Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications

Segmental arterial mediolysis leading to spontaneous rupture of splenic artery and fatal hemorrhage in pregnancy

We report an unexpected death of a 22-year-old primigravida who was admitted to the hospital with sudden abdominal pain two days before a scheduled delivery. During an emergency caesarean section due to intrauterine asphyxia, intraabdominal bleeding was observed with no apparent source of bleeding. Newly formed blood clots in the subdiaphragmatic space and arterial bleeding near the splenic hilum required a surgery on the next day. Hemorrhagic shock led to multiple organ failure on the fourth day of admission. The autopsy revealed ruptured splenic artery at the pancreatic tail and near the splenic hilum. Microscopically, different stages of segmental arterial mediolysis were observed in partially thinned and aneurysmatic artery.

Splenic Arterial Embolization for Trauma and Beyond: A Case Series

Splenic artery embolization plays an important role in the management of various medical and surgical conditions that are non-traumatic in etiology, in addition to its well-established and widely discussed role in managing splenic trauma. In nontraumatic emergencies of catastrophic bleeding originating from the spleen or splenic artery, splenic artery embolization can be effective in achieving hemostasis as a definitive management, temporary stabilizing measure, or preoperative optimization technique. In addition to emergency clinical conditions, splenic artery embolization can be performed electively as an alternative to splenectomy for managing patients with hypersplenism. Herein, we report 6 cases of splenic artery embolization performed at our center to highlight its various indications. This article aims to demonstrate the role of splenic artery embolization in different clinical scenarios and the considerations behind the techniques employed through illustrative cases.

Robotic resection for splenic artery aneurysm associated with neurofibromatosis type 1: a case report

BACKGROUND

Neurofibromatosis type 1 is an autosomal-dominant disease characterized by café-au-lait spots and neurofibromas, as well as various other symptoms in the bones, eyes, and nervous system. Due to its connection with vascular fragility, neurofibromatosis type 1 has been reported to be associated with vascular lesions, such as aneurysms. However, there have been few reports of abdominal visceral aneurysms associated with neurofibromatosis type 1. Furthermore, there have been no reports of robotic treatment of aneurysms associated with neurofibromatosis type 1. In this report, we describe the case of a patient with neurofibromatosis type 1 with a splenic artery aneurysm who was successfully treated with robotic surgery.

CASE PRESENTATION

This report describes a 41-year-old Asian woman with a history of neurofibromatosis type 1 who was referred to our hospital for evaluation of a 28 mm splenic artery aneurysm observed on abdominal ultrasound. The aneurysm was in the splenic hilum, and transcatheter arterial embolization was attempted; however, this was difficult due to the tortuosity of the splenic artery. Thus, we suggested minimally invasive robotic surgery for treatment and resection of the splenic artery aneurysm with preservation of the spleen. The postoperative course was uneventful, and the patient was discharged on the eighth day after surgery. At 1 year of follow-up, the patient was doing well, with no evidence of recurrence.

CONCLUSION

We encountered a rare case of splenic artery aneurysm in a patient with neurofibromatosis type 1 who was successfully treated with robotic surgery. There is no consensus on treatment modalities for neurofibromatosis-related aneurysms, and endovascular treatment is considered safe and effective; however, surgery remains an important treatment modality. Especially in patients with stable hemodynamic status, robotic surgery may be considered as definitive treatment. To our knowledge, this is the first successfully treated case of a splenic artery aneurysm in a patient with neurofibromatosis type 1.

Comprehensive analysis of splenic artery variations using computed tomography angiography: development of the IPALGEA classification system

BACKGROUND

The splenic artery, an essential component of abdominal vascular anatomy, exhibits significant variations with clinical implications in surgical and radiological procedures. The lack of a standardized classification system for these variations hinders comparative studies and surgical planning. This study introduces the IPALGEA classification system, based on computed tomography angiography (CTA) findings, to address this gap.

METHODS

A retrospective analysis was conducted on 302 patients who underwent CTA at a tertiary university hospital between August 2021 and January 2022. The study focused on the evaluation of splenic artery variations, including the origin, course, terminal branching patterns, and the relationship between the inferior polar artery and the left gastroepiploic artery. The IPALGEA classification was developed to standardize the reporting of these variations.

RESULTS

The study highlighted a significant prevalence of splenic artery variations, with the most common pattern being a superior course relative to the pancreas. The IPALGEA classification effectively categorized these variations, emphasizing the relationship between the inferior polar artery and the left gastroepiploic artery. The findings revealed that the bifurcation distance of the celiac trunk varied significantly between genders and that the presence of an inferior polar artery correlated with a shorter hilus distance.

CONCLUSION

The IPALGEA classification offers a comprehensive and standardized approach to categorize splenic artery variations. This system enhances our understanding of abdominal vascular anatomy and has significant implications for surgical and radiological procedures, potentially reducing surgical complications and improving patient outcomes.

Emergent method for management of splenic artery aneurysms rupture: A case report

INTRODUCTION AND IMPORTANCE

Although endovascular therapy is becoming more used for the treatment of splenic artery aneurysms (SAAs) instead of open surgery, there is limited information available on the emergent hybrid approach, selectively. We present our experience of hybrid therapy using an emergent endovascular balloon for inflow control and open resection.

CASE PRESENTATION

A 34-year-old woman was brought to the emergency room after it was reported that she had a pseudoaneurysm in her splenic artery at a different medical facility. The patient was hemodynamically stable. Then we underwent a combination of endovascular and open procedures, using balloon proximal control and open aneurysm resection. She was discharged from hospital on the fifth postoperative day after the operation.

CLINICAL DISCUSSION

There is no agreement on how to treat SAA patients. Endovascular procedures such as endovascular intervention are also being used, minimizing the risks of surgery and shortening the patient's hospital stay, but complications remain. We propose to try SAA's emergency hybrid strategy operation with a good prognosis and fewer complications.

CONCLUSION

It seems that, compared to open surgery alone when endovascular procedures were impossible, elective hybrid procedures are more secure and efficient in stable patients and could make the operation easier without more dissection for proximal control of splenic artery.

