Partial splenic embolization for the treatment of hypersplenism in cirrhosis

Change of skeletal muscle mass in cirrhotic patients with hypersplenism after partial splenic artery embolization

PURPOSE

Partial splenic artery embolization (PSAE) is an effective procedure for cirrhotic patients with hypersplenism. The aim of our study is to evaluate the effect of PSAE on skeletal muscle, and to identify the predictor for an improvement in skeletal muscle index (SMI) in cirrhotic patients with hypersplenism after PSAE.

MATERIALS AND METHODS

466 cirrhotic patients with hypersplenism underwent PASE between Dec 2013 and Mar 2022. Medical records and CT images of enrolled patients were analyzed.

RESULTS

105 cirrhotic patients with hypersplenism were enrolled. Sarcopenia was observed in 60.00 % (63/105) of these patients, 68.25 % (43/63) of male patients, and 31.75 % (20/63) of female patients. In cirrhotic patients, no significant change in the mean SMI at the third lumbar vertebra (L3) level after PSAE. In patients with sarcopenia, the L3 SMI increased from 36.77 cm2/m2 (baseline) to 43.38 cm2/m2 (P < 0.01), the L3 subcutaneous fat area (SFA) increased from 79.16 cm2 (baseline) to 103.52 cm2 (P < 0.01) at 12-month follow-up after PSAE. In patients without sarcopenia, the L3 SMI decreased from 58.38 cm2/m2 (baseline) to 49.44 cm2/m2 (P < 0.05), the L3 SFA increased from 89.63 cm2 (baseline) to 94.77 cm2 (P > 0.05) at 12-month follow-up after PSAE. Univariate and multivariate analysis demonstrated splenic infarction rate (OR: 0.01, P = 0.0032) and SMI (OR: 0.84, P < 0.001) were independent predictors for an improvement in skeletal muscle in patients with sarcopenia.

CONCLUSIONS

In cirrhotic patients with sarcopenia, an improvement in skeletal muscle and fat mass was observed after PSAE; splenic infarction rate and the L3 SMI before PSAE predicted an improvement in skeletal muscle index in patients with sarcopenia after PSAE.

The use of splenic embolization in immune thrombocytopenia: A systematic review and meta-analysis

The effectiveness of splenic embolization (SE) in treating refractory immune thrombocytopenia (ITP) remains uncertain. A systematic literature review was undertaken to assess the effectiveness and safety of SE in treating both paediatric and adult patients with ITP. We conducted an extensive search employing predefined criteria. We extracted platelet counts at baseline and at multiple intervals following SE, along with details of the proportion of embolized spleen parenchyma and the proportion of patients exhibiting complete or partial platelet count responses. We identified nine eligible reports for the analysis of effectiveness (228 patients) and 15 reports for the safety analysis (151 patients). Pooled estimates of complete response (platelet count >100 × 109/L) and overall response (platelet count >30 × 109/L) were 50.1% (95% CI: 38-62.3) and 74.4% (95% CI: 64.9-83.9) respectively. Most studies applied an embolization of at least 60% of the spleen parenchyma. Nearly all the patients suffered from mild adverse events (AEs), 1.3% suffered from serious AEs and one patient died (0.7%). In conclusion, SE resulted in an overall response rate in 74.4% of patients with ITP. However, this finding derives from uncontrolled studies of low to moderate quality.

Partial Splenic Embolization in Paediatric Sickle Cell Disease Patients with Hypersplenism

PURPOSE

To assess the safety and efficacy of partial splenic embolization (PSE) to reduce the need of transfusions and improve hematologic parameters in patients with hypersplenism and sickle cell disease (SCD).

MATERIAL AND METHODS

This prospective study includes 35 homozygous hemoglobin S patients with SCD and hypersplenism who underwent PSE from 2015 until 2021 in Kinshasa. Patients were evaluated, before and after PSE (1, 3 and 6 months), using clinical, laboratory and ultrasonographic methods. PSE was performed with the administration of gelatin sponge particles embolizing 60-70% of the splenic parenchyma.

RESULTS

The mean age was 10 (± 4) years and (21/35, 60%) were male. After PSE Leucocytes decreased at 3 months (16 692.94 vs 13 582.86, p = 0.02) and at six months Erythrocytes increased 2 004 000 vs. 2 804 142 (p < 0.001), Platelets increased (168 147 vs. 308 445, p < 0.001) and Hemoglobin increased (5.05 g/dL vs. 6.31 g/dL, p < 0.001) There was a significant dicrease in the need of transfusions from 6 (2-20) before PSE to 0.06 (0-1) after PSE (p < 0.001). The most frequent complication was splenic rupture (4/35, 11.4%), seen only and in all patients with hypoechogenic nodules at baseline.

CONCLUSION

PSE is a safe procedure in patients with SCD and hypersplenism, that do not have hypoechogenic nodules in the spleen. PSE improves the hematological parameters and reduces the frequency of blood transfusions.

Bone-Regeneration Therapy Using Biodegradable Scaffolds: Calcium Phosphate Bioceramics and Biodegradable Polymers

Calcium phosphate-based synthetic bone is broadly used for the clinical treatment of bone defects caused by trauma and bone tumors. Synthetic bone is easy to use; however, its effects depend on the size and location of the bone defect. Many alternative treatment options are available, such as joint arthroplasty, autologous bone grafting, and allogeneic bone grafting. Although various biodegradable polymers are also being developed as synthetic bone material in scaffolds for regenerative medicine, the clinical application of commercial synthetic bone products with comparable performance to that of calcium phosphate bioceramics have yet to be realized. This review discusses the status quo of bone-regeneration therapy using artificial bone composed of calcium phosphate bioceramics such as β-tricalcium phosphate (βTCP), carbonate apatite, and hydroxyapatite (HA), in addition to the recent use of calcium phosphate bioceramics, biodegradable polymers, and their composites. New research has introduced potential materials such as octacalcium phosphate (OCP), biologically derived polymers, and synthetic biodegradable polymers. The performance of artificial bone is intricately related to conditions such as the intrinsic material, degradability, composite materials, manufacturing method, structure, and signaling molecules such as growth factors and cells. The development of new scaffold materials may offer more efficient bone regeneration.

Risk factors for portal vein system thrombosis after partial splenic embolisation in cirrhotic patients with hypersplenism

AIM

To determine risk factors for portal venous system thrombosis (PVST) after partial splenic artery embolisation (PSAE) in cirrhotic patients with hypersplenism.

MATERIALS AND METHODS

Between March 2014 and February 2022, 428 cirrhotic patients with hypersplenism underwent partial splenic artery embolisation and from these patients 208 were enrolled and 220 were excluded. Medical records of enrolled patients were collected. Computed tomography (CT) images were reviewed by two blinded, independent radiologists. Statistical analyses were performed by using SPSS.

RESULTS

Progressive PVST was observed in 18.75% (39/208) of cirrhotic patients after PSAE. No significant differences in peripheral blood counts, liver function biomarkers, and renal function were observed between the patients with progressive PVST and the patients without progressive PVST. The imaging data showed significant differences in PVST, the diameters of the portal, splenic, and superior mesenteric veins between the progressive PVST group and non-progressive PVST group. Univariate and multivariate analysis demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for progressive PVST. Seventeen of 173 (9.83%) patients showed new PVST; the growth of PVST was observed in 62.86% (22/35) of the patients with pre-existing PVST. Spleen infarction percentage and the diameter of the splenic vein were independent risk factors for new PVST after PSAE.

