An Overview of Splenic Embolization

Celiac trunk arterial variations and their clinical implications: Role of imaging

The awareness of anatomical variations of hepatic arteries and celiac trunk is very important in interventional radiology, liver transplant and intra-abdominal oncologic surgeries. Radiology plays an important role in the identification of these variants non-invasively. Digital subtraction angiography was the gold standard for their identification. Computed tomography (CT) angiography non-invasively provides detailed knowledge of various anatomical vascular variations. This pictorial review highlights the role of multidetector computed tomography (MDCT) in the identification of celiac trunk-hepatic arterial system variations and clinical consequences.

Radiological and Surgical Treatments of Portal Hypertension

Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.

Taking the Road Less Travelled: A Case Report of Distal Splenic Artery Embolisation via the Pancreaticoduodenal Arcade in Splenic Trauma With Celiac Artery Stenosis

Celiac axis stenosis (CAS) is one of the most prevalent splanchnic arterial pathologies. It seldom results in clinically severe ischemic bowel disease because of the rich collateral circulation from the superior mesenteric artery. Knowledge about the collaterals in celiac artery stenosis guides various interventional procedures. Here, we describe a case of a 19-year-old female with American Association for the Surgery of Trauma (AAST) grade IV splenic injury found to have CAS. Distal splenic artery embolisation was performed via the collateral pathway through the pancreaticoduodenal arcade.

Efficacy and Safety of Transarterial Chemoembolization and Repeated Partial Splenic Embolization for Hepatocellular Carcinoma with Hypersplenism and Thrombocytopenia

Aim

Partial splenic embolization (PSE) combined with transarterial chemoembolization (TACE) has been reported in treatment of hepatocellular carcinoma (HCC) with cirrhotic hypersplenism and thrombocytopenia. However, efficacy and safety of repeated PSE when required are unclear. This study aims to investigate post-procedural changes in peripheral blood cell and hepatic function, progression-free survival (PFS), and safety of HCC patients with hypersplenism received TACE and repeated PSE compared to those received TACE alone.

Methods

This retrospective study included 102 HCC patients with hypersplenism who received TACE (n = 73) or TACE+PSE (n = 29) from January 2014 to December 2021. Changes in peripheral blood cell and hepatic function were investigated at 1 week, 2, 6, 12, 18, and 24 months. TACE procedure sessions and adverse events were recorded. PFS and prognostic factors were analyzed.

Results

Despite response to initial PSE being limited, repeated PSE increased platelet (PLT) again, which peaked at 18 months. It also continued to improve red blood cell (RBC) and hemoglobin, which showed significant differences in changes from baseline between two groups until 24 months, as well as Child-Pugh scores at 12 and 18 months. Mean TACE procedure sessions were significantly higher in TACE+PSE group than that in TACE alone group (4.55 vs 3.26, P = 0.019). TACE+PSE group had longer median PFS (19.4 vs 9.5 months, P = 0.023) than TACE alone group, where PSE was an independent protective factor (HR, 0.508; P = 0.014). Initial and repeated PSE showed no significant differences in safety.

Conclusion

Repeated PSE is effective in increasing PLT again and improving RBC, hemoglobin and liver function. It contributed to performing serial TACE procedures thereafter. TACE combined with repeated PSE has significantly longer PFS than TACE alone, where PSE was an independent protective factor. Moreover, the safety of repeated PSE was comparable to initial PSE.

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.

Colosplenic Fistula Following Splenic Embolization in a Sickle Cell Disease Patient

This case report details a rare instance of a colosplenic fistula following splenic embolization in a patient with sickle cell disease. The patient, a 29-year-old female, presented with symptoms of left hypochondrial pain and fever. Imaging revealed a splenic abscess characterized by an air-fluid level. Intraoperative observations disclosed that the spleen was entirely replaced by an abscess cavity, with the presence of colosplenic fistulae. A splenectomy and colonic resection were performed. This report highlights a rare complication that occurred a long time after splenic embolization, underscoring the need for a high level of suspicion to prevent serious complications.

Successful splenic artery embolization in a patient with Behçet's syndrome-associated splenic rupture: A case report

BACKGROUND

Splenic rupture associated with Behçet's syndrome (BS) is extremely rare, and there is no consensus on its management. In this case report, a patient with BS-associated splenic rupture was successfully treated with splenic artery embolization (SAE) and had a good prognosis after the intervention.

