Partial splenic embolization for hypersplenism before and after liver transplantation

Quantitative splenic embolization possible: application of 8Spheres conformal microspheres in partial splenic embolization (PSE)

BACKGROUND

To investigate the safety and efficacy of 8Spheres in partial splenic embolization. To explore the possibility of accurate control of splenic embolic volume by quantifying the number of microspheres used during PSE.

METHOD

The data of 179 patients who underwent PSE were collected. The patients were divided into two groups: 300-500 um microsphere group (N = 83) and 500-700 um microsphere group (N = 96). The spleen volume before PSE, infarct volume and infarct rate of the spleen after PSE, changes in peripheral blood cells after PSE, postoperative adverse events and incidence of infection were compared between the two groups.

RESULTS

300-500 um group vs 500-700 um group: postoperative spleen volume (cm³): 753.82 ± 325.41 vs 568.65 ± 298.16 (P = 0.008); spleen embolization volume (cm³): 525.93 ± 118.29 vs 630.26 ± 109.71 (P = 0.014); spleen embolization rate: 41.1 ± 12.3% vs 52.4 ± 10.1% (P = 0.021). Leukocytes and platelets were significantly increased after PSE in both groups; leukocyte, 1 month: 4.13 ± 0.91 vs 5.08 ± 1.16 (P = 0.026); 3 months: 4.08 ± 1.25 vs 4.83 ± 0.98 (P = 0.022); platelet, 1 month: 125.6 ± 20.3 vs 138.7 ± 18.4 (P = 0.019); 3 months: 121.8 ± 16.9 vs 134.3 ± 20.1 (P = 0.017). Incidence of abdominal pain after PSE, 72 (86.7%) vs 69 (71.9%), P = 0.027. The incidence of other adverse events and infections after PSE was not statistically different.

CONCLUSION

PSE with 8Spheres is safe and effective. The use of 500-700 um microsphere for PSE can make the increase of peripheral blood cells more stable. Each vial of 8Spheres corresponds to a certain volume of splenic embolization, so it is possible to achieve quantitative embolization in PSE.

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.

Relationship Between Graft Liver Function and the Change of Graft Liver and Spleen Volumes After Technical Variant Liver Transplantation

BACKGROUND

Although there have been a few reports describing the changes of graft liver and spleen volumes after liver transplantation (LT), little is known about the relationship between graft liver function and the changes of these volumes after technical variant liver transplantation (TVLT). We therefore performed a retrospective study to investigate the relationship between graft liver function and these volumes after TVLT.

METHODS

We retrospectively investigated the cases of 140 TVLT procedures that were performed in our department between July 1987 and October 2012 and in which follow-up was conducted at our department. We calculated the graft liver volume to standard liver volume (GV/SLV) ratio, the spleen volume to standard spleen volume (SV/SSV) ratio, and the spleen volume to graft liver volume (S/L) ratio by CT volumetry. We clarified the relationship between graft liver function (according to the pathological findings) and the graft liver and spleen volumes at 2, 5, and 10 years after TVLT.

RESULTS

In the normal liver function group, the GV/SLV, SV/SSV, and S/L ratios decreased until 6 months after TVLT and then converged at 10 years after TVLT to 0.95, 1.27, and 0.27, respectively. In the graft liver failure group, the GV/SLV, SV/SSV, and S/L ratios at 10 years after TVLT were 0.67, 5.01, and 1.55, respectively. A significant correlation was observed between the GV/SLV ratio and the presence of mild liver fibrosis at 2 and 5 years after TVLT (P = .03 and P = .04, respectively).

CONCLUSIONS

Post-transplant CT-volumetry is a noninvasive and effective means of evaluating graft liver status.

Big spleens and hypersplenism: fix it or forget it?

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

Partial splenic artery embolization in cirrhotic patients

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

Splenic Artery Embolization as a Treatment Option for Chronic Pancytopenia Secondary to Hypersplenism

It is well known that splenectomy is the standard of care in the management of clinically significant hypersplenism; however, some patients are found to be unacceptably high risk to tolerate open or even laparoscopic surgery. We present a 62-year-old female with significant comorbidities who was declared a very high risk for any open surgical intervention. She underwent splenic artery embolization with remarkable improvement of her platelet count. Her postoperative course was uneventful and the patient was discharged from the hospital on the fifth hospital day.

Embolization of nonliver visceral tumors

Catheter-directed embolization of visceral tumors, with the exception of the liver, has received limited attention in the literature. The visceral arterial anatomy can be complex and its understanding is critical for procedure planning and limiting complications. Embolization of splenic neoplasms is exceedingly rare. Preoperative embolization for adrenal, renal, and gut tumors plays an important role in select patients. Embolization has been used successfully in the treatment of pancreatic insulinomas and in limited cases of unresectable pancreatic adenocarcinomas. Embolization of bleeding visceral tumors can be accomplished with a high likelihood of success.

Partial splenic embolization

Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.

