Splenic Artery Embolization Research Articles

S3473 Management of Splenic Subcapsular Hematoma in Setting of Chronic Pancreatitis via Percutaneous Drainage and Splenic Artery Embolization

S3473 Management of Splenic Subcapsular Hematoma in Setting of Chronic Pancreatitis via Percutaneous Drainage and Splenic Artery Embolization

Two-step complete splenic artery embolization for the management of symptomatic sinistral portal hypertension

Background Sinistral portal hypertension (SPH) is a rare clinical syndrome. The purpose of this study was to assess the clinical outcomes and safety of splenic artery embolization (SAE) in the treatment of SPH. Methods This retrospective study included 39 SPH patients who underwent SAE treatment between August 2009 and May 2021. The cases had esophageal, gastric, or ectopic varices detected by endoscopy or enhanced CT, with symptoms or signs of upper gastrointestinal (GI) bleeding and/or postprandial fullness. Clinical symptom improvement rate, complications, and symptomatic recurrence rate were observed and analyzed after treatment. Results All the procedures were performed successfully. Of all patients, 17 received the 2-step complete SAE procedure, 19 received only the first step of the 2-step protocol (i.e., partial splenic embolization [PSE] procedure), and the remaining three received the 1-step complete SAE procedure. After the procedures, the symptoms completely disappeared in all patients, and the main complications were post-embolization syndromes, with 27 patients (69.2%) developing a low-grade fever, 24 (61.5%) developing abdominal pain and 4 (10.3%) developing nausea or mild vomiting. During the prolonged follow-up, varicose veins were gradually reduced as detected by enhanced CT; liver function parameters and platelet count remained in the normal range. Only one patient who underwent PSE treatment developed upper GI rebleeding 7 months after the procedure. Conclusion Two-step complete SAE is a safe and feasible procedure for the treatment of symptomatic SPH.

Cost Utility of Splenic Artery Angioembolization for High-Grade Splenic Injury

Abstract 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.

Thrombocytopenia in Chronic Liver Disease: Challenges and Treatment Strategies.

Thrombocytopenia is a common hematologic complication seen in patients with chronic liver disease (CLD). The pathophysiology of thrombocytopenia in CLD is multifactorial, primarily stemming from platelet sequestration and decreased platelet production. This review focuses on the pathophysiology and current treatment options in the treatment of thrombocytopenia in chronic liver disease. While platelet transfusions are the gold standard of treatment, considerations ought to be given to CLD patients who can benefit from transjugular intrahepatic portosystemic shunt and splenic artery embolization. Finally, the recent approval of thrombopoietin receptor agonists for use in CLD patients paves a way for a safe and effective alternative method of improving platelet levels and reducing the need for recurrent platelet transfusions.

Splenic trauma: endovascular treatment approach.

The spleen is a commonly injured organ in blunt abdominal trauma. Splenic preservation, however, is important for immune function and prevention of overwhelming infection from encapsulated organisms. Splenic artery embolization (SAE) for high-grade splenic injury has, therefore, increasingly become an important component of non-operative management (NOM). SAE decreases the blood pressure to the spleen to allow healing, but preserves splenic perfusion via robust collateral pathways. SAE can be performed proximally in the main splenic artery, more distally in specific injured branches, or a combination of both proximal and distal embolization. No definitive evidence from available data supports benefits of one strategy over the other. Particles, coils and vascular plugs are the major embolic agents used. Incorporation of SAE in the management of blunt splenic trauma has significantly improved success rates of NOM and spleen salvage. Failure rates generally increase with higher injury severity grades; however, current management results in overall spleen salvage rates of over 85%. Complication rates are low, and primarily consist of rebleeding, parenchymal infarction or abscess. Splenic immune function is felt to be preserved after embolization with no guidelines for prophylactic vaccination against encapsulated bacteria; however, a complete understanding of post-embolization immune changes remains an area in need of further investigation. This review describes the history of SAE from its inception to its current role and indications in the management of splenic trauma. The endovascular approach, technical details, and outcomes are described with relevant examples. SAE is has become an important part of a multidisciplinary strategy for management of complex trauma patients.

