Transsplenic Access Research Articles

Role of Interventional Radiology in the Management of Liver Transplant Complications in Children

AbstractLiver transplantation (LT) is a common solid organ transplant in the pediatric population. The common indications for LT, as well as its complications, differ between adults and children. This difference necessitates unique pediatric interventional radiology (IR) interventions. This article focuses on unique vascular complications occurring post-pediatric LT and highlights the importance of IR in their management. It explores IR's involvement in the workup of patients' pre-LT and management of complications following portosystemic shunts. We discuss advantages and disadvantages of different access routes as well as the prevalence, clinical picture, diagnosis, and management of complications after pediatric LT. These complications encompass portal vein stenosis, portal vein thrombosis, hepatic artery stenosis, hepatic artery thrombosis, hepatic artery pseudoaneurysm, arterioportal fistula, hepatic vein stenosis, and inferior vena cava stenosis. The choice of endovascular technique for a clinical indication depends on vascular anatomy, time since LT, and patient-specific factors. Transsplenic access is a useful alternative to transhepatic or transjugular access. The decision to place a stent in a child is influenced by the expected growth of the child and risk of focal narrowing at stent edge (because of recipient growth). Technical challenges in pediatric patient management, including uncooperative patients and sedation issues, must be considered. Pediatric LT complications can present with significant challenges in the posttransplant care of recipients and may lead to serious morbidity and graft failure if not managed effectively. IR techniques like balloon angioplasty, stent placement, thrombolysis, and embolization have demonstrated success in treating these complications, improving patient outcomes, and reducing long-term morbidity and mortality. By enhancing the understanding of medical practitioners and interventional radiologists about complex vascular complications, this article aims to contribute to better posttransplant care and improved outcomes for LT in pediatric populations. Continued collaboration between specialties and research will advance the field of pediatric LT and IR, to create even more effective treatment strategies.

Safety and effectiveness of transsplenic access for portal venous interventions: a single-center retrospective study.

To assess the safety and effectiveness of percutaneous transsplenic access (PTSA) for portal vein (PV) interventions among patients with PV disease. Adult patients with PV disease were enrolled if they required percutaneous catheterization for PV angioplasty, embolization, thrombectomy, variceal embolization, or transjugular intrahepatic portosystemic shunt (TIPS) placement for a difficult TIPS or recanalization of a chronically occluded PV. The procedures were performed between January 2018 and January 2023. Patients were excluded if they had an active infection, had a chronically occluded splenic vein malignant infiltration of the needle tract, had undergone splenectomy, or were under age 18years. Thirty patients (15 women, 15 men) were enrolled. Catheterization of the PV through PTSA succeeded for 29 of 30 patients (96.7%). The main adverse effect recorded was flank pain in 5 of 30 cases (16.7%). No bleeding events from the spleen, splenic vein, or percutaneous access point were recorded. Two cases (6.7%) each of hepatic bleeding and rethrombosis of the PV were reported, and a change in hemoglobin levels (mean [SD], - 0.5 [1.4] g/dL) was documented in 14 cases (46.7%). PTSA as an approach to accessing the PV is secure and achievable, with minimal risk of complications. Minimal to no bleeding is possible by using tract closure methods.

Recanalization of portal vein thrombosis after pediatric liver transplantation: Efficacy and safety of the transsplenic access.

Endovascular management of portal vein thrombosis (PVT) is challenging. Transsplenic access (TSA) is growing as an access option to the portal system but with higher rates of bleeding complications. The aim of this article is to evaluate the efficacy and safety of transsplenic portal vein recanalization (PVR) using a metallic stent after pediatric liver transplantation. This is a retrospective review of 15 patients with chronic PVT who underwent PVR via TSA between February 2016 and December 2020. Two children who had undergone catheterization of a mesenteric vein tributary by minilaparotomy were excluded from the patency analysis but included in the splenic access analysis. The technical and clinical success of PVR and complications related to the procedure via TSA were evaluated. Thirteen children with PVT were treated primarily using the TSA. The mean age was 4.1 years (range, 1.5-13.7 years), and the most common clinical presentation was hypersplenism (60%). Technically successful PVR was performed in 11/13 (84.6%) children, and clinical success was achieved in 9/11 (81.8%) children. No major complications were observed, and one child presented moderate pain in the TSA (from a total of 17 TSA). The median follow-up was 48.2 months. The median primary patency was 9.9 months. Primary patency in the first 4 years was 75%, and primary assisted patency was 100% in the follow-up period. Transsplenic PVR is a safe and effective method for the treatment of PVT after pediatric liver transplantation.