Selection of endovascular treatment strategies and analysis of the efficacy of different locations and types of splenic artery aneurysms

PURPOSE

To analyze the selection of endovascular treatment strategies and the efficacy of various locations and types of splenic artery aneurysms (SAAs).

METHODS

Sixty-three cases of patients diagnosed with SAA from January 2016 to October 2021 were collected, and their clinical data and follow-up results were analyzed.

RESULTS

Among the 63 patients, 55 had true SAAs, and 8 had false SAAs. The average diameter of the true SAAs was 2.0 ± 0.8 cm. There were 10 cases of intra-aneurysm embolization, 24 cases of intra-aneurysm and aneurysm-bearing artery embolization, 10 cases of bare stent-assisted coil embolization, and 11 cases of stent grafts. The false SAAs had an average diameter of 2.3 ± 1.1 cm. Aneurysm-bearing artery embolization was applied in 5 cases, and stent grafts were applied in 3 cases. The incidence of complications after embolization of the aneurysm-bearing artery was higher (P < 0.01). Postembolization syndrome occurred in 10 patients; 7 patients developed splenic infarction to varying degrees, 1 patient had mildly elevated blood amylase, and 1 patient developed splenic necrosis with abscess formation, all of which improved after active treatment. The average length of hospital stay was 5.5 ± 3.2 days. The average follow-up time was 17.2 ± 16.1 months, and the aneurysm cavity of all patients was completely thrombotic.

CONCLUSION

Endovascular treatments of SAAs are safe and effective. For various locations and types of SAAs, adequate selection of treatment is necessary. Stent grafts are recommended for their safety, economy, practicality, and preservation of the physiological functions of the human body.

Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy

BACKGROUND

Sinistral, or left-sided, portal hypertension (SPH) is a rare cause of upper gastrointestinal (GI) hemorrhage resulting from obstruction of the splenic vein. Venous drainage from the spleen via collaterals can result in venous hemorrhage into both the retroperitoneal and intra-abdominal spaces due to increased venous blood pressure in peripancreatic and gastroduodenal vasculature. SPH can occur secondary to pancreatitis with thrombosis of the splenic vein. Another possible cause is the surgical ligation of the splenic vein as part of pancreaticoduodenectomy (PD). Although splenectomy has been traditionally considered as the treatment of choice to relieve venous hypertension, individual concepts for each patient have to be developed. Considering the venous collateral drainage pathways, a comprehensive approach involving surgical, endoscopic, and interventional radiology interventions may be necessary to address the underlying cause of variceal bleeding. Among these approaches, splenic artery embolization (SAE) has demonstrated efficacy in mitigating the adverse effects associated with elevated venous outflow pressure.

SUMMARY

This review summarizes key imaging findings in SPH patients after PD and highlights the potential of minimally invasive embolization for curative treatment of variceal hemorrhage.

KEY MESSAGES

(i) SPH is a potential consequence after major pancreas surgery. (ii) Collateral flow can lead to life-threatening abdominal bleeding. (iii) Depending on the origin and localization of the bleeding, a dedicated management is required, frequently involving interventional radiology techniques.

Portal Hypertension Due to a Traumatic Arteriovenous Fistula in a Patient With a Celiac Artery Aneurysm

This article describes a rare case of a traumatic splenic arteriovenous fistula (AVF) causing portal hypertension in a patient presenting with abdominal pain, diarrhea, and melena. A 78-year-old was admitted to the hospital with abdominal pain. The patient's history was notable for prior laparotomy and left nephrectomy for a gunshot wound. Workup demonstrated portal hypertension with a dilated splenic vein with aneurysmal changes and a saccular celiac artery aneurysm. Celiac angiogram demonstrated a communication between celiac and portal circulation. The patient underwent laparotomy with ligation of the splenic artery and resection of the celiac artery aneurysm. In conclusion, splenic AVFs are relatively rare in clinical practice. Once the diagnosis is established, operative intervention is required to avoid complications of portal hypertension. Surgical ligation has been used in this case with a successful outcome.

In Vitro Drug Loading, Releasing Profiles, and In Vivo Embolic Efficacy and Safety Evaluation of a Novel Drug-Eluting Microsphere (CalliSpheres)

Background: To investigate morphology, physical property, loadability, stability, and release profiles of a novel drug-eluting microsphere, CalliSpheres, in vitro and to explore its embolic efficacy and safety in vivo. Materials and Methods: CalliSpheres (50-150 μm, 100-300 μm, and 300-500 μm) and doxorubicin in different amounts (20, 40, 80, and 100 mg) and concentrations (5 and 10 mg/mL) were prepared for experiments. Dynamic light scattering and an Agilent 1260 high-performance liquid chromatography system were used to quantify bead diameters and the efficiency of drug loading and release, respectively. Twelve New Zealand rabbits were treated with catheter-aided hepatic embolization using CalliSpheres. Results: CalliSpheres displayed a red color after loading with doxorubicin, and the mean diameters decreased by 20.7-25.8%. Almost 100% of the drug was incorporated with CalliSpheres in different sizes immersed with doxorubicin 20 mg, while loading efficiency ranged from 75.8% to 100.0% with doxorubicin at 40, 80, and 100 mg dependent on CalliSpheres sizes (smaller sizes, higher loading efficiency). Elevated loading efficiency was observed at higher concentration of doxorubicin solutions. Regarding release profiles, doxorubicin was released from CalliSpheres quickly at the very beginning, and doxorubicin release percentage was increased in the 50-150 μm group (39.2% ± 1.2%) compared with the 100-300 μm group (31.3% ± 1.3%) and 300-500 μm group (31.7% ± 2.5%). Digital subtraction angiography, computed tomography, and histopathologic emanation results proved in vivo safety and embolic efficacy of CalliSpheres. Conclusions: CalliSpheres present with good physical characteristics and satisfactory loading and releasing profiles in vitro and are well tolerated and efficient in embolization in vivo.

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.

