imaging demonstrated a non-cirrhotic liver with a 25-cm spleen, patent portal, hepatic and splenic veins, and no ascites. LFT's were normal, and an MRCP showed no evidence of PSC. Viral, autoimmune, and genetic etiologies of chronic liver disease were unrevealing. A transjugular liver biopsy revealed a borderline elevated hepatic venous pressure gradient of 8 mmHg. Histology showed moderate macrovesicular steatosis (30%) and a NAFLD activity score (NAS) of 3/8. In addition, there were prominent periportal shunt vessels with muscularization of small portal vein branches and nodular regenerative hyperplasia changes; all consistent with a diagnosis of “obliterative portal venopathy (OPV).” There was mild periportal fibrosis (2/4), but no cirrhosis. A full hypercoaguable work-up failed to reveal an underlying clotting disorder. A partial splenic artery embolization was performed to reduce the spleen volume, prevent recurrent portal hypertensive bleeding, and improve the patient's thrombocytopenia. Several weeks post-procedure, his platelet count rose to the 200,000 range, and there was complete resolution of varices on follow-up EGD. He has since developed evidence of some thrombosis in the splenic and portal veins, requiring anti-coagulation. Discussion: OPV has also been termed “hepatoportal sclerosis,” “noncirrhotic intrahepatic portal hypertension,” and “idiopathic presinusoidal portal hypertension,” a rare etiology of portal hypertension diagnosed by the astute pathologist, based on specific histologic features. There is usually minimal-to-moderate portal fibrosis, but no cirrhosis and a patent splenoportal venous axis. The mechanism of disease pathogenesis is unclear, but in our patient, an autoimmune/inflammatory disease of the gut may predispose to portal bacteremia/pylephlebitis, which may result in thrombosis, sclerosis, and obstruction of small- and medium-sized portal vein radicals. His long-term exposure to 6 MP/imuran is another putative precipitating factor.

Severe gastric variceal bleeding successfully treated by emergency splenic artery embolization

Bleeding from gastric varices due to splenic vein obstruction is extremely rare in children, but it can be catastrophic. Reported herein is the case of a teenager with splenic vein thrombosis and chronic decompensated liver disease from autoimmune hepatitis who presented with massive gastric variceal bleeding. Standard medical management did not control the bleeding. Due to decompensated liver disease and continuous active bleeding, emergency partial splenic artery embolization was preferred over splenectomy or a shunt procedure. Bleeding was successfully controlled by partial splenic artery embolization by decreasing the inflow of blood into the portal system. It is concluded that emergency partial splenic artery embolization is a safer alternative life-saving procedure to manage severe gastric variceal bleeding due to splenic vein obstruction in a patient with high surgical risk. To our knowledge, only one other patient with similar management has been reported in the pediatric age group.

Partial splenic artery embolization in portal hypertension patients with hypersplenism: Two interval-spaced sessions’ technique

PurposeTo evaluate the ability of interval spaced sessions of transcatheter partial splenic artery embolization (PSE) to avoid the potential post procedure major complications, in portal hypertension patients with hypersplenism. Material and methodsThe study included 50 patients (39 male and 11 females). All patients had liver cirrhosis and portal hypertension with hypersplenism and hyperactive bone marrow. All patients underwent PSE in two sessions separated at least by 1month interval. Immediate, short and intermediate term follow-up for 1year were done. ResultsWe had no post procedure mortality. None of the patients developed septic shock, splenic abscess or needed emergency surgery. Ten of our patients developed subcapsular collections which were treated conservatively. All of our patients showed significant increase in the thrombocyte count after the first session which becomes remarkable after the second session and remained at appropriate levels during the follow up period. ConclusionPSE using two (interval-spaced) sessions with careful pre- and post procedure medications and care; is really effective non surgical minimally invasive procedure in avoiding the potential post procedure complications while achieving remarkable hematologic response on controlling hypersplenism in cirrhotic patients with portal hypertension.

Successful Treatment of Refractory Ascites after Liver Transplantation with Splenic Artery Embolization