Transsplenic tract closure after transsplenic portalvenous access using gelfoam-based tract plugging

BackgroundTo assess the feasibility and safety of a gelfoam torpedo plugging technique for embolization of the transsplenic access channel in adult patients following transvenous portal vein interventions.Materials and methodsBetween 09/2016 and 08/2021, an ultrasound guided transsplenic portalvenous access (TSPVA) was established in twenty-four adult patients with a 21-G needle and 4-F microsheath under ultrasound guidance. Afterwards, sheaths ranging from 4-F to 8-F were inserted as needed for the procedure. Following portal vein intervention, the splenic access tract was embolized with a gelfoam-based tract plugging (GFTP) technique. TSPVA and GFTP were performed twice in two patients. Patients’ pre-interventional and procedural characteristics were analyzed to assess the feasibility and safety of the plugging technique according Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. Values are given as median (minimum;maximum). Subgroup analysis of intercostal vs. subcostal puncture site for TSPVA was performed using the two-sided Mann–Whitney-U test or Student’s t-test and Fisher’s exact test. Level of significance was p < 0.05.ResultsThe study population’s age was 56 (29;71) years and 54% were female patients. Primary liver disease was predominantly liver cirrhosis with 62% of the patients. Pre-interventional model for end-stage liver disease score was 9 (6;25), international normalized ratio was 1.15 (0.86;1.51), activated partial thromboplastin time was 33s (26s;52s) and platelet count was 88.000/µL (31.000;273.000/µL). Ascites was present in 76% of the cases. Craniocaudal spleen diameter was 17cm (10cm;25cm). Indication for TSPVA was assisted transjugular intrahepatic portosystemic shunt placement in 16 cases and revision in two cases, portal vein stent placement in five cases and variceal embolization in three cases. TSPVA was successfully established in all interventions; interventional success rate was 85% (22/26). The splenic access time was 33min (10min;133min) and the total procedure time was 208min (110min;429min). Splenic access was performed with a subcostal route in 11 interventions and with an intercostal route in 15 interventions. Final sheath size was 4-F in 17 cases, 5-F in three cases, 6-F in five cases, 7-F in two cases and 8-F in one case. A median of two gelfoam cubes was used for GFTP. TSPVA- and GFTP-related complications occurred in 4 of 26 interventions (15%) with a subcapsular hematoma of the spleen in two patients (CIRSE grade 1), access-related infection in one patient (CIRSE grade 3) and both in one patient (CIRSE grade 3). In detail, one access-related complication occurred in a patient with subcostal TSPVA (CIRSE grade 1 complication) and the other three complications occurred in patients with intercostal TSPVA (one CIRSE grade 1 complication and two CIRSE grade 3 complication) (p = 0.614). No patient required interventional or surgical treatment due to puncture tract bleeding.ConclusionGelfoam-based plugging of the puncture tract was feasible and safe for transsplenic access in adult patients undergoing percutaneous portal vein interventions. The lack of major bleeding complications and complete absorption of the gelatine sponge make it a safe alternative to transjugular and transhepatic access and re-interventions via the splenic route.

Safety of Percutaneous Transmesenteric and Transsplenic Access for Portosystemic Shunt Creation in Patients with Portal Vein Obstruction: Single-Center Experience and Review of Literature.

To evaluate the safety of ultrasound-guided percutaneous mesenteric vein access compared to transsplenic portal vein access for portosystemic shunt placement in patients with portal vein obstruction. Eight patients underwent portosystemic shunt creation through either a transsplenic (n = 4) or transmesenteric (n = 4) approach. The superior or inferior mesenteric vein was percutaneously accessed under ultrasound guidance using a 21G needle and a 4F sheath. Hemostasis at the mesenteric access site was achieved with manual compression. For transsplenic access, sheath sizes between 6 and 8F were used and tract embolization with gelfoam was performed. Portosystemic shunt placement was successful in all patients. While there were no bleeding complications with transmesenteric access, hemorrhagic shock requiring splenic artery embolization occurred in one patient in which the transsplenic approach was used. Ultrasound-guided mesenteric vein access seems feasible and a valid alternative to the transsplenic access in case of portal vein obstruction. Level of Evidence Level 4, case series.