CASE SUMMARY

The patient was admitted for pain in the left upper abdominal quadrant. He was diagnosed with splenic rupture. Multiple oral and genital aphthous ulcers were observed, and acne scars were found on his back. He had a 2-year history of BS diagnosis, with symptoms of oral and genital ulcers. At that time, he was treated with oral corticosteroids for 1 month, but the symptoms did not alleviate. He underwent SAE to treat the rupture. On the first day after SAE, the patient reported a complete resolution of abdominal pain and was discharged 5 d later. Three months after the intervention, a computed tomography examination showed that the splenic hematoma had formed a stable cystic effusion, suggesting a good prognosis.

CONCLUSION

SAE might be a good choice for BS-associated splenic rupture based on good surgical practice and material selection.

Partial splenic embolization with embosphere microspheres (700-900 µm) for the treatment of hypersplenism: comparison of selective superior splenic artery embolization and inferior splenic artery embolization

Objective: To compare clinical outcomes of superior versus inferior splenic artery embolization in partial splenic embolization (PSE) and identify predictors of major complications. Material and methods: This retrospective case-control study included 73 patients who underwent PSE between May 2005 and April 2021. They were divided into two groups: the superior and middle splenic artery embolization group (Group A, n = 37) and the inferior and middle splenic artery embolization group (Group B, n = 36). Outcome differences and major complications between the groups were assessed. Logistic regression was used to analyze potential predictors of major complications, and the optimal cutoff value for splenic embolization rates was determined using the Youden index. Results: There were no significant differences in laboratory and radiological outcomes between the two groups. Group A had a significantly lower incidence of major complications than Group B (p = 0.049), a lower Visual Analog Scale (VAS) score for pain (p = 0.036), and a shorter hospital stay (p = 0.022). Independent risk factors for major complications included inferior and middle splenic artery embolization (odds ratio [OR] = 3.672; 95% confidence interval [CI] = 1.028-13.120; p = 0.045) and a higher spleen embolization rate (OR = 1.108; 95% CI = 1.003-1.224; p = 0.044). The optimal cutoff for spleen embolization rate to predict major complications was 59.93% (sensitivity 77.8%, specificity 63.6%). Conclusion: Using 500-700 µm microspheres for PSE, targeting the middle and superior splenic artery yields similar effects to targeting the middle and inferior artery, but results in lower rates of major complications and shorter hospital stays. To effectively minimize the risk of major complications, the embolization rate should be kept below 59.93%, regardless of the target vessel.

Prognosis of LSPD versus TIPS for the treatment of esophagogastric variceal bleeding in cirrhosis

BACKGROUND

This study aimed to compare postoperative complications in patients with esophagogastric variceal bleeding (EVB) who underwent laparoscopic splenectomy combined with pericardial devascularization (LSPD) versus transjugular intrahepatic portosystemic shunt (TIPS) procedures.

METHODS

A retrospective collection of medical records was conducted from January 2014 to May 2020 at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The study included patients from the departments of trauma surgery, interventional radiology, and general surgery who were diagnosed with EVB caused by portal hypertension and treated with LSPD or TIPS. Follow-up data were obtained to assess the occurrence of postoperative complications in both groups.

RESULTS

A total of 201 patients were included in the study, with 104 cases in the LSPD group and 97 cases in the TIPS group. There was no significant difference in the 1-year and 3-year post-surgery survival rates between the TIPS and LSPD groups (P = 0.669, 0.066). The 3-year survival rate of Child-Pugh B patients in the LSPD group was higher than TIPS group (P = 0.041). The LSPD group also had a significantly higher rate of freedom from rebleeding at 3-year post-surgery compared to the TIPS group (P = 0.038). Stratified analysis showed no statistically significant difference in the rebleeding rate between the two groups. Furthermore, the LSPD group had a higher rate of freedom from overt hepatic encephalopathy at 1-year and 3-year post-surgery compared to the TIPS group (P = 0.007, < 0.001). The LSPD group also had a lower rate of severe complications at 3-year post-surgery compared to the TIPS group (P = 0.020).

CONCLUSION

Compared to TIPS, LSPD does not increase the risk of mortality and rebleeding, while demonstrating fewer complications. In patients classified as Child-Pugh A and B, the use of LSPD for treating EVB is both safe and effective.

Non-operative management of high-grade splenic injury: a systematic review protocol

OBJECTIVE

The objective of this review is to establish whether embolization is more effective than clinical observation for adult patients with grade III-V splenic injuries. The findings will be used to guide future practice and, if necessary, inform future research design and conduct.