Introduction: Refractory ascites after orthotopic liver transplantation is rare. While secondary precipitating causes can be identified in a sizable number, a small proportion of the patients with post-transplantation ascites have no identifiable cause. Splenic artery embolization has recently been reported as an effective method of treating refractory ascites in such cases. We present a case of successful treatment of refractory ascites after liver transplantation with partial splenic artery embolization. Case: A 52-year-old Caucasian male had received an orthotopic liver transplant in March, 2011 for hepatocellular carcinoma and chronic hepatitis C induced liver cirrhosis. The patient developed refractory ascites 2 months after transplantation requiring repetitive therapeutic paracenteses. Liver biopsy and echocardiography showed no evidence of rejection or recurrent hepatitis and congestive heart failure, respectively. Transjugular hepatic venogram and pressure evaluation showed a kink at the anastomosis of right hepatic vein and inferior vena cava which was successfully stented with resolution of pressure gradient post intervention. The patient continued to have refractory ascites despite these measures and underwent partial splenic artery embolization (SAE) to decrease the inflow of blood to the portal circulation. After SAE, the patient had significant reduction in ascites with decreased need for paracentesis, improved renal function and reduced diuretic requirement. Discussion: Refractory ascites (RA) is an uncommon complication of orthotopic liver transplantation which poses a serious challenge to the clinician. It is associated with increased risk of renal failure and peritoneal infections, increased hospital stay and shortened survival. In majority of patients with RA, treatment of secondary causes including right sided heart failure, acute or chronic graft rejection and hepatic inflow or outflow obstruction, leads to resolution of ascites. In the patients with no identifiable cause, treatment of ascites is challenging. Transjugular intrahepatic portosystemic shunting has shown mixed results as a treatment strategy. Splenic artery embolization leading to decreased splenic inflow and decreased portal hypertension has shown encouraging results in the recent years. Conclusion: Owing to its effectiveness in decreasing portal hypertension and low complication risk, splenic artery embolization appears to an attractive treatment option for the challenging problem of refractory ascites after liver transplantation.

Safety and efficacy of splenic artery coil embolization for hypersplenism in liver cirrhosis

Partial splenic artery embolization is an effective treatment for hypersplenism but often lacks long-term benefits. To evaluate the long-term effects of coil embolization of the splenic artery in patients with liver cirrhosis and hypersplenism. Forty-nine patients with liver cirrhosis and hypersplenism underwent coil embolization of the main splenic artery. The coils were deployed in the mid- or distal segment of the splenic artery to allow collateral blood flow to the spleen. The following data were collected from 2 weeks to 4 years after the embolization: technical success, length of hospital stay, white blood cell count, platelet count, splenic volume, and complication. The technical success rate of splenic artery coil embolization was 100%. The post embolization syndrome rate was 75% (36/49) with no incidence of major complications. The mean length of hospital stay was 9 days. After embolization, the patient's white blood and platelet counts increased significantly, peaked at 2 weeks, and gradually decreased during the 4-year follow-up period, but remained at significantly higher levels than pre-embolization levels. Follow-up CT scans demonstrated a gradual increase in the volume of the enhanced portions of the spleens with a decrease in the volume of unenhanced portion. No significant changes occurred in the red blood cell count and liver function after the embolization. Embolization of the mid-and distal main splenic artery with coils is a safe and effective treatment of hypersplenism in cirrhosis with long-term hematologic benefits.

Bovine Hemoglobin

Introduction: Management of severe symptomatic anemia in critically ill Jehovah’s Witness patients remains a challenge. The paucity of therapeutic alternatives to human red blood cells has prompted the use of blood substitutes. Case Report: A 19-year-old female Jehovah’s Witness patient presented to the emergency department following several episodes of syncope. She was found to have a positive Coombs test and was diagnosed with warm-bodied autoimmune hemolytic anemia. Upon admission, her hemoglobin was 8.4 g/dL, then dropped to a nadir of 2.8 g/dL 4 days later. She received traditional management with corticosteroids, intravenous immune globulin, rituximab, and partial splenic artery embolization. Despite these therapies, hemoglobin levels failed to respond, and she experienced signs of marked ischemia. A decision was made to give 2 units of Hemopure, a bovine hemoglobin-based oxygen carrier, and the hemoglobin levels increased to 8.7 g/dL 10 days later. The patient’s overall clinical condition improved leading to subsequent hospital discharge. Conclusion: This case exemplifies the ingenuity that health care practitioners must use in critical situations involving the medical management of anemic Jehovah’s Witness patients who refuse blood products. Hemopure was used as “bridging treatment” to help save a patient from the devastating effects of ischemia resulting from severe anemia.

Vaginal bleeding in a patient with type C liver cirrhosis without a past history of laparotomy: successful treatment with partial splenic artery embolization.