Percutaneous Direct Puncture of Retropancreatic Splenic Vein and Portal Thrombectomy in a Patient With Liver Transplantation and Simultaneous Splenectomy.

Portal vein thrombosis following liver transplantation is generally managed by endovascular treatment. Although several techniques are available for portal venous access, trans-splenic access is of interest because it avoids damage to the liver graft. However, the spleen cannot be punctured to access the portal vein after splenectomy. We herein report a case of portal vein thrombosis following living donor liver transplantation with simultaneous splenectomy successfully treated by percutaneous intervention with direct puncture of the retropancreatic splenic vein. The splenic vein was punctured under computed tomography guidance in the prone position. Portal venography revealed a contrast defect due to a thrombus in the extrahepatic to intrahepatic portal vein. The portal vein was reopened after thrombectomy, and the portal vein thrombosis did not recur for 2 y. The technique and advantages of our approach are described.

Transsplenic Portal System Catheterization: Review of Current Indications and Techniques.

Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of portal vein access, transsplenic access (TSA) has gained recognition as an effective and safe technique to access the portal system in patients with contraindications to traditional approaches. Recently, the utility of percutaneous TSA has grown, with described treatments including recanalization of chronic portal vein occlusion, placement of stents for portal vein stenosis, portal vein embolization of the liver, embolization of gastric varices, placement of complicated transjugular intrahepatic portosystemic shunts, and interventions after liver transplant. The authors provide a review of percutaneous TSA, including indications, a summary of related portal vein diseases, and the different techniques used for access and closure. In addition, an imaging-based review of technical considerations of TSA interventions is presented, with a review of potential procedural complications. With technical success rates that mirror or rival the standard methods and reported low rates of major complications, TSA can be a safe and effective option in clinical scenarios where traditional approaches are not feasible. ©RSNA, 2022.

A Review of Transsplenic Access for Portal Vein Interventions

Transsplenic portography was one of the first procedures performed in the developing specialty of interventional radiology. The technique was first described by Abeatici and Campi in 1951.[1] The procedure continued with various techniques until a standardized approach to these procedures was developed by Kreel in 1970 to increase the safety of the procedure and consistency of results.[2] Transsplenic portography had a relatively high rate of complications but was an important diagnostic tool until computed tomography (CT) rendered the procedure obsolete for diagnostic purposes.[3] Portography from this approach allowed the characterization of portal anatomy, direct measurement of portal pressure, characterization of varices, treatment of variceal bleeding, evaluation of infections, and diagnosis of hepatic tumors. The general procedure involved blind insertion of a 19-gauge needle into the 9th to 10th intercostal space with a slightly upward and posterior trajectory. The trajectory was adjusted until blood dripping from the needle indicated intravascular placement. A splenic pressure measurement was then taken (normal: 8–14 mm Hg from a transsplenic 19-gauge needle). 50 mL of 50% contrast was then injected and imaging was performed with cut-film. At the end of the procedure, the needle was removed without any maneuvers to aid hemostasis (as these embolic techniques were relatively unknown at that time). There was significant bleeding risk with these early procedures, and as such, the procedure was largely abandoned in the late 1970s with the wide adoption of abdominal CT. It was not until the early 2000s that renewed interest in transsplenic access led to series entering the literature with a new focus on therapeutic interventions from a splenic vein approach. Of note, these procedures had a significantly lower complication rate compared with the early studies in part owing to the ability to use advanced hemostatic maneuvers. Since 2009, there have been several small studies demonstrating safe and effective transsplenic interventions. In a series of 46 patients who underwent endovascular portal vein interventions via a transsplenic approach, technical success was achieved in 44 procedures, major bleeding complicated 3 procedures, and 6 patients experienced minor bleeding.[4] In a series of 22 pediatric patients who underwent successful transsplenic procedures, there was 1 major bleed and 1 minor bleed.[5] In another series on pediatric patients, 12 of 44 had significant bleeding.[3] In a series of 11 adults in which transsplenic access was performed to allow portal venous reconstruction (PVR) with transjugular intrahepatic portosystemic shunt (TIPS) placement in chronically thrombosed portal veins, 11 of 11 had TIPS placed successfully with no bleeding complications.[6] The available series are small but do give useful data on method of access and hemostasis given the variability in outcomes. In the series with the highest bleeding complications, 12 of 44 (27%), gel foam alone was used for tract embolization.[3] In Habib's TIPS-PVR series in which coils were utilized, there were no bleeding complications.[6]