CONCLUSION

The present study demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for PVST after PSAE in cirrhotic patients with hypersplenism.

Evaluation of splenic infarction ratio and platelet increase ratio after partial splenic artery embolization

OBJECTIVE

The spleen is part of the lymphatic system and is one of the least understood organs of the human body. It is involved in the production of blood cells and helps filter the blood, remove old blood cells, and fight infection. Partial splenic artery embolization (PSE) is widely used to treat pancytopenia and portal hypertension. The efficacy of PSE for improving thrombocytopenia has been well demonstrated. In this study, we evaluated the splenic infarction ratio and platelet increase ratio after PSE.

METHODS

Forty-five consecutive patients underwent PSE from January 2014 to August 2022. We retrospectively evaluated the splenic infarction volume and ratio after PSE and analyzed the relationship between the splenic infarction ratio and platelet increase ratio after PSE.

RESULTS

The platelet increase ratio was correlated with the splenic infarction ratio after PSE. The cutoff value for the splenic infarction ratio with a two-fold platelet increase was 63.0%.

CONCLUSION

We suggest performance of PSE in patients with a splenic infarction ratio of 63% to double the expected platelet count.

Partial splenic embolization as a rescue and emergency treatment for portal hypertension and gastroesophageal variceal hemorrhage

BACKGROUND

Partial splenic embolization (PSE) is a non-surgical procedure which was initially used to treat hypersplenism. Furthermore, partial splenic embolization can be used for the treatment of different conditions, including gastroesophageal variceal hemorrhage. Here, we evaluated the safety and efficacy of emergency and non-emergency PSE in patients with gastroesophageal variceal hemorrhage and recurrent portal hypertensive gastropathy bleeding due to cirrhotic (CPH) and non-cirrhotic portal hypertension (NCPH).

METHODS

From December 2014 to July 2022, twenty-five patients with persistent esophageal variceal hemorrhage (EVH) and gastric variceal hemorrhage (GVH), recurrent EVH and GVH, controlled EVH with a high risk of recurrent bleeding, controlled GVH with a high risk of rebleeding, and portal hypertensive gastropathy due to CPH and NCPH underwent emergency and non-emergency PSE. PSE for treatment of persistent EVH and GVH was defined as emergency PSE. In all patients pharmacological and endoscopic treatment alone had not been sufficient to control variceal bleeding, and the placement of a transjugular intrahepatic portosystemic shunt (TIPS) was contraindicated, not reasonable due to portal hemodynamics, or TIPS failure with recurrent esophageal bleeding had occurred. The patients were followed-up for six months.

RESULTS

All twenty-five patients, 12 with CPH and 13 with NCPH were successfully treated with PSE. In 13 out of 25 (52%) patients, PSE was performed under emergency conditions due to persistent EVH and GVH, clearly stopping the bleeding. Follow-up gastroscopy showed a significant regression of esophageal and gastric varices, classified as grade II or lower according to Paquet's classification after PSE in comparison to grade III to IV before PSE. During the follow-up period, no variceal re-bleeding occurred, neither in patients who were treated under emergency conditions nor in patients with non-emergency PSE. Furthermore, platelet count increased starting from day one after PSE, and after one week, thrombocyte levels had improved significantly. After six months, there was a sustained increase in the thrombocyte count at significantly higher levels. Fever, abdominal pain, and an increase in leucocyte count were transient side effects of the procedure. Severe complications were not observed.

CONCLUSION

This is the first study analyzing the efficacy of emergency and non-emergency PSE for the treatment of gastroesophageal hemorrhage and recurrent portal hypertensive gastropathy bleeding in patients with CPH and NCPH. We show that PSE is a successful rescue therapy for patients in whom pharmacological and endoscopic treatment options fail and the placement of a TIPS is contraindicated. In critically ill CPH and NCPH patients with fulminant gastroesophageal variceal bleeding, PSE showed good results and is therefore an effective tool for the rescue and emergency management of gastroesophageal hemorrhage.

Pediatric liver cirrhosis interventional procedures: from biopsy to transjugular intrahepatic portosystemic shunt

Cirrhosis is a complex diffuse process whereby the architecture of the liver is replaced by abnormal nodules because of the presence of fibrosis. Several pediatric diseases such as extrahepatic portal vein obstruction, biliary atresia, alpha-1-antitrypsin deficit and autoimmune hepatitis can lead to cirrhosis and portal hypertension in children. In this article the authors describe interventional radiology procedures that can facilitate the diagnosis and treatment of diseases associated with liver cirrhosis and portal hypertension in the pediatric population. These procedures include image-guided liver biopsy, mesenteric-intrahepatic left portal vein shunts, balloon-occluded retrograde transvenous obliteration, transjugular intrahepatic portosystemic shunts and splenic embolization.

Efficacy and safety of heparin plus dexamethasone after partial splenic embolization for liver cirrhosis with massive splenomegaly

PURPOSE

The aim of this study was to investigate the efficacy and safety of the combination of low-molecular-weight heparin + dexamethasone after partial splenic embolization in cirrhotic patients with massive splenomegaly.

METHODS

This study included 116 patients with liver cirrhosis complicated with massive splenomegaly who underwent PSE in Union Hospital from January 2016 to December 2019, and they met the criteria. They were divided into two groups: PSE + Hep + Dex group (N = 54) and PSE group (N = 62). We conducted a retrospective study to analyze the efficacy and safety of the two groups of patients.

RESULTS

The volume of splenic embolization was 622.34 ± 157.06 cm³ in the PSE + Hep + DEX group and 587.62 ± 175.33 cm³ in the PSE group (P = 0.306). There was no statistically difference in the embolization rate of the spleen between the two groups (P = 0.573). WBC peaked 1 week after PSE and PLT peaked 1 month after PSE in both groups; it gradually decreased later, but was significantly higher than the preoperative level during the 12-month follow-up period. The incidences of abdominal pain (46.3% vs 66.1%, P = 0.039), fever (38.9% vs 75.8%, P < 0.001), PVT (1.9% vs 12.9%, P = 0.026), refractory ascites (5.6% vs 19.4%, P = 0.027) were lower in the PSE + Hep + DEX group than in the PSE group. The VAS score of abdominal pain in PSE group was higher than that in PSE + Hep + DEX group on postoperative days 2-8 (P < 0.05). Splenic abscess occurred in 1(1.6%) patient in the PSE group and none (0.0%) in the PSE + Hep + DEX group (P = 0.349).

CONCLUSIONS

The combined use of dexamethasone and low-molecular-weight heparin after PSE is a safe and effective treatment strategy that can significantly reduce the incidence of complications after PSE (such as post-embolization syndrome, PVT, refractory ascites).

Repeated partial splenic artery embolization for hypersplenism improves platelet count

Splenic embolization is a minimally invasive alternative to splenectomy for the treatment of hypersplenism. This was a retrospective study of 101 patients with hypersplenism caused by cirrhosis who were treated with splenic embolization and for whom 6 months of follow-up data were available. Of these patients, 65 underwent partial splenic artery embolization (PSE), including 23 who underwent repeated PSE (RPSE). The incidence of abdominal pain was significantly higher in the PSE group than in the total splenic artery embolization (TSE) group (P < 0.001), and its duration was also longer in the PSE group (P = 0.003). Biochemical markers of liver function were compared before and after the operation; aminotransferase indices decreased (alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase), total bilirubin increased slightly, and albumin and prealbumin decreased after the operation (all P < 0.001). Platelet (PLT) counts began to increase at 1 week postoperatively, peaked at 1 month postoperatively, and then decreased gradually. There was no significant intergroup (PSE and TSE) difference at any time point (1 day, 1 week, 1 month, and 6 months postoperatively, P > 0.05). There was a significant intergroup (PSE and RPSE) difference in the mean postoperative change in PLT count (P = 0.45). Splenic embolization can improve the inflammatory indicators of liver function. Performing PSE twice or more improves the PLT counts.