Splenic Artery Embolism in Liver Transplant Patients: A Single-Center Experience

BACKGROUND

Hypersplenism, portal hypertension, and ascites have been seen after liver transplants. Patients are usually treated medically with refractory patients potentially undergoing splenectomy. Splenic artery embolism (SAE) is an alternative that can be performed to limit the surgical intervention that may have the benefit of improving portal hypertension. Few studies have studied the effect on main portal vein (MPV) velocities and hepatic artery resistive indices (HARIs) which may be beneficial as markers of portal hypertension.

PURPOSE

This study aims to evaluate the efficacy and safety of interventional radiology (IR)-guided SAE for the management of portal hypertension in patients who have had liver transplants.

METHODS

A retrospective analysis was conducted on liver transplant patients who had undergone IR-guided SAE post-transplant at a single tertiary transplant center from 2012 to 2022. The primary outcome of intervention efficacy was quantified by peak HARIs and MPV velocities. Ultrasound with Doppler obtained before and after the intervention was reviewed for these parameters. Secondary outcomes included adverse events at the time of the procedure and within one year of the procedure, the need for splenectomy, and spleen size.

RESULTS

Twenty-eight patients met the criteria for inclusion. The mean age of patients was 52.5 years (21-71 years) and the time after transplant was 149.5 days (2-1588 days). About 96.4% of SAEs were technically successful (n=27). Twenty-one patients had MPV velocities available, and 24 had peak HARIs available. In these patients, HARIs decreased by an average of 0.063 (95% CI 0.014-0.112) after SAE. MPV velocity decreased by an average of 47.2 cm/s (95% CI 27.3-67.1) after SAE. About 10.4% of patients (n=3) developed a procedure-related complication, all of which were femoral access site aneurysms. No (0) patients suffered from bleeding, infections, or abscesses after the procedure. About 10.7% of patients (n=3) required splenectomy after SAE: one splenectomy was due to technical failure and two were due to refractory symptoms.

CONCLUSION

We performed one of the first analyses on MPV and RI and showed that our patients saw an improvement post-embolization with a theoretical improvement in portal hypertension. The complication rate and risk of infection seem to be acceptable risks, making SAE a feasible option for management.

Women of childbearing age have higher mortality rates following inpatient interventions for splenic artery aneurysms

INTRODUCTION

Splenic artery aneurysms (SAAs) are the most common type of splanchnic aneurysms. Current guidelines recommend repair of all SAAs in women of childbearing age since maternal mortality is high. The purpose of this study was to evaluate treatment modalities and outcomes following inpatient SAA repair in women.

METHODS

The National Inpatient Sample (NIS) database from 2012-2018 was queried. Patients with SAAs were identified utilizing International Classification of Disease (ICD) 9 and 10 codes. Childbearing age was defined as 14-49 years of age. The primary outcome was in-hospital mortality.

RESULTS

A total of 561 patients were admitted with a diagnosis of SAA between the years of 2012-2018. There were 267 (47.6%) female patients and of these 103 (38.6%) were of childbearing age. The overall in-hospital mortality rate was 2.7% (n=15). There were no differences in rates of elective admissions or type of repair (open versus endovascular) between women of childbearing age and the remainder of the cohort. However, women of childbearing age were significantly more likely to undergo a splenectomy compared to the remainder of the cohort (32.0% versus 21.4%, P=.028). Women of childbearing age had higher rates of in-hospital mortality compared to the remainder of the cohort (5.8% versus 2.0%, P=.040). Subset analysis of the women of childbearing age revealed that those undergoing a splenectomy versus no splenectomy (14.8% versus 2.6%, P=.039) and those treated in the non-elective versus elective setting (10.5% versus 0%, P=.032) had higher rates of in-hospital mortality. There was one patient with an ICD code associated with pregnancy and they survived.

CONCLUSION

Women of childbearing age had higher in-hospital mortality following inpatient interventions for SAAs with all of the deaths occurring in the non-elective setting. These data support the pursuit of aggressive elective treatment of SAAs in women of childbearing age.

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.

Proximal Splenic Artery Embolization for Refractory Ascites and Hydrothorax Post-Liver Transplant

PURPOSE

Proximal splenic artery embolization (pSAE) has been advocated as a valuable tool to ameliorate portal hyper-perfusion (PHP). The purpose of this study was to determine the safety and efficacy of pSAE to treat refractory ascites (RA) and/or refractory hydrothorax (RH) in the setting of PHP post-liver transplant.

MATERIAL AND METHODS

A total of 30 patients who underwent pSAE for RA and/or RH after liver transplantation (LT) between January 2007 and December 2017 were analyzed retrospectively. The patients were divided into groups according to the time frame from pSAE to clinical resolution in order to identify predictors of RA/RH response to the procedure.

RESULTS

Twenty-four (80%) patients responded to pSAE within three months, whereas 6 (20%) still required additional treatments for RA/RH at three months post-pSAE. In all cases clinical symptoms resolved within six months. Complications after pSAE were as follows: 2 cases of splenic infarction (6.6%), one case of post-splenic embolization syndrome (3.3%), one case of hepatic artery thrombosis (3.3%) and one case of portal vein (PV) thrombosis (3.3%). Increased intraoperative PV flow volume and increased pre-pSAE PV velocity, as well as higher estimated glomerular filtration rate were associated with early RA/RH resolution.

CONCLUSION

pSAE is safe and effective in treating RA and RH due to PHP after LT. This study suggests that clinical parameters indicating more severe PHP and better kidney function are possible predictors for early response to pSAE.

Long-Term Effects of Proximal Splenic Artery Embolization on Splenic Volume and Platelet Count

BACKGROUND

The spleen is the most commonly injured visceral organ in blunt abdominal trauma. Post-splenectomy infection risk has led to the shift toward spleen preserving procedures and splenic artery embolization (SAE) is now the treatment of choice for hemodynamically stable patients with splenic injury. This study aims to assess the long-term effect of SAE on splenic volume and platelet count.

MATERIALS AND METHODS

Using CPT codes, 66 patients who underwent SAE were identified, and 14 of those who had the necessary imaging and laboratory follow-up were included in the study. Indications for SAE were portal hypertension in 8 patients, bleeding in 4 patients, and thrombocytopenia in 1, and one patient had a separate indication. Splenic volume was calculated by automated volumetric software (Aquarius, TeraRecon, Inc.). Paired t-tests were performed to compare splenic volume and platelets before and after SAE.