Closure of Transsplenic Access Tracts Using Tract Embolics: Success, Clinical Outcomes, and Complications in a Tertiary Center

Abstract Purpose The aim of the study was to evaluate the safety and effectiveness of transsplenic venous access closure. Materials and Methods Twenty patients (mean age: 51.8 years; range: 28–72), underwent 21 transsplenic venous access procedures over 4 years in this retrospective study. Comorbidities, active hemorrhage, anticoagulation, coagulation parameters, platelets, indications for transsplenic access, needle gauge, sheath size, variceal embolization method, tract embolization method, bleeding complications, and transfusion requirements and additional procedures to manage bleeding complications were recorded. Results Preprocedure comorbidities included portal hypertension (n = 18/20, 90%), portal vein thrombosis (n = 14/20, 70%), hemorrhage (n = 6/20, 30%), splenic vein thrombosis (n = 7/20, 35%), anticoagulation (n = 2/20, 10%), and sinistral portal hypertension (n = 2/20,10%). Mean baseline international normalized ratio was 1.3 (range: 1–1.9), platelets 122 (range: 18–492). Most common transsplenic access indications were gastric varices with nonpatent portosystemic shunt (n = 11/21, 52%) and portal vein targeting for transjugular intrahepatic portosystemic shunt (n = 8, 38%). Most common access sheath sizes were 4-French (n = 5, 24%) and 6-French (n = 6, 29%). Fifteen procedures (71%) involved variceal embolization. Transsplenic tracts were embolized with microfibrillar collagen alone (n = 7), coils and microfibrillar collagen (n = 8), or others (n = 6). Based on the Society of Interventional Radiology adverse event classification system, embolization complications included one major (splenic artery pseudoaneurysm and a splenic vein pseudoaneurysm) and three moderate (19%) adverse bleeding events, which required blood transfusion. Conclusion Transsplenic venous access tract embolization is a safe and moderately effective method to achieve tract hemostasis, with an overall clinical failure rate of 20%.

Endovascular management of portal vein obstruction in hepatobiliary cancer patients.

The purpose of this article is to describe the procedural safety, technical success, and clinical success of endovascular management of portal and mesenteric venous obstruction in patients with hepatobiliary neoplasms. Institutional Review Board (IRB)-approvedHIPAA compliant retrospective review of 21 consecutive patients with hepatobiliary malignancies who underwent endovascular portal vein recanalization and stent placement between January 2012 and March 2020. Clinical diagnoses were pancreatic cancer (n = 19), colon cancer metastatic to the liver (n = 1), and cholangiocarcinoma (n = 1). Presenting signs and symptoms included: ascites, abdominal pain, abnormal liver function tests, diarrhea, and gastrointestinal bleeding. Stent patency and patient survival are presented with Kaplan-Meier method. The technical success rate was 100%. A transhepatic approach was used in 20 cases (95.2%); trans-splenic access in one. Primary stent patency was 95.2%, 84%, and 68% at 1, 3, and 6 months, respectively. All stent occlusions were caused by tumor progression. A total of 80% of patients reported symptomatic improvement. Patient survival at 10 months was 40%. The early death rate was 4.76%. There were no bleeding complications from the percutaneous tracts. Endovascular recanalization with stent placement is safe with high technical and clinical success.

Short-term outcome of portal vein embolization vs. simultaneous portal and hepatic vein embolization for major liver resection – preliminary results?

Purpose: In a retrospective analysis we compared the effect and clinical outcome of simultaneous and sequential hepatic vein embolization (HVE) compared to portal vein embolization (PVE). Method: All patients, treated with PVE only or PVE with simultaneous or sequential HVE, prior to the major hepatectomy were included in the analysis. N-butyl-cyanoacrylate was used for PVE via transhepatic /transsplenic access, whereas HVE vascular plugs were applied for HVE via the jugular vein. Future remnant liver volume (FRLV) prior and following interventions was assessed via CT volumetry. Laboratory parameters and clinical courses were obtained from the clinical charts. Results: 16 patients were treated with simultaneous PVE and HVE, whereas the other 16 patients received PVE only and another 4 received sequential PVE and HVE. Left-sided thrombosis was observed in 6 patients after the simultaneous intervention and in 1 patient in the PVE group. Significant hypertrophy was noted in all patients (1.6-fold in the PVE group and 1.5-fold in the simultaneous group). Additional HVE induced a non-significant hypertrophy following PVE. However, only 8 of 16 patients in the simultaneous group, 9 of 16 patients in the PVE only group, and only one patient in the sequential group could undergo resection. The main reason for the drop-off was disease progression (12), impaired liver function (3) and portal venous thrombus (1). Conclusion: PVE and simultaneous PVE/HVE resulted in comparable hypertrophy induction and drop-off rates, however, the simultaneous treatment caused more left-sided portal vein thrombosis, which may jeopardize the surgery. Additional HVE after PVE might be useful for initial insufficient hypertrophy.