INTRODUCTION

The spleen is one of the most frequently injured intra-abdominal organs, with a reported adult mortality of 7% to 18% following trauma. Non-operative management has become a standard of care for hemodynamically stable patients. In clinical practice, the decision whether to prophylactically embolize or manage high-grade injuries with observation alone remains controversial.

INCLUSION CRITERIA

Sources including adult patients with grade III-V splenic injuries secondary to blunt trauma will be included in this review. Eligible studies must include comparisons between 2 cohorts of patients undergoing either prophylactic embolization or clinical observation only. Outcomes will include mortality rate, failure of treatment, intensive care unit admission, length of hospital stay, blood transfusion requirements, and patient satisfaction.

METHODS

A systematic review with meta-analysis will be conducted. PubMed, Embase, and CINAHL will be searched for eligible studies, as will trial registries and sources of gray literature. Study selection, quality appraisal, and data extraction of outcomes will be performed in duplicate. Methodological quality will be evaluated using JBI critical appraisal tools. Studies will, where possible, be pooled in statistical meta-analysis. A random effects model will be used and statistical analysis will be performed. The certainty of the findings will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

REVIEW REGISTRATION

PROSPERO CRD42023420220.

Splenic artery embolisation for blunt splenic trauma: 10 years of practice at a trauma centre

INTRODUCTION

Splenic artery embolisation (SAE) has transformed the management of splenic trauma. The aim of this study was to review the outcomes and postprocedural management of blunt splenic trauma patients treated with SAE at a trauma centre over a 10-year period.

METHODS

Details of patients undergoing SAE for blunt trauma between January 2012 and January 2022 were acquired from a prospectively maintained database. Patient records were reviewed for demographic information, splenic injury grades, embolisation efficacy, complications, and associated injuries and mortality. Data relating to Injury Severity Scores (ISS) and postprocedural practice (vaccinations, antibiotic prescribing, follow-up imaging) were also obtained.

RESULTS

Thirty-six patients (24 male, 12 female) with a median age of 42.5 years (range 13-97 years) were identified. American Association for the Surgery of Trauma splenic injury grades were III (n = 7), IV (n = 20) and V (n = 9). Seventeen patients had isolated splenic injury and 19 had additional injuries to other organ systems. Median ISS was 18.5 (range 5-50). SAE succeeded first time in 35/36 cases, and upon the second attempt in 1/36 cases. No patients died because of splenic injury or SAE although four patients with polytrauma died owing to other injuries. SAE complications occurred in 4/36 cases. For survivors, vaccinations were administered in 17/32 cases, and long-term antibiotics were initiated in 14/32 cases. Formal follow-up imaging was arranged in 9/32 cases.

CONCLUSIONS

These data show that SAE is an effective means of controlling splenic haemorrhage secondary to blunt trauma with no patient requiring subsequent laparotomy. Major complications occurred in 11% of cases. Follow-up practice varied regarding further imaging, antibiotic and vaccination administration.

Partial Splenectomy and Splenic Wrapping for a High-Grade Splenic Injury: A Case Report

The spleen is one of the most commonly injured organs in blunt abdominal trauma, accounting for a vast portion of solid organ injuries, and may lead to rapid haemodynamic instability, requiring urgent operative intervention. Total splenectomies result in relative immunocompromise, with a risk of overwhelming post-splenectomy infection (OPSI) post splenectomy. This case reports the surgical management of a 20-year-old male with a grade IV splenic laceration after a motor vehicle accident. The patient underwent a trauma laparotomy with a partial splenectomy because of early take-off of the upper-lobar branch of his splenic artery, with an absorbable mesh wrap to tamponade the spleen. The patient avoided the need for a total splenectomy and was discharged after six days in the hospital with an uncomplicated recovery.

Retrospective Evaluation of Splenic Artery Embolization Outcomes in the Management of Blunt Splenic Trauma: A Single Centre Experience at a Large Level 1 Trauma Centre

PURPOSE

Retrospective review of splenic artery embolization (SAE) outcomes performed for blunt abdominal trauma.

MATERIALS AND METHODS

11-year retrospective review at a large level-1 Canadian trauma centre. All patients who underwent SAE after blunt trauma were included. Technical success was defined as angiographic occlusion of the target vessel and clinical success was defined as successful non-operative management and splenic salvage on follow-up.