Partial Splenic Embolization for the Management of Severe Refractory Thrombocytopenia in Antiphospholipid Syndrome: A Case Report and Literature Review

Antiphospholipid syndrome is an autoimmune condition characterized by arteriovenous thromboembolic events. Thrombocytopenia is a common finding among these patients and is typically of mild severity not requiring any treatment. However, severe cases of thrombocytopenia should be treated. Steroids, intravenous immune globulin (IVIG), and immunomodulatory agents are the first-line treatment options, and surgical splenectomy is usually reserved for more severe and refractory cases of thrombocytopenia. Herein, we report the case of a 30-year-old man with primary antiphospholipid syndrome and severe thrombocytopenia. The patient's thrombocytopenia had been refractory to almost all the medical managements, and surgical splenectomy could not be an option due to the patient's high-risk condition for surgery. The patient was successfully managed by partial splenic embolization (PSE) which was a unique application of this technique.

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.

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

Purpose

To 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 methods

This 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.

Results

The 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).

Conclusions

Permanent 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.

Partial splenic embolization treats recurrent left pleural effusions in a patient with portal venous system thrombosis

A 56-year-old female with thrombocythemia complicated by portal venous system thrombosis presented with recurrent left pleural effusions after failed recanalization via mechanical thrombectomy and stenting at an outside center. With no other cause, splenic vein thrombosis and left-sided portal hypertension was suggested as a possible etiology. Partial splenic embolization was performed with immediate decrease in effusions and resolution by 8 weeks. Portal and splenic venous system thrombosis may cause recurrent pleural effusions from left-sided portal hypertension and fluid leakage across diaphragmatic defects. Upper pole partial splenic embolization may treat recurrent left pleural effusions and offer an alternative to splenectomy.

An updated meta-analysis of partial splenic embolization versus splenectomy in the treatment of hypersplenism due to cirrhosis

OBJECTIVE

To evaluate the efficacy and safety of partial splenic embolization (PSE) versus splenectomy (SP) for hypersplenism.

MATERIAL AND METHODS

Pubmed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Science and Technology Periodical Database (VIP) databases were systematically searched to identify all relevant studies. Stratified meta-analysis was also conducted to control the influence of confounding factors on the research results.

RESULTS

Twenty-three studies comparing PSE with SP involving a total of 1849 hypersplenism patients were selected. Postoperative increased level of platelet (PLT) [mean difference (MD) = -65.51; 95% confidence interval (CI), -81.33 to -41.69; p < .00001] were better in SP than in PSE; however, PSE was associated with less operation time (MD = -53.47; 95% CI, -65.01 to -41.94; p < .00001), less intraoperative blood loss (MD = -61.58; 95% CI, -80.35 to -42.82; p < .00001), shorter hospital stay (MD = -2.98;95% CI, -4.07 to -1.88; p < .00001) and lower complication rate [odds ratio (OR) = 0.53; 95% CI, 0.32 to 0.90; p = .02] compared with the SP. Meanwhile, there was no significant difference in postoperative increased level of white blood cells (WBC) (MD = -1.02; 95% CI, -2.16 to 0.11; p = .08) and postoperative increased level of hemoglobin (HB) (MD = -4.09; 95% CI, -14.06 to 5.88; p = .42) between PSE and SP group.

CONCLUSION

PSE had similar efficacy with SP in improving postoperative PLT, WBC, and HB levels. Moreover, PSE had the advantages of less trauma and fewer complications as well as faster recovery when compared with SP. Therefore, we tended to be cautious about SP and considered that patients with hypersplenism might benefit more from PSE.

Short-term Effects of Hepatic Arterial Buffer Responses Induced by Partial Splenic Embolization on the Hepatic Function of Patients with Cirrhosis According to the Child-Pugh Classification

Objective This study primarily aimed to investigate the short-term effects of partial splenic embolization (PSE) on the Child-Pugh score and identify predictive factors for changes in the score caused by PSE. The secondary aim was to analyze changes in various parameters at one month postoperatively using these identified factors. Methods Between September 2007 and December 2019, 118 patients with cirrhosis and hypersplenism underwent PSE at our hospital. Testing was conducted preoperatively and at one month after PSE. Results Overall, the Child-Pugh score was not significantly changed postoperatively. The Child-Pugh score before PSE was identified as the strongest independent predictor of ameliorated and deteriorated Child-Pugh scores after PSE. Higher pretreatment Child-Pugh scores were correlated with higher posttreatment amelioration rates of the score. A significant decrease in the portal vein diameter and a significant increase in the common hepatic artery diameter were evident at the same level postoperatively in 64 patients with Child-Pugh class A (group A) and in 54 patients with Child-Pugh class B or C (group B/C) preoperatively. According to Murray's Law, PSE resulted in decreased portal venous flow and increased hepatic arterial flow, suggesting a hepatic arterial buffer response (HABR) induced by the procedure. Despite equivalent splenic infarction rates and similar posttreatment changes in hepatic hemodynamics, PSE significantly increased the Child-Pugh score of group A; however, the procedure significantly decreased the score of group B/C. Conclusion Considering original portal venous-hepatic arterial hemodynamics, PSE is expected to produce HABR-mediated hepatic functional improvements in cirrhosis patients with Child-Pugh class B/C.

Splenic non-infarction volume determines a clinically significant hepatic venous pressure gradient response to partial splenic embolization in patients with cirrhosis and hypersplenism

BACKGROUND

This study aimed to investigate changes in the hepatic venous pressure gradient (HVPG) by partial splenic embolization (PSE) and to identify the determinants of a clinically meaningful postoperative HVPG reduction.

METHODS

Sixty-eight patients with cirrhosis and hypersplenism who underwent PSE at our department between September 2007 and June 2020 were included. The HVPG was evaluated pre- and immediately post-PSE. The patients were divided into three groups according to their preprocedural HVPG: low-HVPG (< 10 mmHg, n = 22), intermediate-HVPG (10 mmHg ≤ HVPG < 16 mmHg, n = 33), and high-HVPG (≥ 16 mmHg, n = 13).

RESULTS

Overall, PSE significantly reduced HVPG from 12.2 ± 4.0 to 9.4 ± 3.6 mmHg (p < 0.01) with a relative decrease of 22.2 ± 20.4%. In addition, HVPG reductions were 19.4 ± 28.7%, 24.0 ± 15.9%, and 22.5 ± 13.3% in the low-, intermediate-, and high-HVPG groups, respectively, indicating no significant difference in HVPG reduction between the groups. An HVPG decrease of ≥ 20% from the baseline, defined in this study as a clinically significant HVPG response to PSE, was achieved in 55.9% of all patients. Multivariate logistic regression and receiver operating characteristic curve analyses identified splenic non-infarction volume as an independent determinant of a 20% decrease in HVPG (p < 0.05), with a cut-off of 139.2 cm³ (sensitivity, 76.3%; specificity, 60.0%; p < 0.05).

CONCLUSIONS

The splenic non-infarction volume, namely the residual functional spleen volume, independently determines a clinically significant HVPG response to PSE in patients with cirrhosis and hypersplenism.