Successful Living-Donor Liver Transplantation With Intraoperative Endovascular Recanalization via Transsplenic Access in a Recipient With Grade III Portal Vein Thrombosis: A Case Report

Extensive portosplenomesenteric thrombosis is regarded as a relative contraindication to liver transplantation because of the complexity of the surgical procedure. This report describes a case of living-donor liver transplantation (LDLT) for a patient with extensive portosplenomesenteric thrombosis, in whom portal flow was successfully restored by intraoperative transplenic portal vein and superior mesenteric vein stenting after surgical thrombectomy. The patient’s liver function remained normal with a patent portal vein stent 6 months after LDLT, and Doppler ultrasonography demonstrated a normal wave form for portal flow. To the best of our knowledge, this is the world’s first case of endovascular management of the portal vein via percutaneous transsplenic access during LDLT, demonstrating that transsplenic access can be an alternative approach without liver graft injury when the superior mesenteric vein branch and inferior mesenteric vein cannot be used as access routes.

03:45 PM Abstract No. 78 Closure of transsplenic access tracts using microfibrillar collagen: success, clinical outcomes, and complications

To report clinical experience with transsplenic vascular access closure using microfibrillar collagen (Avitene, Bard; Murray Hills, NJ). 24 patients, mean age 52 years (range: 1.5-75), underwent 26 transsplenic vascular access procedures over 4 years in this retrospective study. Comorbidities, active hemorrhage, anticoagulation, hemoglobin, INR, platelets, prior TIPS, and variceal classification were recorded. Indications for transsplenic access, needle gauge, sheath size, variceal embolization method, tract embolization method, major/minor bleeding complications, and follow-up hemoglobins were recorded. Pre-procedure comorbidities included portal hypertension (n=19,79%), portal vein thrombosis (n=16,67%), hemorrhage (n=8,33%), splenic vein thrombosis (n=7,29%), anticoagulation (n=3,12.5%), and sinistral portal hypertension (n=2,8%). Mean baseline hemoglobin was 9.4 (range:6.3-13), INR 1.3 (range:1-1.9), and platelets 122 (range:18-492). 1 patient had prior TIPS (3.8%). Most common transsplenic access indications were gastric varices with non-patent portosystemic shunt (n=10,38%) and portal vein targeting for TIPS (n=8,30%). One transsplenic access was intentionally arterial. Most common access needle was 22-gauge (n=16,62%); and sheath size, 4-French (n=7,27%) and 6-French (n=7,27%). 13 procedures (50%) involved variceal embolization. Transsplenic tracts were embolized with microfibrillar collagen (n=8), coils and microfibrillar collagen (n=9), or other (n=9). Microfibrillar collagen tract embolizations included 1 major and 2 minor (18%) complications: one splenic artery pseudoaneurysm requiring embolization, and two self-limiting splenic bleeds requiring small-volume blood transfusion. 4 minor (44%) bleeds occurred in 9 tract embolizations without microfibrillar collagen. Transsplenic access tract embolization with microfibrillar collagen is an alternative method to achieve tract hemostasis. In a high-risk patient population, vigilance is necessary to treat potential complications.

New Techniques and Devices in Transjugular Intrahepatic Portosystemic Shunt Placement.

Recently, new techniques and devices in transjugular intrahepatic portosystemic shunt (TIPS) placement have emerged that can improve upon the standard procedure. Ultrasound guidance during TIPS with intracardiac echocardiography (ICE), placement of controlled expansion (CX) stents, and portal vein recanalization (PVR) via transsplenic access are three techniques with new data supporting their implementation. ICE guidance can improve the technical success of difficult cases, decrease procedure time, and decrease complications such as capsular puncture, hemobilia, and hepatic artery injury. CX stents offer the operator better control over the final portosystemic gradient, which is particularly useful in patients with a high risk of post-TIPS hepatic encephalopathy. Finally, transsplenic access provides a stable, antegrade route for PVR, which can be used to optimize transplant candidacy as well as treat the sequelae of portal hypertension in patients with portal vein thrombosis. This article will describe the benefits, technical parameters, and patient selection criteria for each of these new techniques.

