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

A Sri Lankan child with hypersplenism secondary to pre-hepatic portal hypertension, successfully managed with partial splenic artery embolization: a case report and review of the literature

Background

Hypersplenism, one of the major complications of portal hypertension, is traditionally treated by splenectomy. However, partial splenic artery embolization is an evolving minimally invasive intervention to treat these patients effectively.

Case presentation

A 13-year-old girl was referred for further evaluation of isolated splenomegaly with pancytopenia. She did not have bleeding manifestations or features of anemia. She never had hematemesis or melena. On examination, she was pale. Abdominal examination revealed massive splenomegaly of 10 cm below the costal margin without hepatomegaly. Rest of the examination was unremarkable. Her investigations revealed a white cell count of 1700/mm3 (neutrophils 9.8% and lymphocytes 88.7%), hemoglobin 9.5 g/dL and platelet count 42,000/mm3. Blood picture showed pancytopenia without abnormal cells. Her reticulocyte count was 1.9%. Complete liver profile was normal. Abdominal ultrasonography revealed massive splenomegaly with the oblique length of 17 cm and normal echogenic liver with normal size. Cavernous transformation of portal vein with portal hypertension was evident. Mesenteric angiogram showed portal vein thrombosis and markedly tortuous splenic artery. Anti-nuclear antibodies and double-stranded DNA were negative. Ham test and urine for hemosiderin were negative. Clauss fibrinogen assay was normal. Hemoglobin high performance liquid chromatography for hemoglobin subtypes was normal. Anti-phospholipid antibodies were negative. JAK2 V617F mutation was not identified. Diagnosis of pre hepatic portal hypertension was made. Her upper gastrointestinal endoscopy was normal. Partial splenic artery coil embolization was done by interventional radiology team. Vaccines against capsulated organisms were given. Post-procedure contrast abdominal computed tomography revealed infarction of approximately 70% of the spleen and blood counts were improved. Index case is in the follow up for 3 years. She is on penicillin prophylaxis with regular blood count and annual upper gastrointestinal endoscopy monitoring.

Conclusions

Minimally invasive interventions such as partial splenic artery embolization should be considered in managing the patients with hypersplenism secondary to portal hypertension.

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.

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.

Splenic artery embolization with detachable balloons for hypersplenism

Objective

This study was performed to investigate the efficacy of proximal splenic artery embolization using detachable balloons for patients with hypersplenism and portal hypertension.

Methods

Twelve patients diagnosed with hypersplenism with thrombocytopenia or leukocytopenia caused by portal hypertension were treated by proximal splenic artery embolization with detachable balloons and metallic fibered coils. All patients were followed for up to 6 months. Blood parameters, coagulation factors, and liver function indicators were measured. Enhanced computed tomography and abdominal ultrasonography examinations were also performed in advance to confirm the infarction area and evaluate the changes in spleen size.

Results

Postoperative angiography demonstrated complete embolization of the proximal splenic artery in all 12 patients. Thrombocyte and leukocyte counts rose significantly in all patients in 2 weeks and stayed significantly higher than those before embolization throughout the 6-month follow-up. The total bilirubin concentration and prothrombin activity recovered significantly and returned to normal levels 6 months later. Computed tomography revealed partial infarction and liquefaction of the splenic parenchyma in nine patients.

Conclusions

Proximal splenic artery embolization using detachable balloons could be considered a safe and effective therapeutic modality in alleviating hypersplenism secondary to portal hypertension.

Partial Splenic Artery Embolization to Treat Hypersplenism Secondary to Hepatic Cirrhosis: A Meta-Analysis