Splenic Artery Embolisation for the Emergency Treatment of Sinistral Portal Hypertension: A Systematic Review

Abstract Objectives Sinistral portal hypertension (SPH) is caused by increased pressure on the left portal system secondary to splenic vein stenosis or occlusion and may lead to gastric varices. The definitive management of SPH is splenectomy, but this is associated with significant mortality and morbidity in the acute setting. In this systematic review, we investigated the efficacy and safety of splenic artery embolisation (SAE) in managing refractory variceal bleeding in patients with SPH. Methods A comprehensive literature search was conducted using MEDLINE and Embase databases. A qualitative analysis was chosen due to heterogeneity of the studies. Results Our search yielded 339 articles, 278 of which were unique. After initial screening, 16 articles relevant to our search remained for full text review. Of these, 7 were included in the systematic review. All 7 papers were observational, 6 were retrospective. Between them they described 29 SAE procedures to control variceal bleeding. The technical success rate was 100% and there were no cases of rebleeding during follow up. The most common complication was post-embolisation syndrome. Four major complications occurred, two resulting in death. These deaths were the only 30-day mortalities recorded and were in patients with extensive comorbidities. Conclusions Although there is a distinct lack of randomized controlled studies comparing SAE to other treatment modalities, it appears to be safe and effective in treating hemorrhage secondary to SPH.

Comparison of three embolic materials at partial splenic artery embolization for hypersplenism: clinical, laboratory, and radiological outcomes

PurposeTo compare effectiveness of three widely used embolic agents in partial splenic embolization (PSE) by analyzing their clinical, laboratory, and radiological outcomes within one year of follow-up.Materials and methodsThis retrospective study examined 179 patients who underwent PSE to manage hypersplenism secondary to cirrhosis. Patients were divided into 3 groups according to embolic agent used. Group 1 (gelatin sponge) included 65 patients, group 2 (embospheres) included 58 patients, and group 3 (PVA) included 56 patients. Clinical, laboratory, and radiological outcomes were compared between groups.ResultsThe technical success rate was 100% in all groups. Pain as a major complication was lower in the gelatin sponge group (20%) compared to the embosphere group (31%) and PVA group (32.3%). Major complications other than pain were found in 20.1%; 24.6% in gelatin sponge group, 15.5% in embosphere group and 19.6% in PVA group (p = 0.045). WBCs and platelet counts showed a significant increase after PSE in all groups. Entire splenic volume as measured by computed tomography after PSE showed no significant difference among the 3 groups; however, the volume of infarcted spleen was significantly lower in the gelatin sponge group compared to other two groups (p = 0.001). The splenic span was significantly reduced one-year post-procedure in three groups (p = 0.006), and it was significantly less in embosphere and PVA groups compared to gelatin sponge group (p < 0.05). Recurrent bleeding was higher in gelatin sponge group (p < 0.05).ConclusionsPermanent embolic materials achieved better laboratory and radiological outcomes than gelatin sponge particles in PSE of cirrhotic hypersplenism patients. However, permanent particles were associated with greater abdominal pain.

Proximal splenic embolisation versus distal splenic embolisation for management of focal distal arterial injuries of the spleen.

To compare the outcomes of proximal (pSAE) versus distal (dSAE) splenic artery embolisation for management of focal distal arterial splenic injuries secondary to blunt splenic trauma. Ethical approval was granted by the hospital research and ethics committee, Project 389/19. All patients who underwent splenic artery embolisation secondary to blunt abdominal trauma from 1 January 2009 to 1 January 2019 were reviewed. Patients with a tandem embolisation (both proximal and distal embolisations) or those with no acute vascular injury on angiography were excluded. Patient demographics, injury type/ AAST grade (2018 classification), technique of embolisation and outcomes were collected. Complications and splenectomy rates up to 30 days were recorded. 136 out of 232 patients had an embolisation performed for a distal vascular injury including active arterial bleeding, pseudoaneurysm or arteriovenous fistula. Mean age was 41 (range 16-84). Mean AAST grade was 4 (range 3-5). Mean Injury Severity Score was 22. pSAE was performed in 79.4% (n = 108) and dSAE in 20.6% (n = 28). Major complications occurred in 12 patients (pSAE n = 12, 11.1%; dSAE n = 0, P > 0.05); 6 pSAE required splenectomy (n = 6, 5.6%). There was no significant difference in outcomes between the two groups or when based on AAST grading. No significant difference was observed between proximal and distal embolisation techniques for blunt trauma patients with a distal vascular injury in terms of technical and clinical success.

Alterations of coagulation and fibrinolysis in patients with blunt splenic injury after splenic artery embolization.