Partial splenic embolization combined with endoscopic therapies and NSBB decreases the variceal rebleeding rate in cirrhosis patients with hypersplenism: a multicenter randomized controlled trial

Background

Global research on endoscopic therapies in combination with partial splenic embolization (PSE) for variceal hemorrhage (VH) is limited. Therefore, we aimed to evaluate the efficacy and safety of endoscopy plus PSE (EP) treatment in comparison to endoscopic (E) treatment for the secondary prophylaxis of VH in cirrhosis patients with hypersplenism.

Methods

Cirrhosis patients with hypersplenism (platelet count < 100, 000/µL) and those who had recovered from an episode of VH were enrolled in a multicenter randomized controlled trial. The participants were randomly assigned into EP and E groups in a 1:1 ratio. The primary endpoint was variceal rebleeding, and the secondary endpoints were severe variceal recurrence and mortality during the 2-year follow-up. Hematological indices, serum biochemical parameters, and the Child–Pugh score were measured at each time point.

Results

From June 2016 to December 2019, 108 patients were enrolled in the study, among which 102 patients completed the protocol (51 in EP and 51 in E group). The rebleeding rate of the varices was significantly reduced in the EP group compared to that in the E group during the 2 years (16% vs. 31%, p < 0.001). The EP group showed a significantly lower variceal recurrence rate than the E group (22% vs. 67%, p < 0.001). The COX proportional hazard models revealed that grouping was an independent predictor for variceal rebleeding (H = 0.122, 95% CI 0.055–0.270, p < 0.001) and variceal recurrence (hazard ratio, H = 0.160, 95% CI 0.077–0.332, p < 0.001). The peripheral blood cell count, Child–Pugh class/score, albumin concentration, and coagulation function in the EP group improved significantly compared to the values observed in the E group at any time point (p < 0.05).

Conclusions

The EP treatment was more effective in preventing variceal rebleeding and variceal recurrence than the conventional E treatment during the secondary prophylaxis of VH in cirrhosis patients with hypersplenism. Furthermore, the EP treatment could significantly increase the peripheral blood cell count and albumin concentration and also improved the coagulation function and the Child–Pugh score.

Clinical trials registration

Trial registration number ClincialTrials.gov: NCT02778425. The URL of the clinical trial: https://clinicaltrials.gov/

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10155-0.

Impact of TIPS on Splenic Volume and Thrombocytopenia

OBJECTIVE. Splenomegaly and thrombocytopenia are common complications in patients with cirrhosis. The present study aimed to evaluate changes in splenic volumes and platelet counts after TIPS insertion. MATERIALS AND METHODS. A total of 104 patients who had a diagnosis of portal hypertension and had undergone TIPS placement between November 2015 and August 2019 were enrolled in this retrospective cohort study. We retrospectively calculated splenic volumes before TIPS placement and at 1-2 and 6-12 months after TIPS placement and monitored the platelet count at 1, 3, 6, and 12 months after TIPS placement. RESULTS. The mean (± SD) portal pressure gradient before TIPS placement was 28.3 ± 4.6 mm Hg; after TIPS placement, it was 11.3 ± 4.5 mm Hg (p < .001). The mean splenic volume of all 104 patients before TIPS placement was 868 ± 409 cm³, and at 1-2 months after TIPS placement, it was 710 ± 336 cm³ (p < .001). Among the 43 patients for whom splenic volume data were available at both 1-2 and 6-12 months after TIPS placement, the mean splenic volume decreased from 845 ± 342 cm³ to 691 ± 301 cm³ and then to 674 ± 333 cm³, respectively. Correspondingly, the number of patients with severe thrombocytopenia decreased from 25 patients (35.7%) before the TIPS procedure to 16 patients (22.9%) in the 1-2 months after TIPS placement and then to 11 patients (15.7%) in the 6-12 months after TIPS implantation. The increase in the platelet count was significantly correlated with decreasing splenic volume (r² = 0.3735; p < .001). CONCLUSION. In most patients, TIPS placement resulted in a significant decrease in splenic volume and a significant increase in the platelet count during the same period.

Role of partial splenic artery embolization in corpuscular correction in cirrhotic patients before anti-viral therapy: a recent update study among Egyptian patients

Background

To evaluate the role of partial splenic artery embolization in corpuscular correction in cirrhotic patients.

Results

Bleeding tendency was experienced in two thirds of patients (66.7%) and anemia in 63.3%. Splenic size ranged from 14.3 to 22 cm. PV diameter ranged from 11 to 18 mm. The mean platelet at the pre-operative laboratory was 34.9 ± 10.3 × 103, corrected to 137.6 ± 37.1 × 103 within 1 month follow-up, and then 140 × 103 after 6 months. The mean of RBCs was 3.6 ± 0.3 × 106, then 4 ± 0.5 × 106 at 1 month follow-up period. WBCs showed correction at the early post-operative period, 3.3 ± 0.4 × 103, compared to 5.4 ± 1.4 × 103 at 1 month. Reduction in splenic size was achieved by 3–6 months. All patients (100%) had post-embolization syndrome. Gelfoam was used in 20 patients, PVA was used in 5 patients, and microspheres were used in 5 patients. Antiviral treatment regimen was started after an adequate rise in corpuscular counts in all patients.

Conclusion

Partial splenic artery embolization is an effective alternative method to surgery in treatment of hypersplenism particularly in cirrhotic patients prepared for antiviral treatment with correction of the associated thrombocytopenia.

Adverse Events Related to Partial Splenic Embolization for the Treatment of Hypersplenism: A Systematic Review

Partial splenic embolization is a common procedure that reduces thrombocytopenia in patients with hypersplenism. The present review evaluated the adverse event profile of partial splenic embolization detailed in 30 articles. Although the technical success rate of the procedure in these papers is high, many patients experienced postprocedural complications. Minor complications such as postembolization syndrome occurred frequently. Major complications were less frequent but sometimes resulted in mortality. Underlying liver dysfunction and high infarction rates may be risk factors leading to major complications. Interventional radiologists should be aware of the complication profile of this procedure and further advance research in techniques dealing with hypersplenism.

Biodegradable Polymers as Drug Delivery Systems for Bone Regeneration

Regenerative medicine has been widely researched for the treatment of bone defects. In the field of bone regenerative medicine, signaling molecules and the use of scaffolds are of particular importance as drug delivery systems (DDS) or carriers for cell differentiation, and various materials have been explored for their potential use. Although calcium phosphates such as hydroxyapatite and tricalcium phosphate are clinically used as synthetic scaffold material for bone regeneration, biodegradable materials have attracted much attention in recent years for their clinical application as scaffolds due their ability to facilitate rapid localized absorption and replacement with autologous bone. In this review, we introduce the types, features, and performance characteristics of biodegradable polymer scaffolds in their role as DDS for bone regeneration therapy.

Long-term outcomes of elective transcatheter dense coil embolization for splenic artery aneurysms: a two-center experience

Objective

This study was performed to analyze the long-term follow-up safety and efficacy of transcatheter dense coil embolization for splenic artery aneurysms.

Methods

Thirty-two patients (18 women, 14 men; age range, 23–56 years; mean age, 43.1 ± 13.6 years) who underwent dense coil embolization for treatment of splenic artery aneurysms from August 2010 to January 2018 were retrospectively reviewed. The size and location of the splenic artery aneurysms, the technical and clinical outcomes of the procedure, and the complications related to the procedure were reviewed.