Hypersplenism induced by splenic vein ligation

Warm autoimmune hemolytic anemia (AIHA) is a rare clinical entity. It is usually caused by an IgG autoantibody directed against the red blood cell membrane that causes extravascular hemolysis predominantly in the spleen. As a result, disease states or procedures that result in hypersplenism would be expected to increase red cell destruction in patients with an underlying warm AIHA. We present the case of a patient with a previously undiagnosed warm AIHA, who developed worsening hemolysis after undergoing splenic vein ligation during a pancreaticoduodenectomy to remove a neuroendocrine tumor.

Splenic embolization in liver transplant recipients: early outcomes

Clinical improvement has been reported following splenic embolization for a wide variety of indications. Improvement following splenic embolization has been described in cirrhotic patients awaiting hepatic transplantation who are not candidates for surgical splenectomy. Occasionally, patients who have undergone hepatic transplantation have conditions that may also benefit from nonsurgical intervention with splenic embolization. Indications include persistent hypersplenism and pancytopenia precluding optimal treatment with antiviral therapy or chemotherapy, risk for persistent gastroesophageal variceal hemorrhage, and splenic artery steal syndrome attenuating hepatic arterial perfusion. Limited data is available on the outcome of splenic embolization in liver transplant recipients. We present the early outcomes of liver transplant recipients who were treated with splenic embolization. A retrospective chart review of all liver transplant recipients who underwent splenic embolization between 1997 and 2006 was performed, under minimal-risk study approval by the institutional review board. Five liver transplant recipients received splenic embolization: 3 for persistent hypersplenism, 1 for increased risk of gastroesophageal variceal hemorrhage, and 1 for splenic artery steal syndrome. The patients with hypersplenism demonstrated hematologic improvement, the patient with gastroesophageal varices did not experience any hemorrhage on follow-up, and the patient with splenic artery steal experienced resolution of the steal phenomenon. Postembolization syndrome was observed but no splenic abscess or death occurred. Mean follow-up was 20.2 months. In conclusion, splenic embolization is a safe and effective nonsurgical alternative for a variety of indications in liver transplant recipients.

Use of splenic artery embolization to relieve tense ascites following liver transplantation in a patient with paroxysmal nocturnal hemoglobinuria

Recurrent venous thrombosis following liver transplantation for Budd-Chiari syndrome is common, particularly in the setting of an underlying myeloproliferative disorder. We describe a patient who developed refractory ascites due to portal vein thrombosis following liver transplantation for Budd-Chiari syndrome in the setting of paroxysmal nocturnal hemoglobinuria. Extensive portal vein thrombosis, dense abdominal adhesions, and portosystemic collaterals precluded the use of a transjugular intrahepatic portosystemic shunt or surgical portosystemic shunt to manage the patient's ascites. Splenic artery embolization to decrease portal hypertension was performed, and this resulted in complete resolution of ascites. This case demonstrates the successful use of splenic artery embolization to manage ascites due to portal vein thrombosis following liver transplantation. Splenic artery embolization may be considered as an alternative option for the management of refractory ascites due to portal hypertension in patients who are unable to undergo safe transjugular intrahepatic portosystemic shunt or surgical shunt placement.

Partial splenic embolization as pretreatment for antiviral therapy in hepatitis C virus infection

Chronic hepatitis C virus infection is frequently complicated by cirrhosis and hypersplenism, which together with several other factors, such as reduced thrombopoietin synthesis in the liver, cause cytopenia. The antiviral combination therapy with pegylated interferon and ribavirin itself is impaired by haematological toxicity. Partial splenic embolization (PSE) by the injection of microspheres via a catheter comprising approximately 30-70% of the splenic parenchyma is now a safe method, which significantly reduces the cytopenia induced by hypersplenism, especially thrombocytopenia. The effect is long lasting up to 20 years and has been documented in a variety of disorders. PSE is now carefully described in a combination modality as a pretreatment to reduce cytopenia in hepatitis C virus-induced cirrhosis patients with hypersplenism, making antiviral therapy possible per se at higher dosages with a sustained duration.

Emergency splenic arterial embolization for massive variceal bleeding in liver recipient with left-sided portal hypertension

Splenic vein thrombosis with gastric variceal bleeding is difficult to manage, and splenectomy may be necessary to stop variceal bleeding. The authors report the case of a post-orthotopic liver transplant patient with bleeding gastric varices secondary to splenic vein thrombosis treated by partial splenic artery embolization. Successful embolization was performed via transcatheter approach depositing Gianturco coils into the intrasplenic artery resulting in immediate cessation of variceal bleeding. No recurrence of bleeding was noted postembolization. In conclusion, splenic artery embolization can be used as treatment for postliver transplant variceal bleeding with hypersplenism.

Partial splenic embolization for the treatment of hereditary spherocytosis

OBJECTIVE

Splenectomy is the standard surgical treatment for hereditary spherocytosis, but partial splenic embolization is another potential option. We retrospectively studied the therapeutic effects of partial splenic embolization as a treatment for hereditary spherocytosis.

CONCLUSION

Partial splenic embolization is a safe and effective alternative to splenectomy or partial splenectomy in the treatment of hereditary spherocytosis.