BackgroundThrombotic complications following splenectomy have been documented. However, there has been sparse literature regarding thrombotic complications following splenic artery embolization (SAE).The objective of this study was to determine changes in coagulation and fibrinolysis and assess the thrombotic risk after SAE in patients with blunt splenic injury (BSI).MethodsThis study included 38 BSI patients who were hemodynamically stable on admission. SAE was performed if the splenic injury was classed as grade III or greater and had no requirement of immediate surgery. Platelet (PLT), fibrinogen (FIB), D‐dimers (D‐D), fibrinogen/fibrin degradation products (FDP), antithrombin III (AT III), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), hemoglobin (Hb), and hematocrit (Hct) were measured before SAE procedures and then 1d, 3d, and 7d after SAE.ResultsThe technical success rate of SAE and the splenic salvage rate were 100%. There was no mortality. Compared with pre‐SAE values, the levels of PLT, FIB, D‐D, and FDP increased significantly at 3 days and 7 days after SAE (p < 0.05). However, AT III, PT, APTT, TT, Hb, and Hct showed no statistically significant difference at 1d, 3d, and 7d after SAE (p > 0.05).ConclusionAlterations in PLT and hemostatic parameters might contribute to the increased risk of thrombotic complications in BSI patients undergoing SAE. Thromboembolism following SAE should be considered and thrombotic prophylaxis should be recommended.

Abstract No. 469 A comparison of outcomes in blunt spleen injuries treated by splenic artery embolization and splenectomy: a 5-year experience

The aim of this study was to compare abscess development, mortality rate, and length of stay between patients treated by splenic artery embolization (SAE) and splenectomy. SAE secondary outcomes were evaluated with respect to patient age and embolization method.

Abstract No. 108 Pilot randomized controlled trial of endovascular coils and vascular plugs for proximal splenic artery embolization in high-grade splenic trauma

Proximal splenic artery embolization (pSAE) is used for non-operative management of high-grade splenic injuries, most often using endovascular coils (EC) or vascular plugs (VP). It is not known which device is superior. The purpose of this pilot trial was to evaluate the feasibility of enrolling patients in a randomized controlled trial (RCT) comparing these devices, and to collect data to inform the design of a larger clinical effectiveness trial.

Splenectomy

Laparoscopic splenectomy has become an established standard of care in the management of surgical diseases of the spleen, except in the hemodynamically unstable trauma patient requiring splenectomy. Although adoption of minimally invasive splenectomy has led to a gradual decrease in the indications for open splenectomy, both procedures are still essential components of spleen surgery. This review describes the indications and contraindications for procedure, preoperative preparation and consent, operative anatomy and technique, and long-term follow-up. Tables review the clinical indications for splenectomy, classification of splenectomy, a comparison of laparoscopic versus open postsplenectomy outcomes, indications and contraindications for partial splenectomy, and reported incidences of postoperative outcomes and complications after splenectomy. Figures depict splenomegaly, the American Society of Hematology 2011 evidence-based practice guidelines for management of primary idiopathic thrombocytopenic purpura in children and adults, a splenic mass, a splenic cyst, massive splenomegaly, laparoscopic splenectomy, the 2014 Centers for Disease Control and Prevention recommendations for adult and pediatric splenectomy vaccination, splenic artery embolization, various laparoscopic approaches to splenectomy, splenic vascularization, division of splenic artery branches, suspensory ligaments of the spleen, laparoscopic exposure and transection of splenic hilum, retrieval bags and related procedures, open splenectomy, stapling, and laparoscopic partial splenectomy. Videos demonstrate purely laparoscopic splenectomy and hand-assisted laparoscopic splenectomy. This review contains 26 figures, 5 tables, 2 videos, and 111 references.

Trends in Blunt Splenic Injury Management: The Rise of Splenic Artery Embolization

IntroductionSplenic injury is common in blunt trauma. We sought to evaluate the injury characteristics and outcomes of BSI admitted over a 10-y period to an academic trauma center. MethodsA retrospective review of adult blunt splenic injury patients admitted between January 2009 and September 2018. ResultsThe 423 patients meeting inclusion criteria were divided by management: Observational (OBS, n = 261), splenic surgery (n = 114 including 4 splenorrhaphy patients), SAE (n = 43), and multiple treatment modalities (3 had SAE followed by surgery and 2 OBS patients underwent splenic surgery at readmission). The most common mechanism of injury was motor vehicle collision (47.8%). The median ISS (OBS 17, SAE 22, Surgery 34) and spleen AIS (OBS 2, SAE 3, Surgery 4) were significantly different. Complication rates (OBS 21.8%, SAE 9.3%, Surgery 45.6%) rates were significantly different, but mortality (OBS 7.3%, SAE 2.3%, Surgery 13.2%), discharge to home and readmission rates were not. Additional abdominal injuries were identified in 26.3% of the surgery group and 2.7% of OBS group. SAE rate increased from 3.0% to 28%; median spleen AIS remained 2-3. Thirty-five patients expired; 28 had severe head, chest, and/or extremity injuries (AIS ≥4). ConclusionSAE rates increased over time. Splenorrhaphy rates were low. SAE was associated with relatively low rates of mortality and complications in appropriately selected patients.