Results

The technical success rate of embolization was 100% (mean aneurysm size, 29.4 ± 6.9 mm; range, 20–43 mm). Two (6.3%) patients underwent a successful repeat intervention procedure for recurrent aneurysm perfusion during follow-up (mean, 36 months; range, 6–72 months). No aneurysm ruptured during follow-up. Splenic infarction was observed in 8 of 32 (25%) patients. No patients developed major adverse events related to the procedure, such as splenic abscess or pancreatitis.

Conclusions

Percutaneous elective transcatheter dense coil embolization is safe and effective to prevent aneurysm rupture and overcome aneurysm recanalization during long-term follow-up.

Long-Term Efficacy and Safety of Partial Splenic Embolization in Hepatocellular Carcinoma Patients with Thrombocytopenia Who Underwent Transarterial Chemoembolization

BACKGROUND

Performing transarterial chemoembolization (TACE) is difficult with the occurrence of thrombocytopenia in cirrhotic patients with hepatocellular carcinoma (HCC). We aimed to evaluate the long-term efficacy and safety of partial splenic embolization (PSE) combined with TACE in patients with HCC with severe thrombocytopenia related to splenomegaly.

METHODS

We conducted a case-control study consisting of 18 HCC patients with severe thrombocytopenia (< 50 × 10⁹/L) who underwent PSE concurrently with TACE (PSE group) and 72 controls who underwent TACE alone (non-PSE group).

RESULTS

Mean platelet counts at 1 month and 1, 3, and 5 years after concurrent PSE and TACE significantly increased compared with baseline (all P < 0.05), whereas the platelet count did not significantly increase after TACE alone. In addition, the platelet count at several time points after treatment in the PSE group was significantly higher than that in the non-PSE group, although the baseline platelet count in the PSE group was significantly lower than that in the non-PSE group. The platelet increase after PSE significantly reduced the need for platelet transfusions (P = 0.040) and enabled the subsequent TACE procedures in time (P = 0.046). The leukocyte counts and hemoglobin concentrations after concurrent PSE and TACE were also significantly increased, without deterioration of Child-Turcotte-Pugh score and unexpected side effects.

CONCLUSION

PSE combined with TACE is effective in inducing and maintaining long-term thrombocytopenia improvement which reduces the need for the platelet transfusion and helps to perform initial and serial TACE, and is well-tolerated in patients with HCC and thrombocytopenia. PSE may be a promising treatment option for HCC patients with severe thrombocytopenia associated with splenomegaly who will undergo TACE.

Partial Splenic Embolization Is a Safe and Effective Alternative in the Management of Portal Hypertension in Children

OBJECTIVE

There are multiple approaches to manage the clinical complications of portal hypertension (PHTN) to treat/prevent spontaneous hemorrhage by mitigating thrombocytopenia. No single approach is ideal for all patients given the heterogeneity of this population. Our goal was to determine whether partial splenic embolization (PSE) was safe and effective in the pediatric population.

METHODS

This is a retrospective review of our single-center experience for all patients ages 0 to 21 who underwent PSE between January 2010 and August 2017. The embolized splenic volume targeted was 60% to 70%.

RESULTS

Twenty-six patients underwent PSE due to thrombocytopenia and/or recurrent variceal bleeding. Patients ranged in age from 18 months to 20 years (mean 13.1 years). The median platelet count before PSE was 53.0 (×10/L). The platelet count improved after PSE with values >100,000 in 21 patients (80.8%). Children with prior esophageal varices showed improvement after PSE with only 9 (34.6%) requiring further endoscopic therapy. After PSE, patients developed transient abdominal pain, distention, fever, and perisplenic fluid collections. Serious complications such as splenic abscess, splenic rupture, bleeding, pancreatic infarction, opportunistic infection, or death were not observed. One patient experienced thrombotic complications after PSE and was later diagnosed with myelodysplastic syndrome.

CONCLUSIONS

PSE is a safe and effective alternative in the management of pediatric PHTN in select populations. PSE may be a favorable alternative to splenectomy and portal systemic shunting because it preserves functional spleen mass and avoids postprocedure accelerated liver disease or encephalopathy.

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

PURPOSE

Splenic abscesses represent a major complication following splenic artery embolization. The purpose of this study was to assess the effectiveness of intra-arterial antibiotics administered during splenic artery embolization in reducing splenic abscess formation.

MATERIALS AND METHODS

406 patients were screened. 313 (77.1%) patients who underwent splenic artery embolization and were >18 years old were included. Mean age of the cohort was 58 ± 15 years (range: 18-88 years). There were 205 (65.5%) male patients and 108 (34.5%) female patients. 197 (62.9%) patients underwent embolization without intra-arterial antibiotics and 116 (37.1%) patients underwent embolization with 1 g ampicillin and 80 mg gentamicin administered in an intra-arterial fashion. Primary outcome was splenic abscess formation. Secondary outcomes included type of splenic artery embolization, embolic agent, and technical success.

RESULTS

Partial splenic embolization was performed in 229 (73.1%) patients. Total splenic embolization was performed in 84 (26.8%) patients. Platinum coils were the most commonly used embolic agent overall (n = 178; 56.9%) followed by particulates (n = 114; 36.4%). Embolization technical success was achieved in 312 (99.7%) patients. 7 (3.6%) splenic abscesses were detected in the non-intra-arterial antibiotic group and 1 (0.9%) in the intra-arterial antibiotic cohort (P = 0.27). Coils were found to be statistically more likely to result in splenic abscesses than any other embolic agent (P = 0.03). Mean time to abscess identification was 74 days ±120 days (range: 9-1353 days).

CONCLUSION

Splenic abscesses occurred more frequently in patients who did not receive intra-arterial antibiotics during splenic embolization; however, this did not reach statistical significance.

Thrombocytopenia in chronic liver disease

Thrombocytopenia is a common haematological disorder in patients with chronic liver disease. It is multifactorial and severity of liver disease is the most influential factor. As a result of the increased risk of bleeding, thrombocytopenia may impact upon medical procedures, such as surgery or liver biopsy. The pathophysiology of thrombocytopenia in chronic liver disease has long been associated with the hypothesis of hypersplenism, where portal hypertension causes pooling and sequestration of all corpuscular elements of the blood, predominantly thrombocytes, in the enlarged and congested spleen. Other mechanisms of importance include bone marrow suppression by toxic substances, such as alcohol or viral infection, and immunological removal of platelets from the circulation. However, insufficient platelet recovery after relief of portal hypertension by shunt procedures or minor and transient recovery after splenic artery embolization have caused many to question the importance and relative contribution of this mechanism to thrombocytopenia. The discovery of the cytokine thrombopoietin has led to the elucidation of a central mechanism. Thrombopoietin is predominantly produced by the liver and is reduced when liver cell mass is severely damaged. This leads to reduced thrombopoiesis in the bone marrow and consequently to thrombocytopenia in the peripheral blood of patients with advanced-stage liver disease. Restoration of adequate thrombopoietin production post-liver transplantation leads to prompt restoration of platelet production. A number of new treatments that substitute thrombopoietin activity are available or in development.