This meta-analysis aimed to explore the effectiveness of partial spleen arterial embolization (PSAE) in the treatment of hypersplenism secondary to hepatic cirrhosis. PubMed, Embase, Cochrane Library, Wan Fang, CNKI, Vip, and CBM databases were searched for randomized controlled trials, cohort studies, and case–control studies that compared PSAE with splenectomy in the treatment of hypersplenism secondary to hepatic cirrhosis from their inception to July 25, 2015. Statistical analysis was conducted in Cochrane Network RevMan v5.3. Primary outcomes included the pre- and postoperative platelet and leukocyte counts and hemoglobin levels. Secondary outcomes were operative time, intraoperative volume of bleeding, and length of hospital stay. Mean and standard deviation were obtained from each study and then pooled using fixed- or random-effects models to calculate the mean difference. Ten original studies investigating 737 patients were included. Both the PSAE group and the splenectomy group yielded higher postoperative platelet and leukocyte counts and hemoglobin levels than the preoperative. The difference of platelet and leukocyte counts and hemoglobin levels between postoperative and preoperative levels in the PSAE group was smaller than that in the splenectomy group. Besides, compared with the splenectomy group, the PSAE group exhibited shorter operative time, less intraoperative bleeding, and shorter length of stay. PSAE is a mini-invasive therapy, which can be applied to treat hypersplenism secondary to hepatic cirrhosis effectively, particularly for patients with a poor overall condition. However, further high-quality studies should be conducted because this meta-analysis is limited by the quality of studies and the large statistical heterogeneity.

Microwave ablation in the spleen versus partial splenic artery embolisation: A new technique for hypersplenism in cirrhosis

BACKGROUND AND STUDY AIMS

Splenectomy has been associated with high perioperative morbidity and mortality. Partial splenic artery embolisation (PSE) was found to be an effective and safer method but with numerous complications. Local thermal ablative techniques such as microwave ablation (MWA) have been tried and were found to be safe and effective alternatives. This randomised controlled study aimed to compare the efficacy and safety of MWA versus PSE in the treatment of hypersplenism in patients with post-hepatitis C cirrhosis.

PATIENTS AND METHODS

In total, 40 patients with post-hepatitis C cirrhosis complicated with hypersplenism were randomised into two groups: Group I: 20 patients treated with percutaneous MWA of splenic parenchyma under ultrasound guidance and Group II: 20 patients treated with PSE using Embosphere.

RESULTS

There was a significant increase in haemoglobin levels in group I compared with group II after 3months of follow-up. However, White blood cell (WBC) count and platelets significantly increased more in group II than in group I after 1month. Postprocedure significant hyperbilirubinaemia, hypoalbuminaemia, decreased prothrombin concentration, and increased creatinine levels were encountered in group II only. There was a significant increase in postoperative complications in group II compared to group I, and a single case of mortality was reported in group II.

CONCLUSION

MWA and PSE were comparably effective; however, MWA was safer than PSE, which caused serious adverse events and mortality. MWA appears to be a good alternative for the treatment of hypersplenism in patients with cirrhosis and portal hypertension.

Partial splenic embolization of patients with hypersplenism by transradial or transfemoral approach: a prospective randomized controlled trial

BACKGROUND

Partial splenic artery embolization (PSE) is an effective treatment modality for patients with hypersplenism. It is less invasive and has a quicker recovery compared with surgical procedures. PSE is usually performed using a femoral artery approach that requires bedrest for a few hours, which is rarely the case for transradial PSE.

PURPOSE

To compare the transradial and transfemoral approaches for embolization of spleen in patients with hypersplenism.

MATERIAL AND METHODS

In all, 84 patients with hypersplenism who required PSE were recruited. They were randomly divided into two groups on the basis of the procedure followed: the transradial approach (R-PSE, n = 39) or transfemoral approach (F-PSE, n = 45). Technical success, puncture rate, total procedure time, X-ray exposure time, length of stay in hospital (LOS), and complications of the two groups were recorded.

RESULTS

The procedure time, X-ray exposure time, and LOS were found to be lower in the R-PSE group than in the F-PSE. However, this difference was not statistically significant.

CONCLUSION

The transradial artery approach for PSE in patients with hypersplenism is feasible with no major complications as compared to the femoral approach.

Laparoscopic splenic artery ligation for hypersplenism in cirrhosis: A case series

BACKGROUND:

Splenectomy for the treatment of hypersplenism in patients with cirrhosis (HIC) is related with complications. Laparoscopic splenic artery ligation (LSAL) may be an alternative treatment option.

AIMS:

To evaluate safety and feasibility of LSAL in the treatment of HIC.

PATIENTS AND METHODS:

Retrospective analysis of prospectively collected data of ten patients with HIC who were treated with LSAL from October 2012 to February 2015.