Post-traumatic Splenic Injury Outcomes for Nonoperative and Operative Management: A Systematic Review.

Splenectomies are widely performed, but there exists controversy regarding care for splenic injury patients. The purpose of this study is to provide a comprehensive review of the literature over the last 20years for operative management (OM) versus nonoperative management (NOM) versus splenic artery embolization (SAE) for traumatic splenic injuries and associated outcomes. A review of literature was performed following the PRISMA guidelines through a search of PubMed, EMBASE, Cochrane Library, JAMA Network, and SAGE journals from 2000 to 2020 regarding splenic injury in trauma patients and their management. Articles were then selected based on inclusion/exclusion criteria with GRADE criteria used on the included articles to assess quality. Twenty retrospective cohorts and one prospective cohort assessed patients who received OM versus NOM or SAE. Multiple studies indicated that NOM, in properly selected patients, provided better outcomes than its operative counterpart. This review provides additional evidence to support the NOM of splenic injuries for hemodynamically stable patients with benign abdomens as it accounts for consistently shorter hospital length of stay, fewer complications, and lower mortality than OM. For hemodynamically unstable patients, management continues to be intervention with surgery. More studies are needed to further investigate outcomes of post-splenectomy patients based on grade of injury, hemodynamic status, type of procedure (i.e., SAE), and failure of NOM in order to provide additional evidence and improve outcomes for this patient population.

Early Pharmacologic Venous Thromboembolism Prophylaxis after Splenic Artery Embolization Is Not Associated with an Increased Risk of Rebleed

Venous thromboembolism (VTE) prophylaxis in the setting of blunt traumatic visceral injury remains controversial. A total of 181 patients underwent splenic artery embolization (SAE) and began pharmacologic VTE prophylaxis at a median time of 59.5 hours (interquartile range, 46 hours). Six patients required splenectomy for rebleed. Fifty-one patients underwent SAE but did not receive anticoagulation therapy since they were considered low risk for VTE, and no splenectomies were performed (P = 1). Multivariate analysis showed no increased risk of need for splenectomy after beginning anticoagulation within 24 hours after SAE (P =.441). This study suggests that patients found to be at a high VTE risk should be considered for thromboprophylaxis within 24 hours after SAE.

Residual Splenic Volume after Main Splenic Artery Embolization is Independent of the Underlying Disease.

Purpose:To assess the safety and efficacy of main splenic artery embolization. To assess the potential difference post-embolization of the residual splenic volume in patients embolized for trauma versus those embolized for (pseudo)aneurysms.Materials and Methods:A retrospective analysis was performed on a cohort of 65 patients (36 males) who underwent pre- and post-embolization computed tomography. Patients’ demographics, pre- and post-interventional medical and radiological data were gathered. Splenic volume calculations were semi-automatically performed via a workstation. Patients with splenic aneurysms or pseudoaneurysms of the main splenic artery (group 1) were compared to those with splenic rupture (group 2) using Wilcoxon rank tests.Results:The main indications for splenic artery embolization were splenic rupture (n = 22; 34%) and splenic pseudoaneurysm (n = 19; 29%). The technical success rate was n = 63; 97%. The procedure-related complication rate was n = 7; 11%, including abscess formation (n = 5; 8%), re-bleeding (n = 1; 1.5 %) and pseudoaneurysm re-opening (n = 1; 1.5%). The overall 30-day mortality was n = 7; 11%.Median follow-up for groups 1 and 2 was 1163 days (61–3946 days) and 702 days (43–2095 days) respectively. When processable (n = 23), the splenic volume in group 1 (n = 7) was 311 cm3 and 257 cm3 (p = 0.1591) before and after embolization respectively, and in group 2 (n = 16) it was 261 cm3 and 215 cm3 (p = 0.4688), respectively.Conclusions:Main splenic artery embolization is efficacious, with low procedure-related complication and 30-day mortality rates. No significant differences in residual post-embolization splenic volume were found between patients treated for splenic rupture versus those treated for splenic arterial (pseudo)aneurysm.