Effects of phased joint intervention on Rho/ROCK expression levels in patients with portal hypertension

The current study investigated the effects of phased joint intervention on clinical efficacy and Rho/Rho-associated coil protein kinase (ROCK) expression in patients with portal hypertension complicated by esophageal variceal bleeding (EVB) and hypersplenism. Patients with portal hypertension (n=53) caused by liver cirrhosis complicated by EVB and hypersplenism treated with phased joint intervention were assessed, and portal hemodynamics, blood, liver function, complications, and rebleeding incidence were analyzed. Reverse transcription-quantitative polymerase chain reaction was used to measure Rho, ROCK1 and ROCK2 mRNA expression levels in peripheral blood mononuclear cells prior to and following phased joint intervention, and western blotting was employed to determine the protein expression levels of Rho, ROCK1, ROCK2, phosphorylated (p) myosin phosphatase target subunit 1 (MYPT1) and total-MYPT1. All patients underwent an emergency assessment of hemostasis with a 100% success rate. Varicose veins were alleviated, and portal hemodynamics and liver function improved following intervention. Furthermore, preoperative and postoperative expression levels of Rho, ROCK1 and ROCK2 mRNA were higher compared with the control group. Notably, the mRNA expression levels of Rho, ROCK1 and ROCK2 in the postoperative group were significantly lower when compared with the preoperative group. Protein expression levels of Rho, ROCK1, ROCK2 and pMYPT1 in the postoperative group were lower, as compared with the preoperative group. Concentration levels of transforming growth factor-β1, connective tissue growth factor and platelet-derived growth factor in peripheral blood were significantly reduced following phased joint intervention. Therefore, the present findings demonstrated that phased joint intervention is able to effectively treat EVB and hypersplenism, and improve liver function. The efficacy of phased joint intervention may be associated with its role in the regulation of the Rho-ROCK signaling pathway.

Portal and splanchnic hemodynamics after partial splenic embolization in cirrhotic patients with hypersplenism

To assess the acute effects of partial splenic embolization (PSE) on portal and splanchnic hemodynamics in patients with cirrhosis. Ninety-five patients with hypersplenism were included in the study. Duplex examinations were performed before and 3 and 7 days after PSE. Portal and splanchnic hemodynamics including vessel cross-sectional area (CSA), mean flow velocities (cm/s), blood flows (mL/min), Doppler indices as portal congestion index (CI), liver vascular index, hepatic artery and superior mesenteric artery (SMA) pulsatility and resistive indices (PI and RI), were performed before and after PSE. In our study, 69 of 95 patients were males (72.6%) and 26 females (27.3%). Chronic hepatitis C virus infection was the main cause of cirrhosis (81.1%). PSE failed technically in six patients (6.3%). After PSE, both CSA and CI significantly decreased (p < 0.05 and <0.01). The portal vein velocity significantly increased (p < 0.01). The portal flow volume (892.4 ± 151 mL/min) did not show significant changes. The hepatic artery RI and PI showed a steady increase that became significant 7 days post-PSE (p < 0.05). The RI and PI of SMA increased significantly after 7 days of PSE (p < 0.05). PSE has an immediate portal decompression effect in patients with portal hypertension without reduction in portal flow. This effect on portal pressure should be investigated in future studies as a potential tool for management of acute variceal bleeding when other medical procedures fail.

A Comparative Study of Surgical Splenectomy, Partial Splenic Embolization, and High-Intensity Focused Ultrasound for Hypersplenism

OBJECTIVES

This study compared splenectomy, partial splenic embolization, and high-intensity focused ultrasound (HIFU) therapy, which represent the traditional, mature, and newest methods for improving thrombocytopenia in hypersplenism, respectively.

METHODS

A total of 69 patients with hypersplenism were treated with surgical splenectomy (n = 31), HIFU (n = 26), or partial splenic embolization (n = 12). They were followed closely for at least 6 months, and the effectiveness of the treatments was compared.

RESULTS

Among the 3 groups, splenectomy was the most effective treatment for increasing peripheral blood cells. Embolization reduced the operating time and hospital stay, but HIFU was relatively safer and less invasive than the other treatments.

CONCLUSIONS

High-intensity focused ultrasound has wide clinical indications for hypersplenism and may be safer than other treatment methods. Therefore, it is a good alternative procedure for patients with a high surgical risk.

An Overview of Splenic Embolization

OBJECTIVE

The purpose of this article is to define the role of splenic embolization in trauma patients and in patients presenting for treatment of thrombocytopenia and portal hypertension. This article reviews the indications, technical considerations, outcomes, and complications of splenic artery embolization.

CONCLUSION

Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries and as an adjunctive procedure in the treatment of thrombocytopenia and portal hypertension.

Portal hypertension: a review of portosystemic collateral pathways and endovascular interventions

The portal vein is formed at the confluence of the splenic and superior mesenteric vein behind the head of the pancreas. Normal blood pressure within the portal system varies between 5 and 10 mmHg. Portal hypertension is defined when the gradient between the portal and systemic venous blood pressure exceeds 5 mmHg. The most common cause of portal hypertension is cirrhosis. In cirrhosis, portal hypertension develops due to extensive fibrosis within the liver parenchyma causing increased vascular resistance. In addition, the inability of the liver to metabolise certain vasodilators leads to hyperdynamic splanchnic circulation resulting in increased portal blood flow. Decompression of the portal pressure is achieved by formation of portosystemic collaterals. In this review, we will discuss the pathophysiology, anatomy, and imaging findings of spontaneous portosystemic collaterals and clinical manifestations of portal hypertension with emphasis on the role of interventional radiology in the management of complications related to portal hypertension.

Thrombocytopenia due to hypersplenism in oncological disease: partial splenic embolization during palliative treatment

Hypersplenism is excess activity of the spleen, resulting in peripheral pancytopenia that predominates in platelet cell lines. Pancytopenia can be limited by reducing the volume of the functional spleen. However, in patients in very poor general condition, a splenectomy may not be possible, due to the risks of surgery and postoperative infection. Another therapeutic alternative in these patients is to reduce the volume of the spleen by super selective percutaneous splenic embolization. We report three cases of peripheral thrombocytopenia due to hypersplenism with a platelet count between 60,000 and 80,000/mm(3), which made it impossible to continue or start a chemotherapy protocol in these patients. For these patients, super selective partial embolization of the splenic parenchyma, with uncharged microspheres (250 microns) quickly resulted in a platelet count above 150,000/mm(3) so that chemotherapy could be continued or initiated.

β-Blocker therapy ameliorates hypersplenism due to portal hypertension in children

BACKGROUND/PURPOSE

Thrombocytopenia due to hypersplenism precludes percutaneous liver biopsy in many cases of chronic liver disease (CLD). The aim of this study was to assess the efficacy of propranolol in correcting platelet counts (>100,000/mm(3)) to ensure percutaneous liver biopsy in children with CLD.

METHODS

From January 2005 to December 2012, 51 consecutive children (mean age 11.5 ± 3.0 years, 34 boys) with CLD who needed liver biopsy but could not be done due to hypersplenism-related thrombocytopenia (platelets <100,000/mm(3) and/or total leukocyte counts <4,000/mm(3) with splenomegaly) were recruited and given a 4-week trial of long-acting propranolol (1.5-2 mg/kg/day). Hemodynamic parameters and splenic artery hemodynamics by Doppler ultrasound were recorded before and after the propranolol trial. Response to therapy was defined as improvement of platelet counts to ≥10(5)/mm(3).

RESULTS

Thirty-two (62.7%) children responded to propranolol therapy and their mean platelet counts increased from 57.5 ± 13.0 × 10(3) to 140.7 ± 43.3 × 10(3)/mm(3), p = 0.0001. Liver biopsy could be done in 29. While comparing responders with non-responders, baseline spleen size (7.4 ± 3.3 vs. 12.7 ± 4.5 cm, p = 0.0001) and platelet counts (57.5 ± 13.0 × 10(3) vs. 39.5 ± 14.5 × 10(3), p = 0.0001) were found to be significant. ROC curve suggested a cut-off value of ≤8.5 cm of spleen and ≥53,000 platelets as predictors of response. With propranolol, mean arterial pressure and spleen size reduced (p < 0.05) and splenic artery resistance increased significantly (p = 0.005) in responders.