RESULTS

Fourteen patients (7 males, 7 females) with a mean age of 51 ± 11.95 years underwent SAE and were followed by a repeat computed tomography scan at an average of 733.57 days. Nine SAEs were performed using vascular plugs, 3 using micro coils, and 2 out of that were with Gelfoam slurry, and 2 using coils only. All embolizations were technically successful with complete cessation of flow. Mean splenic volumes pre- and post-SAE were 903.5 ± 523.73 cm³ and 746.5 ± 511.95 cm³, respectively, representing a mean decrease of 8.31% compared to baseline [P = 0.346]. Minimum platelet counts (x10³) pre-SAE (within 3 months) and post-SAE (2 weeks to 3 months after the procedure) were 55.79 ± 57.11 and 116 ± 145.40, respectively. The minimum platelet count showed a statistically significant mean increase of 134.92% (P = 0.033).

CONCLUSIONS

The splenic volume is not altered significantly by SAE in the long term. Similarly, the platelet count is also not significantly altered at 3 months follow-up. This study, although small, suggests that SAE is a safe intervention that can preserve splenic volume and function in the long term.

Morphological Evaluation of the Splenic Artery, Its Anatomical Variations and Irrigation Territory

BACKGROUND

Precise knowledge of the topographic features of the splenic artery and its branches in the hilum region is of practical interest due to the various interventions on the vessels of the spleen.

MATERIALS AND METHODS

The anatomy of the spleen was studied by means of macroscopic dissection on 330 organ complexes, which were carefully documented and analyzed statistically.

RESULTS

The analysis of the splenic artery trajectory led to identification of four types: straight (43.03%), sinusoidal (27.58%), serpentine (20.91%) and alternating (8.48%). To assess the relation between the trajectory of the splenic artery and its branches we performed a chi square test. Sinuous or serpentine trajectory was associated with the presence of long splenic artery branches (dorsal pancreatic artery or the great pancreatic artery), X2 (2, N = 330) = 12.85, p = 0.001. The artery was located suprapancreatic in 70.30% of cases, anteropancreatic in 4.55%, the vessel had an intrapancreatic course in 14.85% and in 10.00% of cases the artery was located retropancreatic. The presence of inferior polar arteries was associated with a longer pancreas (Spearman's correlation; r = 0.37; p = 0.037). In a multiple regression analysis, inferior polar arteries predicted the length of the pancreas although only a small number of cases could be explained by this model (R2 = 0.127, Adjusted R2 = 0.098; Betta = 0.357; t(330) = 2.091; p = 0.045). There were 30 (9.09%) cases of accessory spleens.

CONCLUSIONS

The arterial supply of the spleen is highly variable in its trajectory, terminal branches, and relation to other organs. The splenic artery tends to be sinuous or serpentine in zones when a large artery branches off (e.g., the dorsal pancreatic or greater pancreatic artery). Multiple short branches tend to stabilize the trajectory of the splenic artery. Inferior polar arteries and accessory spleens contribute to the length of the pancreas, most likely due to increased vascular supply to the tail of the gland.

Impact of Portal Hypertension on Adverse Events after Splenic Arterial Aneurysm Embolization

PURPOSE

To evaluate the outcomes of splenic artery aneurysm (SAA) embolization and compare adverse event (AE) rates after embolization in patients with and without portal hypertension (PHTN).

MATERIALS AND METHODS

A retrospective review of all patients who underwent embolization of SAAs at 2 institutions was performed (34 patients from institution 1 and 7 patients from institution 2). Baseline demographic characteristics, preprocedural imaging, procedural techniques, and postprocedural outcomes were evaluated. Thirty-day postprocedural severe and life-threatening AEs were evaluated using the Society of Interventional Radiology guidelines. Thirty-day mortality and readmission rates were also evaluated. t test, χ² test, and/or Fisher exact test were used for the statistical analysis.

RESULTS

There was no statistically significant difference between patients with and without PHTN in the location, number, and size of SAA(s). All procedures were technically successful. There were 13 (32%) patients with and 28 (68%) patients without PHTN. The 30-day mortality rate (31% vs 0%; P = .007), readmission rates (61% vs 7%; P < .001), and severe/life-threatening AE rates (69% vs 0%; P < .001) were significantly higher in patients with PHTN than in those without PHTN.

CONCLUSIONS

There was a significantly higher mortality and severe/life-threatening AE rate in patients with PHTN than in those without PHTN. SAAs in patients with PHTN need to be managed very cautiously, given the risk of severe/life-threatening AEs after embolization.

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.

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).

Congenital portosystemic shunt with multiple splenic artery aneurysms: Reversing pulmonary hypertension and preventing aneurysm rupture

We report an unusual occurrence of multiple splenic artery aneurysms and splenomegaly in a young woman with severe pulmonary hypertension, secondary to a congenital portosystemic shunt (CPS). The splenic artery was occluded using an Amplatzer Duct Occluder-II device, and closure of the large intrahepatic CPS was achieved using a muscular ventricular septal defect occluder. There was resolution of splenomegaly with normal pulmonary artery pressures, a few months after the procedure.

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.

Hemodynamic effect through a novel endoscopic intervention in management of varices and hypersplenism (with video)

BACKGROUND AND AIMS

We previously reported a new and combined EUS-guided intervention in a patient with portal hypertension, consisting of obliteration of varices and partial splenic embolization (PSE). Performing PSE is known to diminish the increase in portal venous pressure after endoscopic intervention for varices. The aim of this study was to use multidetector CT portal venography to evaluate the anatomy of esophagogastric varices (EGV) and the impact on hemodynamics of portosystemic collaterals shortly after the concomitant procedures.

METHODS

From October 2019 to December 2020, 5 patients with cirrhosis and with clinically significant portal hypertension who had variceal bleeding history and hypersplenism were treated with combined endoscopic obliteration for varices and EUS-guided PSE. Multidetector CT portal venography was applied to assess the anatomic drainage patterns of the EGV, diameters of feeders and drainage vessels, and splenic embolization rate.