RESULTS:

The median (range) age was 33.2 (13-56) years and sex distribution was equal. The median (range) leukocyte counts (×10⁹/L) before, and at 3, 6 and 12 months after LSAL were 2.2 (0.8-8.2) and 5.65 (2.78-10.7), 4.7 (2.8-7.8) and 4.95 (3.4-7.7) respectively. The median (range) platelet counts (×10⁹/L) before and at 3, 6 and 12 months after LSAL were 25.5 (11-65) and 75 (39-289), 74 (32-184) and 76 (56-251) respectively. Following LSAL, there was a significant improvement in total leucocyte count, platelet count and Model for End-Stage Liver Disease (MELD) score (P < 0.05). Two patients (20%) developed intraoperative bleeding and required conversion; one of these two patients developed splenic cyst that required radiological intervention. Four patients (40%) had post ligation syndrome (PLS) that was managed conservatively. During a median (range) follow-up of 19.5 (5-29) months, one patient (10%) required splenectomy due to inadequate response.

CONCLUSION:

LSAL is a safe and feasible treatment option for the palliation of symptomatic HIC, however, further prospective trials are necessary for confirmation.

A novel method for the angiographic estimation of the percentage of spleen volume embolized during partial splenic embolization

PURPOSE

To evaluate the efficacy of estimating the volume of spleen embolized in partial splenic embolization (PSE) by measuring the diameters of the splenic artery and its branches.

MATERIALS AND METHODS

A total of 43 liver cirrhosis patients (mean age, 62.19±9.65 years) with thrombocytopenia were included. Among these, 24 patients underwent a follow-up CT scan which showed a correlation between angiographic estimation and measured embolized splenic volume. Estimated splenic embolization volume was calculated by a method based on diameters of the splenic artery and its branches. The diameters of each of the splenic arteries and branches were measured via 2D angiographic images. Embolization was performed with gelatin sponges. Patients underwent follow-up with serial measurement of blood counts and liver function tests. The actual volume of embolized spleen was determined by computed tomography (CT) measuring the volumes of embolized and non-embolized spleen two months after PSE.

RESULTS

PSE was performed without immediate major complications. The mean WBC count significantly increased from 3.81±1.69×10(3)/mm(3) before PSE to 8.56±3.14×10(3)/mm(3) at 1 week after PSE (P<0.001). Mean platelet count significantly increased from 62.00±22.62×10(3)/mm(3) before PSE to 95.40±46.29×10(3)/mm(3) 1 week after PSE (P<0.001). The measured embolization ratio was positively correlated with estimated embolization ratio (Spearman's rho [ρ]=0.687, P<0.001). The mean difference between the actual embolization ratio and the estimated embolization ratio was 16.16±8.96%.

CONCLUSIONS

The method provides a simple method to quantitatively estimate embolized splenic volume with a correlation of measured embolization ratio to estimated embolization ratio of Spearman's ρ=0.687.

Radiotherapy versus interventional therapy for hepatogenic hypersplenism: An analysis of 75 cases

AIM: To compare the clinical effects, adverse reactions and hospitalization expenses of external irradiation therapy, three dimensional conformal radiation therapy and interventional therapy for the treatment of hepatogenic hypersplenism.

METHODS: Sixty patients with hypersplenism secondary to liver cirrhosis and 15 patients with hypersplenism secondary to liver cancer were selected. Patients with hypersplenism secondary to liver cirrhosis were divided into two groups: one was treated with external irradiation and the other with interventional therapy. Patients with hypersplenism secondary to liver cancer were treated with three dimensional conformal radiation therapy. Spleen size, blood routine index, adverse reactions and hospitalization expenses were compared among the three groups.

RESULTS: Spleen size was reduced and white blood cell count, hemoglobin and platelet count increased significantly in all the three groups of patients after treatment (all P < 0.05). But no significant differences were observed in spleen size and routine blood parameters between the three groups after treatment (P > 0.05). Fever index and pain index were significantly reduced in the external irradiation and three dimensional conformal radiation therapy groups compared to the interventional therapy group (0.57 ± 0.55, 0.64 ± 0.51 vs 1.80 ± 1.21; 0.36 ± 0.63, 1.67 ± 1.12 vs 4.59 ± 3.22, all P < 0.05). The hospitalization expenses were reduced in the external irradiation group compared to the other two groups.

CONCLUSION: External irradiation and three dimensional conformal radiation therapy can achieve the same effects as the interventional therapy and are associated with reduced side effects and hospitalization expenses in the treatment of hepatogenic hypersplenism.