CONCLUSIONS

Propranolol corrects thrombocytopenia and makes liver biopsy possible in almost two-thirds of cases by reducing splenic sequestration through splenic artery vasoconstriction. The baseline spleen size and platelet counts determine the effectiveness of therapy. A trial of β-blocker is worth carrying out in cases where liver biopsy is contraindicated due to hypersplenism-related thrombocytopenia.

High-intensity focused ultrasound ablation: an effective and safe treatment for secondary hypersplenism

OBJECTIVE

Hypersplenism is a common disease. The conventional treatment is splenectomy and partial splenic embolization; however, both of them have high complication rates and technical defects. Therefore, safer and more effective techniques should be considered for the treatment of hypersplenism. High-intensity focused ultrasound (HIFU) may provide an effective and safe way for treatment of hypersplenism. Therefore, we conducted this study to assess the safety and efficacy of HIFU in treatment of secondary hypersplenism.

METHODS

A total of 28 patients who suffered from secondary hypersplenism were treated with HIFU ablation. All patients who underwent HIFU were closely followed-up over a year. MRI scan was performed, and the spleens were observed. Blood counts and liver function tests were also carried out.

RESULTS

In the follow-up process, the levels of white blood cells and platelets in the blood after HIFU were significantly higher than those before HIFU, liver function also improved after HIFU treatment. In addition, the symptoms were ameliorated significantly or even disappeared. The MRI showed that the ablation area had turned into a non-perfused volume, and after 12 months of HIFU ablation, the ablated area shrank evidently; the sunken spleen formed a lobulated shape and the splenic volume decreased.

CONCLUSION

HIFU ablation is a safe, effective and non-invasive approach for secondary hypersplenism.

ADVANCES IN KNOWLEDGE

For the first time we used HIFU ablation to treat secondary hypersplenism. It not only expands indications of HIFU but also provides better choice for the treatment of secondary hypersplenism.

Effects of phased joint intervention on IL-35 and IL-17 expression levels in patients with portal hypertension

The aim of the present study was to investigate the clinical efficacy of phased joint intervention [percutaneous transhepatic variceal embolization (PTVE) + phased partial splenic embolization (PSE)] in patients with portal hypertension complicated by esophageal variceal bleeding and hypersplenism and the effect of this intervention on interleukin-35 (IL-35)/IL-17 expression. A review of 53 patients with portal hypertension caused by liver cirrhosis and complicated by esophageal variceal bleeding and hypersplenism treated with phased joint intervention was conducted, and portal hemodynamics, routine blood examinations and liver function were determined. Quantitative polymerase chain reaction (qPCR) was used to evaluate EBI3, FOXP3 and IL-17 mRNA expression levels in peripheral blood mononuclear cells (PBMC) before and after the phased joint intervention, while western blot analysis was used to determine their protein expression. All 53 patients required emergency hemostasis resulting in an emergency hemostatic rate of 100%. Varicose veins disappeared, portal hemodynamics and liver function improved subsequent to the intervention. The expression levels of EBI3, FOXP3 and IL-17 mRNA in the postoperative group were significantly lower than the preoperative levels (P<0.01). The protein expression levels of EBI3, FOXP3 and IL-17 in the postoperative group were reduced compared with the preoperative levels. The concentrations of IL-35, IL-6 and IL-17 in peripheral blood were significantly reduced after the phased joint intervention (P<0.01). Serum IL-35, IL-6 and IL-17 levels were positively correlated with total bilirubin and international normalized ratio, and negatively correlated with albumin. The phased joint intervention can effectively treat esophageal variceal bleeding and hypersplenism, and improve liver function. The efficacy of this intervention may be associated with the regulation of immune function.

Guidelines on the use of gelatin sponge particles in embolotherapy

Gelatin sponge (GS) is one of the most widely used embolic agents in interventional procedures. There are four commercially available GS products in Japan; however, the endovascular use of Gelfoam and Spongel is off-label, and Gelpart can only be used for hepatic artery embolization and Serescue can only be used for hemostasis of arterial bleeding. GS has been used for a variety of clinical indications, mainly tumor embolization and stopping massive arterial bleeding. The optimal size and preparation procedure of GS particles differs slightly for each clinical indication. In addition, there is a risk of ischemic and/or infectious complications associated with GS embolization in various situations. Therefore, radiologists should be familiar with not only the preparation and handling of GS particles, but also the disadvantages and potential risks, in order to perform GS embolization safely and effectively.

Long-term dynamics of hematological data and spleen volume in cirrhotic patients after liver transplantation-various dynamics depending on etiology

Background

Hypersplenism is a common complication in cirrhotic patients, and liver transplantation would be one of the effective treatments. However, detailed dynamics, especially over a long term, are not fully understood. We investigated the long-term dynamics of hematological data and spleen volumes, as well as their correlation in cirrhotic patients who underwent liver transplantation.

Patients and methods

We studied 53 cirrhotic patients who underwent liver transplantation at our institute and followed for more than 1 year. Hematological data were collected from medical records, while spleen volumes were determined by CT volumetry at 0, 1, 3, 6, 12, 24, 36, 48, 60 postoperative months (POM).

Results

(1) Platelet (Plt) and hemoglobin (Hb) levels were gradually increased up to 18 and 10 POM, respectively, in contrast with white blood cells (WBC), which remained mostly unchanged from pretransplantation levels. (2) Spleen volume was sharply decreased in the first POM, then showed a slower but steady decline up to 48 POM. (3) Spleen volume was significantly correlated with hematological data, though the levels were generally weak (Plt: r = 0.433, p < 0.001; Hb: r = 0.233, p < 0.001; WBC: r = 0.217, p = 0.001). (4) Spleen volume was strongly correlated with all hematological parameters in HBV patients (Plt: r = 0.617, p < 0.0001; Hb: r = 0.401, p < 0.001; WBC: r = 0.387, p < 0.001), in contrast with that in other etiologies, which had generally weak correlations though some were statistically significant.

Conclusions

We investigated the long-term dynamics of hematological data and spleen volume in cirrhotic patients after liver transplantation. Unique dynamics and correlations between them were found among the different etiologies investigated.

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

BACKGROUND

Partial splenic artery embolization is an effective treatment for hypersplenism but often lacks long-term benefits.

PURPOSE

To evaluate the long-term effects of coil embolization of the splenic artery in patients with liver cirrhosis and hypersplenism.

MATERIAL AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Coated transjugular intrahepatic portosystemic shunt does not improve thrombocytopenia in patients with liver cirrhosis

BACKGROUND/AIM

Thrombocytopenia is a common complication of chronic liver disease. The theory of portal decompression to improve thrombocytopenia due to hypersplenism has led to the study of transjugular intrahepatic portosystemic shunt (TIPS) as a potential therapy. However, there is a paucity of data and results have been conflicting. The aim of this study was to determine whether platelet counts improved in cirrhotic patients after placement of the new polytetrafluoroethylene (PTFE)-coated TIPS, developed in 2004.