RESULTS

Within 5 days after concomitant endoscopic interventions, we observed decreased mean diameters of the left gastric vein, short gastric vein, and azygos vein as .3 mm, 1.0 mm, and 5.2 mm compared with 3.11 mm, 7.1 mm, and 5.4 mm before the procedures, respectively. Patients showed increased white blood cells (mean count of 2.7 × 10⁹/L before vs 5.8 × 10⁹/L after) and platelets (mean count of 52.8 × 10⁹/L before vs 95.8 × 10⁹/L after). The mean splenic embolization rate was 64.5% (range, 28.8%-84.6%).

CONCLUSIONS

Our experience may illustrate an alternative technique of combining EUS-guided PSE with endoscopic therapy of varices to treat patients with portal hypertension.

[Selecting the most appropriate surgical treatment of true splenic artery aneurysm]

OBJECTIVE

To analyze the results of diagnosis and treatment of true splenic artery aneurysms.

MATERIAL AND METHODS

We analyzed the results of diagnosis and treatment of 27 patients with true splenic artery aneurysm. All ones underwent surgical treatment at the Botkin Municipal Clinical Hospital between 2017 and 2021. Splenic artery aneurysm >1 cm was an indication for surgical treatment. Surgical option depended on aneurysm location. Laparoscopic splenectomy and aneurysmectomy were performed in 4 cases (14.8%), 5 (18.5%) patients underwent endovascular intervention, laparoscopic clipping was performed in 18 (66.7%) cases. Methods of surgical treatment, general and specific postoperative complications according to the Clavien-Dindo and ISGPS classifications were analyzed.

RESULTS

Laparoscopic clipping was accompanied by fewer general and specific postoperative complications. Specific complications after laparoscopic splenectomy occurred in 2 patients (BL according to the ISGPS 2016 classification). There was one case of acute pancreatitis after endovascular interventions. In long-term postoperative period, aneurysm recanalization after endovascular intervention was observed in 1 case.

CONCLUSION

Surgical treatment of splenic artery aneurysms requires a differentiated approach based on topographic and anatomical assessment of aneurysm relative to the arterial vessel.

Learning from mistakes when reporting urgent and emergency vascular studies

The majority of out-of-hours cases relate to neurological, chest, and gastrointestinal pathologies with acute vascular cases being encountered less commonly. Trainees and exposure of non-vascular/interventional radiology (IR) consultants to angiographic imaging is often limited in working hours and this may lead to reporting on-call cases outside of normal daytime practice. In a recent local review, a number on-call vascular studies were found to contain a number of vascular-related discrepancies. Vascular reporting is a complex subspecialty, which comprises many clear diagnoses (large vessel occlusions, large vessel aneurysms, or dissections); however, also several subtle and complex abnormalities. These more subtle abnormalities, at times, require dedicated vascular specialist review to ensure subtle findings are communicated appropriately to the clinical team. The recent increased complexity of endovascular treatments and their complications has also provided further challenge for the non-specialist reporter. Similarly, improved imaging techniques have allowed for non-obvious but significant findings that may require urgent management, such as small aneurysms and dissection flaps. We will review a range of key vascular findings that demonstrate learning opportunities, particularly within the acute and on-call settings. These will include gastrointestinal haemorrhage, subtle aortic pathologies, head and neck vascular emergencies, small to mid-sized vessel injuries and imaging of post-procedural complications. Educational hints and tips will be provided to enable learning from mistakes encountered by trainees and non-vascular specialist radiologists in the on-call or urgent reporting settings, and these will be reviewed with reference to the literature.

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.

Splenic Arteriovenous Fistula Accompanied by Splenic Artery Aneurysm Associated with Acute-onset Portal Hypertension and Gastrointestinal Bleeding: Case Report and Literature Review

Splenic arteriovenous fistula is an uncommon aetiology of portal hypertension, which has definitive treatment effectiveness and good prognosis. We report a case of portal hypertension and gastrointestinal bleeding in the absence of hepatic parenchymal disease in a 50 year-old woman with multiple pregnancies. Abdominal computed tomography and transabdominal arteriography recorded the presence of tortuous and aneurysmal splenic arteries and the premature filling of enlarged splenic veins, which are highly suggestive of splenic arteriovenous fistula. The above vascular abnormalities were successfully treated by transcatheter embolization. No recurrence or other complications were observed. In addition, a literature review concerning splenic arteriovenous fistula published in recent 30 years was performed to further our understanding of the management strategy on this entity.

Splenic trauma: endovascular treatment approach

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

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.

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.

Unusual case of left-sided portal hypertension induced variceal bleeding after pancreaticoduodenectomy treated with transplenic embolization

With the advances in surgical technique and the accumulation of experiences, pancreatic cancer with portal-superior mesenteric vein (PV-SMV) invasion is no longer considered as an absolute contraindication for surgical resection. After resection of the PV-SMV confluence, congestion of the splenic vein (SV) may develop, resulting in splenomegaly and variceal formation, also known as left-sided portal hypertension (LPH). Along with improved postoperative prognosis, LPH induced varices are given enough time to develop and eventually bleed, which can be lethal. We present a 59-year-old woman who underwent pancreaticoduodenectomy (PD) for pancreatic cancer with a concomitant PV-SMV resection. Massive upper gastrointestinal bleeding and hypovolemic shock occurred 15 months after the surgery. Various exams, including endoscopy, dynamic computed tomography (CT) imaging, celiac, and superior mesenteric artery (SMA) angiography, were performed. However, the exact location of the bleeding could not be identified. LPH-induced varices bleeding was suspected and diagnosed by venography. The varices were embolized with n-BCA and lipiodol mixture by trans-splenic venous approach with complete cessation of bleeding. It is important to identify potential life-threatening LPH-induced varices bleeding, especially if certain clinical histories or classic imaging findings are presented. As for treatment, interventional radiology methods could be considered as the first choice.