Transsplenic splenoportography and portal venous interventions in pediatric patients.

Data regarding transsplenic portal venous access for diagnostic imaging and endovascular intervention in children are limited, possibly due to concerns regarding high bleeding risks and resultant underutilization. To investigate the safety and utility of transsplenic splenoportography and portal venous interventions in children. A retrospective review was performed of all pediatric patients undergoing percutaneous transsplenic portal venous access and intervention at two large tertiary pediatric institutions between January 2012 and April 2017 was performed. Parameters assessed included procedural indications, procedural and relevant prior imaging, technical details of the procedures, laboratory values and clinical follow-up. Transsplenic portal venous access was achieved in all patients. Diagnostic transsplenic splenoportography was performed in 22 patients and was 100% successful at providing the desired anatomical and functional information. Four transsplenic portal venous interventions were performed with 100% success: meso-Rex shunt angioplasty, snare targeted transjugular intrahepatic portosystemic shunt (TIPS) creation through cavernous transformation, pharmacomechanical thrombectomy for acute thrombosis, and transplant portal vein angioplasty. Intraperitoneal bleeding occurred in 2/26 (7.7%) and one case required transfusion (3.8%). No cases of hemorrhage were observed when transsplenic access size was 4 Fr or smaller. Transsplenic splenoportography in children is safe and effective when noninvasive imaging methods have yielded incomplete information. Additionally, a transsplenic approach has advantages for complex portal interventions. Bleeding risks are proportional to tract access size and may be mitigated by tract embolization.

Эмболизация воротной вены чрескожным чресселезеночным доступом у пациентов с распространенными очаговыми заболеваниями печени

Цель. На основании анализа собственного опыта применения селезеночного портального доступа определить его возможности в качестве альтернативы контрлатеральному чреспеченочному доступу.&#x0D; Материалы и методы. Проанализированы результаты предоперационной эмболизации ветвей воротной вены (ЭВВВ) у 11 пациентов с распространенными опухолями печени с использованием чресселезеночного портального доступа.&#x0D; Результаты. Чресселезеночный портальный катетерный доступ прост, безопасен, однако в связи с индивидуальными анатомическими особенностями селезенки этот тип доступа возможен у 61% пациентов, нуждающихся в нем.&#x0D; Выводы. Чресселезеночный портальный доступ может быть использован у пациентов, нуждающихся в ЭВВВ, которым невозможно выполнить портальный доступ через часть печени, запланированную для удаления.

Abstract No. 633 Trans-splenic access for porto-mesenteric interventions: single-center evaluation of safety and efficacy

Treatment of complex portomesenteric pathology (PMP) often requires alternative access sites. This study evaluates the safety and efficacy of endovascular management of PMP via percutaneous trans-splenic access (TSA). A database review of all TSA from 2010-2017 was performed. A total of 36 procedures were performed in 33 patients (18 female, mean age 45, range 2-72). Procedure indication, technical details, technical success (defined as successful access to splenic vein), procedural success, 30-day mortality and major and minor adverse events (AEs) were evaluated. TSA was achieved in all cases using ultrasound guidance and 20g Chiba needle. The splenic vein was accessed in an intrasplenic location. Contrast injection was used to confirm needle access. An .018” wire and Neff sheath was placed (Cook Medical). Depending on the planned intervention the access was then exchanged for the appropriate sized sheath ranging from 4F to 7F. The access tract was embolized using Gelfoam, coils, plugs or nBCA/lipiodol. Clinical indications included: access for TIPS placement or revision (n = 19), variceal embolization (n = 11), portal vein intervention (n = 8), splenic shunt creation (n = 2), and arterioportal fistula embolization (n = 1). Sheath size included: 4F (n = 4), 5F (n = 3), 6F (n = 27), 7F (n = 2). Access site was embolized with Gelfoam (n = 30), coils (n = 2), Amplatzer plug (n = 2), nBCA/Lipiodol (n = 2). Technical success for TSA was 100%. 30-day mortality was 8.3% (n = 3), and was unrelated to access in all cases. Intra-procedural bleeding requiring embolization occurred in 8.3% (n = 3). Post procedure bleeding was seen in 27.7% (n = 10) cases; of these, 13.9% (n = 5) required transfusion. No cases required a secondary embolization procedure. Procedural success was 94.4% (n = 34). Endovascular management of complicated PMP is a challenging task and TSA, although not without risk, is a feasible adjunct tool in the management of these patients.