METHODS

This is a retrospective cohort study of 68 patients with chronic liver disease who underwent a TIPS procedure. One-hundred twenty controls who did not undergo a TIPS procedure were matched on average for age, sex, race, model for end-stage liver disease (MELD) score, and etiology of liver disease. Platelet and hemoglobin counts were recorded during the month prior to the TIPS procedure (baseline) and over the following 12-14 months or until transplanted or death.

RESULTS

While platelet counts improved during the first 3 months after TIPS with a mean increase of 11.25 × 103/μL (p = 0.064), they returned to baseline (pre-TIPS) with mean platelets of 91.31 × 103 μL by 12-14 months in comparison with a mild decrease of 10.2 × 103 μL in platelet counts in the control group from 100.4 × 103 μL to 90.2 × 103 (p = 0.119). There was also no significant correlation between platelet counts and etiology of liver disease, age, race, gender, or MELD score. Hemoglobin counts were found to have a small increase of 0.657 g/dL over the 12-14 month course in the TIPS group, which was statistically significant (p = 0.003).

CONCLUSION

There does not appear to be a significant improvement in thrombocytopenia in cirrhotic patients after TIPS placement, despite advances in TIPS stents. However, there may be a mild improvement in anemia after TIPS implantation.

Single-center experience with elective transcatheter coil embolization of splenic artery aneurysms: technique and midterm follow-up

PURPOSE

To review a single-center experience with elective coil embolization of splenic artery aneurysm (SAA) and analyze efficacy of the technique at midterm follow-up.

MATERIALS AND METHODS

From 2002 through 2011, 50 patients (28 women, 22 men; age range, 24-89 y; mean age, 53.5 y ± 13.6) underwent transcatheter coil embolization for treatment of SAAs. Pseudoaneurysms and ruptured aneurysms were excluded. A total of 63 SAAs were treated (size, 13-97 mm; mean, 29 mm). Ninety-eight percent of aneurysms were treated with coils alone. Regular follow-up consisted of an office visit and imaging. Patient medical records were reviewed for aneurysm location, procedural approach, and technical and clinical outcomes.

RESULTS

Ninety-eight percent of procedures were technically successful at thrombosing the aneurysm at the time of procedure. Repeat intervention was performed in four of 47 patients (9%) because of continued aneurysm perfusion at follow-up. Mean time to repeat intervention was 125 days (range, 42-245 d). All repeat interventions were technically successful. Neither aneurysm growth nor aneurysm rupture was observed in any patient during the follow-up period (mean, 78 weeks; range, 9 d to 7.1 y). There were no major adverse events. Major splenic infarction occurred in three of 33 patients (9%) with no underlying liver disease and normal splenic volume and in seven of 14 patients (50%) with portal hypertension.

CONCLUSIONS

Percutaneous transcatheter coil embolization is a safe, effective, and minimally invasive treatment for SAAs as evidenced by high rates of technical success and freedom from aneurysm rupture.

Simultaneous combined balloon-occluded retrograde transvenous obliteration and partial splenic embolization for portosystemic shunts

PURPOSE

To evaluate the efficacy and safety of simultaneous combined balloon-occluded retrograde transvenous obliteration (B-RTO) and partial splenic embolization (PSE) for gastric varices and/or hepatic encephalopathy.

MATERIALS AND METHODS

B-RTO was performed in 19 consecutive patients with gastric varices and/or hepatic encephalopathy, of whom 10 received simultaneous combined B-RTO and PSE (group 1) and nine received B-RTO monotherapy (group 2). To evaluate the safety of these techniques, we analyzed 20 patients who received PSE monotherapy during the same period as a control group (group 3). Outcomes were retrospectively assessed.

RESULTS

No significant differences were observed in baseline characteristics among the three groups except for significantly lower platelet counts and larger spleen volumes in group 3. In all cases in groups 1 and 2, gastric varices disappeared and hepatic encephalopathy improved after treatment. Procedure times were not significantly different between groups 1 and 2 (P = .7435). In group 1, the volume of sclerosing agent required for B-RTO was significantly lower (P = .0355) and exacerbation of esophageal varices was significantly less frequent (P = .0146) than in group 2. Few serious complications occurred in patients who received combined therapy.

CONCLUSIONS

This study indicates that concomitant PSE may help diminish the increase in portal venous pressure after B-RTO for portosystemic shunts, and may allow a reduction in the volume of hazardous sclerosing agent used. It is worth evaluating the efficacy of simultaneous B-RTO and PSE in a prospective study.

Laparoscopic splenectomy with interferon therapy in 100 hepatitis-C-virus-cirrhotic patients with hypersplenism and thrombocytopenia

BACKGROUND AND AIM

We intended to determine whether laparoscopic splenectomy (Lap-Sp) contributes to treatment with interferon therapy in hepatitis C virus (HCV)-cirrhotic patients with thrombocytopenia caused by hypersplenism.

METHODS

From December 2004 to August 2008, 100 cirrhotic patients (54 men and 46 women) underwent Lap-Sp for a clinical application of interferon therapy. All the patients were Child-Pugh class A or B with thrombocytopenia (average platelet count, 56 × 10(3) /mm(3)). The HCV genotype was type 1 in 80 patients and type 2 in 20 patients.

RESULTS

Pure laparoscopic or hand-assisted laparoscopy was performed in 78 and 22 patients, respectively, without mortality. Conversion to open surgery was not required in any of the patients. The platelet counts improved (mean platelet count 172 × 10(3) /mm(3) 1 month after surgery) and interferon (IFN) therapy was started in 97 patients. In this study period, 36 patients obtained a sustained virologic response. Eight patients discontinued IFN therapy because of depression, neutropenia or other reasons.

CONCLUSIONS

Lap-Sp permits most patients with HCV cirrhosis and hypersplenism to receive sufficient IFN therapy. Therefore, Lap-Sp can become a strong supportive surgery for cirrhotic patients who require antiviral therapy.

Partial splenic embolization using Bletilla striata particles for hypersplenism in cirrhosis: a prospective study

The article evaluates the long-term follow-up results of PSE using Bletilla striata (BS) particles for hypersplenism in cirrhosis, as compared to PSE using gelfoam particles. Fifty-nine patients with cirrhosis-induced hypersplenism were treated with PSE. The patients were randomly assigned into two groups: gelfoam group, which includes 32 patients using gelfoam particles as the embolic material, and BS group, which includes 27 patients using BS particles. The peripheral blood cell counts and parameters for complications associated with PSE were measured during the follow-up. The mean values of leukocyte and thrombocyte, but not hemoglobin, were significantly increased after PSE (p < 0.01) in both groups. The values of leukocyte and thrombocyte during the long-term follow-up were significantly improved in BS group than that in gelfoam group (both p < 0.01). The frequency of bleeding episodes from esophageal varices in both groups was significantly reduced after PSE (both p < 0.01), but the post-PSE bleeding episodes showed no remarkable differences between the two groups (p = 0.084). Post-embolization syndrome consisted mainly of fever, nausea and vomiting, and abdominal pain in the two groups. The incidence of grade II to III abdominal pain in BS group (82.8%, 27/33) was significantly higher than in gelfoam group (57.9%, 33/57) (p = 0.020). The mean survival time was 61.5 ± 9.1 (median 60, 1-157) months in gelfoam group and 63.4 ± 9.9 (median 52, 0-161) months in BS group, which showed no significant difference (p = 0.930). In conclusion, BS particles could be used as the embolic material in PSE. Compared to gelfoam used in PSE, BS can achieve even better efficacy in alleviating hypersplenism. It provides a long-term effect on the hematological parameters, bleeding from esophageal varices and good palliation, and improved clinical status contributing to symptomatic control.