Revisiting the Spleen—An Imaging Review of the Common and Uncommon Splenic Pathology

The spleen is the largest lymphatic organ and is responsible for both hematological and immunological functions. Several common etiologies such as trauma, developmental variants, infectious/inflammatory conditions, and benign and malignant lesions can occur in the spleen. The role of imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) in diagnosing these conditions continues to evolve. The main objective of this review article is to illustrate the role of imaging in identifying the common and uncommon pathology of the spleen.

Evaluation of perfusion changes using a 2D Parametric Parenchymal Blood Flow technique with automated vessel suppression following partial spleen embolization in patients with hypersplenism and portal hypertension

To evaluate the feasibility and potential value of 2D Parametric Parenchymal Blood Flow (2D-PPBF) for the assessment of perfusion changes following partial spleen embolization (PSE) in a retrospective observational study design.Overall, 12 PSE procedures in 12 patients were included in this study. The outcome of the study was the platelet response (PR), calculated as the percentage increase of platelet count (PLT), following PSE. To quantify perfusion changes using 2D-PPBF, the acquired digital subtraction angiography series were post-processed. A reference region-of-interest (ROI) was placed in the afferent splenic artery and a target ROI was positioned on the embolization territory of the spleen on digital subtraction angiography series pre- and post-embolization. The ratios of the target ROIs to the reference ROIs were calculated for the Wash-In-Rate (WIR), the Time-To-Peak (TTP) and the Area-Under-the-Curve (AUC). Comparisons between pre- and post-embolization data were made using Wilcoxon signed-rank test and Spearman's rank correlation coefficient (r). Afterwards, the study population was divided by the median of the TTP before PSE to analyze its value for the prediction of PR following PSE.Following PSE, PLT increased significantly from 43,000 ± 21,405 platelets/μL to 128,500 ± 66,083 platelets/μL with a PR of 255 ± 243% (P = .003). In the embolized splenic territory, the pre-/post-embolization 2D-PPBF parameter changed significantly: WIRpre-PSE 1.23 ± 2.42/WIRpost-PSE 0.09 ± 0.07; -64 ± 46% (p = 0.04), TTPpre-PSE 4.41 ± 0.99/TTPpost-PSE 5.67 ± 1.52 (P = .041); +34 ± 47% and AUCpost-PSE 0.81 ± 0.85/AUCpost-PSE 0.14 ± 0.08; -71 ± 18% (P = .002). A significant correlation of a 2D-PPBF parameter with the PLT was found for TTPpre-PSE/PLTpre-PSE r = -0.66 (P = .01). Subgroup analysis showed a significantly increased PR for the group with TTPpre-PSE >4.44 compared to the group with TTPpre-PSE ≤4.44 (404 ± 267% versus 107 ± 76%; P = .04).2D-PPBF is an objective approach to analyze the perfusion reduction of embolized splenic tissue. TTP derived from 2D-PPBF has the potential to predict the extent of PR during PSE.

A systematic review of splenic artery variants based on cadaveric studies

PURPOSE

The splenic artery (SA) is the largest and most tortuous branch of the celiac trunk with a wide spectrum of variants, particularly in its terminal branches.

METHODS

The current study presents a systematic review of the English literature on the SA variations, with emphasis on its terminal branching patterns.

RESULTS

Thirty cadaveric studies (3132 specimens) were included in the analysis. The SA originated from the celiac trunk in 97.2%, from the abdominal aorta in 2.1% and from the superior mesenteric or the common hepatic artery in 0.7% of cases. A suprapancreatic course was observed in 77.4%, retropancreatic course in 17.8%, anteropancreatic course in 3.4% and intrapancreatic course in 1.3%. In the majority of cases, the SA bifurcated into superior and inferior lobar arteries (83.4%), with trifurcation and quadrifurcation in 11.3% and 2.7%, respectively. Five or more lobar branches (1.4%) and a single lobar artery (1.2%) were rarely identified. The distributed branching pattern was found in 72.7%, whereas the magistral pattern in 26.9%. The inferior and superior polar arteries (IPA and SPA) were found in 47.7% and 41.7% of cases, respectively, while polar artery agenesis was recorded in 28.2%. The SPA usually originated from the SA main trunk (53.6%) or from the superior lobar artery (33.1%). The IPA emanated mainly from the left gastroepiploic artery (53%), from the SA (23.5%) or the inferior lobar artery (21.9%). Intersegmental anastomoses between adjacent arterial segments were identified in 14.2%.

CONCLUSION

Knowledge of the SA aberrations is important for surgeons and radiologists involved in angiographic interventions.

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.

Multiple Incidental Unruptured Splenic Artery Aneurysms Following Severe Trauma

Splenic artery aneurysm is a relatively rare, potentially life-threatening condition due to its high potential for rupture. We report a case of two incidentally found unruptured splenic artery aneurysms in a 39 year-old female victim of severe trauma resulting from a motor vehicle accident (MVA). Management by coiling of the splenic artery aneurysm and embolization to the entire segment distal to it was successfully performed for this patient.

Giant anevrisms of the splenic artery about six cases

Splenic artery aneurysms are rare. Giant aneurysms more than 2,5cm are extremely rare. The splenic artery is the third site after the aorta and iliac arteries, and the first location for aneurysmal lesion of the visceral arteries. The etiology of splenic artery aneurysms is not yet well established, however, fibromuscular dysplasia, non-cirrhotic portal hypertension and pregnancy seem to contribute to the emergence and evolution of arterial lesions. The majority of splenic artery aneurysms are asymptomatic. However, epigastric or left hypochondrial pain may occur. Doppler ultrasound, computed tomography angiography or magnetic resonance imaging are usually performed in the diagnostic workup. Treatment procedure, surgical or endovascular, depends on the aneurysmal site (proximal or distal) and the type of elective or urgent intervention. The present study reports six cases of splenic artery aneurysm, with a diameter greater than 50mm, treated successfully with surgery.