A 47-year-old female patient with type C liver cirrhosis underwent endoscopic injection sclerotherapy for esophageal varices 13years ago. The patient had no past history of hysterectomy or any other gynecological disorders. She was admitted to our hospital because of persistent vaginal bleeding and exacerbation of anemia. A contrast-enhanced computed tomography scan revealed marked dilation of not only the inferior mesenteric vein, but also the left ovarian vein, the uterine vein and the internal iliac vein. A celiac arteriography showed that the blood in the splenic vein was flowing almost totally hepatofugally into the dilated inferior mesenteric vein. An ovarian venography demonstrated knob-shaped dilation of the left ovarian vein draining into the left internal iliac vein. A proximally wedged left ovarian venography visualized the right ovarian vein and the right internal iliac vein with contrast medium via a palisade venous plexus from the dilated uterine and ovarian veins. Partial splenic embolization (PSE) was performed to increase platelet count and to reduce splenic venous blood flow into the ovarian vein. Following the PSE, the platelet count increased, and the blood flow in the dilated ovarian vein and uterine vein diminished. In addition, the portal blood flow became hepatopetal, and remarkably increased. There has as yet been no case report in which vaginal bleeding developed in women with liver cirrhosis without any past history of hysterectomy or other gynecological disorders. The present case report may be warranted in view of the rarity of the condition.

Formula to Predict Platelet Count after Partial Splenic Arterial Embolization in Patients with Hypersplenism

To establish a formula to guide appropriate embolization volume for postprocedural platelet gain following partial splenic arterial embolization (PSE) for hypersplenism. The hepatic volume (Vh) and splenic volume (Vsp) were measured by using 2-mm-thick computed tomography images before and after PSE in 20 patients with various chronic liver diseases. A formula was derived from the relationship between the platelet count increase ratio (dPlt%) and the organ volumes, which was then evaluated in another cohort. After an embolization of a median of 72.1% of the spleen (interquartile range, 38.2%-93.8%), the dPlt% was 67.7% ± 40.0 and significantly correlated with the increasing ratio of Vh to Vsp (P = .019, ρ = 0.52). Because the difference in Vh/Vsp ratio after PSE was significantly correlated with the spleen embolization ratio (eVsp%; P = .0003, ρ = 0.72), the estimated dPlt% could be derived from the Vh/Vsp ratio before PSE and the eVsp%. The estimated dPlt% was significantly correlated with the actual dPlt% (P = .0003, ρ = 0.72). When the formula was evaluated in another cohort of 14 cases, another strict correlation was observed (P < .0001, ρ = 0.92). These data suggest that platelet count after PSE can be predicted before the procedure by using the Vh/Vsp ratio and the anticipated spleen embolization volume. The use of such a prediction can prevent too much or too little embolization, thereby leading to an improvement in the risk/return trade-off in PSE.

Partial Splenic Artery Embolization for Thrombocytopenia and Uncontrolled Massive Ascites After Liver Transplantation

Thrombocytopenia (platelet < 60,000/mm3) and uncontrolled massive ascites (ascitic fluid > 1000 mL/d over 10 days) after liver transplantation (OLT), although uncommon, usually represent serious complications. Splenectomy is a useful treatment despite its many side effects. Recently, partial splenic artery embolization (PSAE) is considered to be a nonsurgical, less invasive treatment. In this study, we retrospectively reviewed the results of PSAE after OLT. Between October 2008 and February 2010, 11 patients underwent PSAE after OLT due to thrombocytopenia (n = 6) or refractory ascites (RA; n = 5). Six patients (54.5%) were males and 3 (27.3%) were children. The primary liver disease was virus-related liver cirrhosis (n = 6), biliary atresia (n = 3), fulminant hepatitis (n = 1), or alcoholic liver cirrhosis (n = 1). Seven grafts were from living and four from deceased donors. The major axial size of spleen was 12.1 to 23.4 cm and its average embolized volume, 76.4% (range = 70%–80%). As the result, the platelet count significantly increased after PSAE in all patients maintaining values greater than 100,000/mm3 in four thrombocytopenic patients (66.7%). Cases of RA showed marked decreases after PSAE (100%). The follow-up was 6 to 28 months. After PSAE, patients experienced abdominal pain (n = 9, 81.8%), fever (n = 2, 18.2%), and abdominal distension (n = 2, 18.2%). However, there was no serious complication after PSAE such as splenic abscess, rupture, pancreatic infarction, sepsis, or death. In conclusion, PSAE was effective and safe and can be the choice for thrombocytopenia or RA related to hypersplenism after OLT.