Transjugular Intrahepatic Portosystemic Shunt Using the Trans-splenic Approach and a Snare Technique

AbstractTransjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the secondary prevention of variceal bleeding and management of refractory ascites. Portal vein thrombosis presents technical difficulty during TIPS due to nonvisualization of portal vein. In such patients, trans-splenic approach can be utilized to navigate thrombosed portal vein and use a snare as a fluoroscopic guidance for the intraparenchymal pass. We present the case of a 63-year old man who received the successful TIPS procedure via trans-splenic access without any complication.

Trans-splenic Access for Portal Venous Interventions in Children: Do Benefits Outweigh Risks?

The primary concern of trans-splenic access for portal interventions is the risk of life-threatening intraperitoneal bleeding. To review the clinical indications and efficacy and evaluate the risk factors for intraperitoneal bleeding during trans-splenic portal interventions in children. A retrospective review of consecutive patients who underwent trans-splenic portal interventions at a tertiary care pediatric institution between March 2011 and April 2017 was performed. Forty-four procedures were performed in 30 children with a median age of 5 (0.3-18) years. Clinical indications, technical success, procedural success, and incidence of complications were recorded. Potential risk factors for intraperitoneal bleeding were evaluated using Wilcoxon rank and Fisher's exact tests. Trans-splenic access was 100% successful. In 35/44 (79%) procedures, the subsequent intervention was successful including recanalization of post-transplant portal vein occlusion in 10/13, embolization of bleeding Roux limb varices in 8/8, recanalization of chronic portal vein thrombosis in native liver in 7/13, splenoportography and manometry in 6/6, and occlusion of portosystemic shunts in 4/4 procedures. Intraperitoneal bleeding occurred during 12/44 (27%) procedures and was managed with analgesics, blood transfusion, and peritoneal drainage without the need for splenectomy or splenic artery embolization. Statistically significant correlation of bleeding was found with intraprocedural anticoagulation, but not with patient age, weight, platelet count, INR, ascites, splenic length, splenic venous pressure, vascular sheath size, or tract embolization technique. Trans-splenic access is a useful technique for successful pediatric portal interventions. Although it entails a substantial risk of intraperitoneal bleeding, this can be managed conservatively.

Portal Vein Embolization via Percutaneous Transsplenic Access prior to Major Hepatectomy for Patients with Insufficient Future Liver Remnant

PurposeTo evaluate the feasibility and safety of percutaneous transsplenic portal vein embolization (PVE) before major hepatectomy for patients with insufficient future liver remnant. Materials and MethodsFrom May 2014 to June 2015, 27 transsplenic PVEs were attempted in 26 patients. In 16 patients, transsplenic PVE was indicated because of huge or multiple tumors in the trajectory of the puncture (n = 15) or a high-positioned liver (n = 1), which prevented safe ipsilateral transhepatic access. In the remaining 10 patients, transsplenic access was planned. A perihilar splenic vein was punctured using a 21-gauge Chiba needle under ultrasound and fluoroscopic guidance. Embolization of portal venous branches was performed using gelatin sponge particles followed by application of coils, an AMPLATZER Vascular Plug (AGA Medical Corporation, Golden Valley, Minnesota), or glue to prevent recanalization. Embolization of transsplenic routes was performed using coils followed by glue. ResultsTranssplenic PVE was successful in 24 (88.9%) of 27 sessions; 3 procedures failed because of splenic vein dissection (n = 1) and failed splenic vein puncture (n = 2). Major complications occurred in 1 patient (3.8%) with splenic vein dissection. Minor complications occurred in 2 patients: a small amount of fluid collection in the splenic hilar area in 1 patient and glue migration along the splenic vein in 1 patient. Planned liver resection was performed in 24 of 26 patients at 4.9 weeks ± 3.5 after PVE. ConclusionsTranssplenic PVE is safe and feasible and can be an effective alternative treatment for patients with a challenging ipsilateral, transhepatic route.