Yttrium-90 Portal Vein Radioembolization in Sprague-Dawley Rats: Dose-Dependent Imaging and Pathological Changes in Normal Liver

PURPOSE

Portal vein embolization (PVE) is an established neoadjuvant method to induce future liver remnant hypertrophy prior to surgical resection of hepatic tumors. The purpose of our study was to examine the feasibility of PVE with glass ⁹⁰Y microspheres (Y90 PVE) in Sprague-Dawley rats. We tested the hypothesis that increased doses of Y90 PVE would increase target lobe fibrosis and atrophy.

METHODS

Twenty-two rats were assigned to four groups for Y90 PVE to the right median lobe: very high- (273.8 MBq; n = 2), high- (99.9 MBq; n = 10), medium- (48.1 MBq; n = 5), and low-dose (14.8 MBq; n = 5). An untreated control group included seven rats. ⁹⁰Y PET/CT of ⁹⁰Y distributions confirmed lobar targeting. MRI volumes were measured at baseline, 2-, 4-, 8- and 12-weeks. Explanted hepatic lobes were weighed, sectioned, and stained for H&E and immunohistochemistry. Digitized slides allowed quantitative measurements of fibrosis (20 foci/slide).

RESULTS

Ex vivo measurements confirmed 91-97% activity was localized to the target lobe (n = 4). The percent growth of the target lobe relative to baseline was - 5.0% (95% CI - 17.0-6.9%) for high-, medium dose rats compared to + 18.6% (95% CI + 7.6-29.7%) in the low-dose group at 12-weeks (p = 0.0043). Radiation fibrosis increased in a dose-dependent fashion. Fibrotic area/microsphere was 22,893.5, 14,946.2 ± 2253.3, 15,304.5 ± 4716.6, and 5268.8 ± 2297.2 μm² for very high- (n = 1), high- (n = 4), medium- (n = 3), and low-dose groups (n = 5), respectively.

CONCLUSION

Y90 PVE was feasible in the rat model, resulted in target lobe atrophy, and dose-dependent increases in hepatic fibrosis at 12 weeks. The onset of imaging-based volumetric changes was 8-12 weeks.

Meta-analysis of Intraprocedural Comparative Effectiveness of Vascular Plugs Vs Coils in Proximal Splenic Artery Embolization and Associated Patient Radiation Exposure

PURPOSE

To compare vascular plugs to coil embolization of the proximal splenic artery and evaluate differences in radiation exposure to the patients.

METHODS

An electronic literature search was performed for relevant studies from January 2000 to July 2018 that compared the efficacy of vascular plugs vs coils in splenic artery embolization. Only studies that investigated coil or vascular plug use, without combination with other embolic agents, were included. Meta-analysis was performed using a fixed effects model approach with the inverse variance-weighted average method to determine pooled differences in time to vessel occlusion, procedure time, fluoroscopy time, total number of devices used, and radiation exposure. Heterogeneity was assessed using the I square statistic. Pooled outcomes were compared, and quality assessments were evaluated using the Newcastle Ottawa Scale.

RESULTS

Eight studies met inclusion criteria. 81 patients were embolized with vascular plugs and 52 patients with coils only. The most common indication for splenic artery embolization was trauma. Time to vessel occlusion was shorter in the vascular plug group by 7.11 minutes (P = 0.003). Fluoroscopy time was shorter by 13.82 minutes in the vascular plug cohort, and these patients received less radiation (-439 mGy) compared to the coil group (P = 0.006 and P = 0.02, respectively). The number of devices was significantly fewer in the vascular plug group (-3.54; P < 0.001). Procedure time was not statistically significant.

CONCLUSION

Our data supports the vascular plug is superior to coils for embolization of the proximal splenic artery with respect to occlusion time, fluoroscopy time, patient radiation exposure, and number occlusive devices used.

Basic Arterial Anatomy and Interpretation of CT Angiography for Intra-Abdominal or Gastrointestinal Bleeding: Correlation with Conventional Angiographic Findings for Beginners

복강 내 혹은 소화기계의 활동성 출혈이 있는 경우, 원인이 되는 동맥 혈관을 파악하는 것이 중요하다. 조영증강 컴퓨터단층촬영술을 이용한 혈관조영술과 고식적인 카테터 혈관조영술에서 원인이 되는 동맥을 파악하기 위해서는 기본적인 혈관 해부학을 숙지하고 있어야 한다. 기본 해부학을 숙지하고 있다면 혈관의 기원과 주행에 다양한 변이가 있다고 하더라도 이에 대한 접근이 한결 쉬워질 것이다. 영상의학에 갓 입문한 초심자들을 대상으로 하여, 복강 내 혹은 소화기계 활동성 출혈의 원인이 될 수 있는 혈관들을 파악하는 데 도움이 될만한 기본 해부학을 설명하고자 한다.

Feasibility and Safety of Laparoscopic Partial Splenectomy: A Systematic Review

BACKGROUND

Laparoscopic partial splenectomy (LPS) is a challenging procedure. The aim of this review was to evaluate its feasibility, safety, and potential benefits.

METHODS

We conducted a comprehensive review for the years 1995-2018 to retrieve all relevant articles.

RESULTS

A total of 44 studies with 252 patients undergoing LPS were reviewed. Six studies described combined operations. Ranges of operative time and estimated blood loss were 50-225 min and 0-1200 ml, respectively. There are eight patients need blood transfusion in 231 patients with available data. The conversion rate was 3.6% (9/252). Overall, 27 patients (10.7%;27/252) developed postoperative or intraoperative complications. Overall mortality was 0% (0/252). The length of postoperative stay (POS) varied (1-11 days). Among four comparative studies, one showed LPS could reduce POS than laparoscopic total splenectomy (LTS) (LTS 5.4 ± 1.8 days, LPS 4.2 ± 0.8 days, p = 0.027) and complications (pleural effusion (LTS 9/22, LPS 0/15, p = 0.005), splenic vein thrombosis (LTS 10/22, LPS 0/15, p = 0.002)). Another comparative study showed LPS may benefit emergency patients. However, one comparative study showed LPS was associated with more pain, longer time to oral intake, and longer POS in children with hereditary spherocytosis. The fourth comparative study showed robotic subtotal splenectomy was comparable to laparoscopy in terms of POS and complication. The main benefits were lower blood loss, vascular dissection time, and a better evaluation of splenic remnant volume.