Value of Laparoscopic Splenectomy as Salvage Treatment for Relapsed Thrombocytopenia after Partial Splenic Arterial Embolization

Background/Aims: Recently, partial splenic arterial embolization (PSE) has become a supportive intervention for cirrhotic patients with hypersplenism in the administration of interferon therapy. However, relapsed thrombocytopenia is often observed in patients following PSE. This study aimed to report the clinical efficiency of laparoscopic splenectomy as a salvage treatment for relapsed thrombocytopenia following PSE. Methods: From 2005 to 2009, 6 patients with prior PSE treatment underwent laparoscopic splenectomy. We reviewed the surgical method of laparoscopic splenectomy and the peri- and postoperative outcomes. Results: Laparoscopic splenectomy effectively provided sufficient increases in patient platelet counts. In all patients, laparoscopic splenectomy was performed safely with no significant complications despite PSE-associated dense adhesion to the diaphragm and/or retroperitoneal attachments. Conclusion: Laparoscopic splenectomy provides a sufficient increase in patient platelet counts in relapsed thrombocytopenia following PSE. Therefore, laparoscopic splenectomy appears to be a superior supportive therapy for the treatment of thrombocytopenia in cirrhotic patients.

Role of partial splenic arterial embolization for hypersplenism in patients with liver cirrhosis and thrombocytopenia

Hypersplenism is traditionally treated by surgical splenectomy. Transcatheter ablation of splenic parenchyma is an alternative treatment modality. We evaluated the efficacy and safety of partial splenic arterial embolization in 10 patients with chronic liver disease and hypersplenism with thrombocytopenia (platelet count <80,000/microL). At six months follow up, median (range) platelet counts (134.5 [71.5-164] x 10(3)/microL) were significantly higher than those before treatment (33.5 [23-39] x 10(3)/microL; p<0.05]). All patients developed post-embolization syndrome. Left-sided pleural effusion and increase in amount or new development of ascites occurred in six and five patients, respectively. Our data suggest that partial splenic arterial embolization leads to an increase in platelet count in patients with thrombocytopenia due to chronic liver disease and hypersplenism. However, it is often associated with complications.

Evaluation of therapeutic effects on rectal varices using percutaneous color Doppler ultrasonography

We report the usefulness of percutaneous color Doppler ultrasonography (CDU) for evaluating therapeutic effects on rectal varices. Ultrasonographic examination and color flow imaging were performed using a color Doppler unit (Aplio 50 or XV, Toshiba, Tokyo, Japan) with a 3.5 MHz convex probe. We performed endoscopic injection sclerotherapy (EIS) for rectal varices in seven patients and partial splenic arterial embolization (PSE) for hypersplenism in four. We examined color flow images and measured the velocity of blood flow in rectal varices using fast-Fourier transform analysis by CDU in all eleven patients, before and after treatments. Rectal varices were detected by Doppler color flow imaging in all eleven patients before treatments. Blood flowvelocity in the rectal varices ranged from 5.7-11.6 cm/s (mean 8.6 cm/s). Rectal varices were observed in all patients by colonoscopy; enlarged, tortuous large varices with red color sign in nine and enlarged, tortuous large varices without red color in two. Seven days after EIS or PSE, CDU showed an extreme decrease in blood flow in all eleven rectal varices, compared to values before EIS or PSE. CDU can be performed repeatedly and is useful for evaluating the therapeutic effects of treatments for rectal varices.

Partielle Milzarterienembolisation zur Behandlung eines Hypersplenismus bei Leberzirrhose

A 52-year-old man with liver cirrhosis and ascites, hepatorenal syndrome and severe pancytopenia was admitted to hospital for treatment and consideration for future liver transplantation. Laboratory tests revealed severe leukocytopenia and thrombocytopenia, which had persisted after otherwise successful treatment of spontaneous bacterial peritonitis and a hepatorenal syndrome. There was no evidence of a toxic cause such as drugs or alcohol nor of an underlying haematologic disease. The most likely diagnosis was hypersplenism. Because of the high risk of a splenectomy it was decided to perform a partial splenic arterial embolization. Both leukocyte and thrombocyte counts rose after the intervention and continued to stay within normal range. This made it possible to discharge the patient from inpatient treatment until he was admitted again for a subsequently successful liver transplantation. Partial splenic artery embolization can be successfully used to treat severe leukocytopenia and thrombocytopenia in patients with liver cirrhosis and hypersplenism.

Hyperanmonemia due to portal-azygos venous shunt treated with balloon-occluded retrograde transvenous obliteration followed by partial splenic artery embolization

Hyperanmonemia due to portal-azygos venous shunt treated with balloon-occluded retrograde transvenous obliteration followed by partial splenic artery embolization

New methods for the management of esophageal varices

Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow-up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients' quality of life. Recently, we have performed EVL at 2-mo (bi-monthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.

The use of partial splenic artery embolization made it possible to administer interferon and ribavirin therapy in a liver transplant patient with fibrosing cholestatic hepatitis C complicated with thrombocytopenia

The use of partial splenic artery embolization made it possible to administer interferon and ribavirin therapy in a liver transplant patient with fibrosing cholestatic hepatitis C complicated with thrombocytopenia