Acute Pancreatitis with Hemorrhagic Pseudocyst in a Heart-Transplant Patient

<h3>Introduction</h3> In the last 3 decades heart transplantation has been dramatically evolving leading to successful results. Nevertheless, complications have been always on the side parallel to it. Although acute pancreatitis was one of the listed serious complications that was well reported, still the causes and best way of management is not clear yet. <h3>Case Report</h3> A 40-year-old woman was admitted to the hospital two weeks post heart transplant with abdominal pain. She is known to have dilated cardiomyopathy who underwent heart transplant with uneventful post-operative course. Her immunosuppressive regimen included prednisolone, mycophenolate mofetil and tacrolimus .she was complaining of epigastric pain radiating to the back. Her Labs showed amylase of 144 . The CT abdomen showed Evidence of large loculated Pseudo-pancreatic (image A), which has suggested late presentation of pancreatitis with no evidence of biliary pancreatitis. She was started on hydration, analgesia, and empirical antibiotic. A repeated CT showed progression of pseudocyst and formation of smaller cysts. Furthermore, she had a drop of hemoglobin Hb from 8 to 5. Urgent CT angiogram showed a bleeding splenic artery into the peripancreatic cyst (image B). Embolization of the proximal splenic artery was done by IR. We opted for conservative management . It was though that any trial for draining the cyst may lead to infection. As may be a cause of this event, tacrolimus was substituted with cyclosporine . A repeated abdominal CT scan showed improvement and no changes in the pseudocyst. She was kept on Conservative management aiming for repeating the CT scan within 6 weeks <h3>Summary</h3> The proper timing for diagnosing acute pancreatitis remains difficult due to the obscure symptoms and signs that patient with post-transplant may show. It needs always high index of clinical suspicion to avoid the catastrophic sequalae .In addition, dealing with complications itself remains controversial in terms of the appropriate modality of treatment for such immunocompromised patient .

Splenic artery embolization with N-butyl cyanoacrylate in patients with blunt abdominal trauma

Introduction Splenic artery embolization (SAE) has been shown to be safe and effective for non-operative management of patients with splenic trauma while preserving splenic function. A variety of coils, plugs, particles and liquid embolics have all been used. NBCA (n-butyl cyanoacrylate) is used less frequently than other modalities but is effective. Methods A retrospective review of all patients who underwent SAE with NBCA for blunt abdominal trauma at a single tertiary medical center over a six-year period. Results Out of 123 SAE patients, 7 utilized NBCA; 6 patients had intraparenchymal splenic artery pseudoaneurysms, 2 had intraparenchymal arteriovenous fistulas, and 5 had active extravasation from the spleen on CT imaging. There was 100% technical success rate. There were no acute post-op complications or complications at 30-day and 90-day follow up. One patient died 2 days following SAE secondary to worsening subdural hematoma unrelated to SAE. Conclusions NBCA is safe and effective in treating patients with splenic injury particularly in patients with high grade splenic injury demonstrating extensive intraparenchymal vascular injury and/or intraprocedural extravasation in distal locations.

Splanchnic Vein Thrombosis in Liver Cirrhosis After Splenectomy or Splenic Artery Embolization: A Systematic Review and Meta-Analysis.

Splenectomy and splenic artery embolization are major treatment options for hypersplenism and portal hypertension in liver cirrhosis, but may lead to splanchnic vein thrombosis (SVT), which is potentially lethal. We conducted a systematic review and meta-analysis to explore the incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization and the risk factors for SVT. All relevant studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization was pooled. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Sixty-six studies with 5632 patients with cirrhosis were included. The pooled incidence of SVT after splenectomy and splenic artery embolization was 24.6% (95% CI 20.2-29.3%) and 11.7% (95% CI 7.1-17.3%), respectively. A meta-analysis of three comparative studies demonstrated that the incidence of SVT after splenectomy was statistically similar to that after splenic artery embolization (OR 3.15, P = 0.290). Platelet count, mean platelet volume, preoperative splenic or portal vein diameter, preoperative or postoperative portal blood velocity, splenic volume and weight, and periesophagogastric devascularization were significant risk factors for SVT after splenectomy. Postoperative use of preventive antithrombotic therapy was a significant protective factor against SVT after splenectomy. SVT is common in liver cirrhosis after splenectomy and splenic artery embolization. Coagulation and hemostasis factors, anatomical factors, and surgery-related factors have been widely identified for the assessment of high risk of SVT after splenectomy. Prophylactic strategy after splenectomy, such as antithrombotic therapy, might be considered in such high-risk patients. This study was registered in PROSPERO with a registration number of CRD42019129673.

Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic 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.