CONCLUSIONS

In early series of highly selected patients, LPS appears to be feasible and safe when performed by experienced laparoscopic surgeons.

Splenic artery aneurysm as a rare cause of an upper GIT bleed

Upper gastrointestinal bleeding (UGIB) is a common life-threatening presentation in the emergency department. Causes are typically divided into variceal and non-variceal bleeds. Non-variceal pathologies typically include bleeding peptic ulcers, haemorrhagic gastritis and Mallory Weiss Tears. Occassionally, less common pathologies are encountered such as Dieulafoy's lesions, haemosuccus pancreas, haemobilia or aorto-enteric fistula. The following report documents the case of a 49-year-old man who presented with an UGIB. His risk factors included a history of nonsteroidal anti-inflammatory drug, smoking and ethanol abuse. Despite his typical presentation and risk factors, investigation revealed an unusual and rare pathology. He was found to have a giant splenic artery aneurysm, abutting and eroding the gastric mucosa. Diagnosis was made using a combination of gastro-oesophagoscopy and CT scan. Successful treatment consisted of angio-embolisation of the aneurysm.

A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification

Variceal hemorrhage may cause high rebleeding and mortality rates. Preventing the first episode of variceal bleeding is mandatory in patients with high-risk esophageal varices (EV). This study aimed to identify factors that predict the recurrence of EV after endoscopic treatment (ET), and to develop a reasonable therapeutic strategy for EV in cirrhosis. From January 2012 to December 2014, 45 patients with cirrhosis and high-risk EV underwent ET, including sclerotherapy and/or ligation. Statistical analyses identified factors associated with the recurrence of EV after ET, and the Kaplan-Meier method determined the cumulative variceal recurrence rates. The 1-, 2-, and 3-year cumulative posttreatment recurrence rates for EV were 13.3%, 29.5%, and 32.2%, respectively. No significant differences were evident between the patients with and without variceal recurrences at 1-year posttreatment. The multivariate regression analyses identified a history of partial splenic embolization (PSE) and the pretreatment Child-Pugh classification as independent predictors of variceal recurrences at 2 years (p < 0.05) and 3 years (p < 0.05) posttreatment. While EV did not recur after ET and splenic artery embolization in cases with Child-Pugh class A, the overall posttreatment variceal recurrence rates were 0% and 66.7% when PSE was performed before and after ET, respectively, in those with Child-Pugh class B or C. Splenic artery embolization significantly reduced the hepatic venous pressure gradient and markedly lowered the Child-Pugh score in 15 patients. Adjunctive PSE and pretreatment Child-Pugh class A could be independently associated with reduced cumulative recurrence rates of EV post-ET. From the perspectives of portal hemodynamics and hepatic function, splenic artery embolization before or after ET could prevent posttreatment variceal recurrence in patients with Child-Pugh class A, and PSE before ET could achieve the long-term eradication of EV following ET in those with Child-Pugh class B or C.

Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports

Background

There is no definitive strategy for gastrointestinal bleeding due to left-sided portal hypertension after pancreaticoduodenectomy (PD) for pancreatic cancer (PC) with concomitant portal vein resection (PVR).

Case presentation

Case 1: A 70-year-old woman underwent a PD for PC with PVR. Seven years after her surgery, she suffered severe anemia with suspected gastrointestinal bleeding. Computed tomography scan (CT) revealed varices at a portion of the pancreaticojejunostomy (PJ). Angiography revealed that splenic venous flow drained into the varices and then into the portal vein. A diagnosis of bleeding varices of the PJ due to left-sided portal hypertension was made. Following a partial splenic artery embolization, her anemia improved.

Case 2: An 80-year-old male underwent a PD for pancreatic head cancer combined with resection of the confluence of the portal and splenic veins with a reconstruction between the portal and superior mesenteric veins. Eighteen months after his surgery, he developed melena with negative endoscopy findings in his large and small bowel. CT revealed varices at the site of the PJ that communicated with the jejunal and portal veins. He underwent obliteration of the varices via a trans-portal-venous approach. As a result, he remained without melena until he died of PC 17 months after the embolization.

Conclusions

Left-sided portal hypertension following a PD with bleeding varices can be treated by interventional radiology with minimal invasiveness.

A rare case of non-traumatic intrasplenic pseudoaneurysms in a patient with acute T-cell lymphoblastic leukemia

Pseudoaneurysm (PSA) or false aneurysm is a vascular lesion resulting from a focal and incomplete rupture of the arterial wall (intimate and/or elastic lamina), that allows blood to escape into the arterial wall; this small contained break causes a contained collection of blood and the creation of a "new" less resistant vessel wall, consisting of adventitia and perivascular tissues. Intrasplenic pseudoaneurysms are rare and more frequently recognize traumatic origin, sometimes are also unexpected lesions due to non-recent trauma. In contrast, non-traumatic intrasplenic pseudoaneurysms are rare complications usually due to splenic infarction, infiltration by malignant systemic disorders, infectious process, chronic pancreatitis, and arteritis. Both traumatic and non-traumatic PSA are potentially life threatening, known to cause spontaneous rupture of the spleen with massive hemoperitoneum. Contrast-enhanced CT is the gold standard technique to detect splenic PSA; however, it is important to know how to recognize it also with other imaging methods such as with ultrasound (US) and contrast-enhanced ultrasound (CEUS). US and CEUS can be often the first-line diagnostic techniques and allow to detect these lesions; they are also very useful in the follow-up. Our case report can be a reminder of the utility of the US and CEUS in detecting splenic pseudoaneurysms, which are potentially a life-threatening complication; we also recall the semiotics of these lesions with baseline ultrasound (US), color Doppler US and contrast-enhanced ultrasound (CEUS). Then, we highlight the role of contrast-enhanced CT in confirming the diagnosis and we report about the diagnostic and therapeutic value of angiography. We have to think about the possibility of a pseudoaneurysm even in the absence of a recent trauma, associated with other conditions such as a lymphoproliferative disease.