RESULTS

138 patients were included of which 68.1% were male. The median age was 47 years (interquartile range (IQR) = 32.5 years). The most common mechanisms of injury were motor vehicle accidents (37.0%), mechanical falls (25.4%), and pedestrians hit by motor vehicles (10.9%). 70.3% of patients had American Association for the Surgery of Trauma (AAST) grade 4 injuries. Patients were treated with proximal SAE (n = 97), distal SAE (n = 23) or combined SAE (n = 18), and 68% were embolized with an Amplatzer plug. No significant differences were observed across all measures of hospitalization (Length of hospital stay: x2(2) = .358, P = .836; intensive care unit (ICU) stay: x2(2) = .390, P = .823; ICU stay post-procedure: x2(2) = 1.048, P = .592). Technical success and splenic salvage were achieved in 100% and 97.8% of patients, respectively. 7 patients (5%) had post-embolization complications and 7 patients (5%) died during hospital admission, but death was secondary to other injuries sustained in the trauma rather than complications related to splenic injury or its management.

CONCLUSION

We report that SAE as an adjunct to non-operative management of blunt splenic trauma can be performed safely and effectively with a high rate of clinical success.

Amplatzer™ Vascular Plugs for Embolisation: A 10-Year Single-Centre Retrospective Study

Our objective was to investigate the indications, effectiveness, and safety of Amplatzer™ Vascular Plugs (AVPs) in clinical practice. To retrospectively identify patients managed with AVPs at the Dijon University Hospital between January 2011 and April 2021, we searched materials vigilance registries and procedure reports. The 110 identified patients underwent 111 procedures with delivery of 202 AVPs into 118 vessels; 84% of the procedures were performed by radiologists with over 10 years' experience and 67% were scheduled. Varicocele, haemostasis, pelvic varicose veins, and arterio-venous dialysis fistulas accounted for 69% of procedures. The technical and clinical success rates were 99% and 97%, respectively. The single major complication was AVP migration in a high-flow internal iliac vein, with no residual abnormalities after successful device retrieval. Several AVPs and/or concomitant injection of coils or liquid agents were used in 80% of cases. The use of AVPs alone occurred chiefly for splenic artery embolisation in trauma patients and for collateral vein occlusion in dysfunctional arterio-venous dialysis fistulas. No cases of recanalisation occurred during the 19 ± 29 month follow-ups. Based on their good safety and effectiveness profile, AVPs deserve to be part of the therapeutic armamentarium of every interventional radiologist.

Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney

According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Impact of Treatment Modalities on Discharge Disposition in Blunt Splenic Injuries

BACKGROUND

Management of blunt splenic trauma has evolved over several decades, trending towards nonoperative management and splenic artery embolization. Extensive research has been conducted regarding the management of blunt splenic injuries, but there is little data on the association of treatment modality with discharge disposition.

METHODS

This is an observational retrospective study conducted at a level-one trauma center with blunt splenic trauma patients of age ≥18 years between January 2010 and December 2021. The primary outcome of unfavorable discharge was defined as discharge to an acute care facility, intermediate care facility, long-term care facility, rehabilitation (inpatient) facility, or skilled nursing facility.

RESULTS

Five hundred seventy-nine patients were included in the analysis, with 108 (18.7%) in the unfavorable group and 471 (81.3%) in the favorable group. Most patients were managed nonoperatively (69.3%), followed by splenectomy (25.0%) and embolization (5.7%). Due to the low number of embolizations performed during the study period, treatment modalities were grouped into two broad categories: intervention (embolization and splenectomies) and nonintervention. The treatment modality was found to have no significant impact on unfavorable discharge. Independent risk factors for unfavorable discharge included age >55 years, injury severity score (ISS) >15, hospital-acquired pneumonia, and in-hospital complications of sepsis.

CONCLUSIONS

This study provides an understanding of specific demographic and clinical factors that may predispose blunt splenic injury trauma patients to an unfavorable discharge. Providers may apply these data to identify at-risk patients and subsequently adapt the care they provide in an effort to prevent the development of in-hospital pneumonia and sepsis.

Experience in managing splenic hilar vascular injury during laparoscopic total gastrectomy

Splenic hilar vascular injury may occur during laparoscopic radical total gastrectomy for splenic hilar lymph node dissection and often causes massive hemorrhage, requiring conversion to laparotomy and splenectomy. Surgeons treating splenic hilar vascular injuries need a way to stop bleeding promptly and accurately. Herein, we report a case of splenic hilar vascular injury during laparoscopic total gastrectomy in which we successfully managed to stop the bleeding and preserve the spleen.

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.

The Impact of Partial Splenic Embolization on Portal Hypertensive Gastropathy in Cirrhotic Patients with Portal Hypertension

This study investigated the impact of partial splenic embolization (PSE) on portal hypertensive gastropathy (PHG). We retrospectively analyzed endoscopic findings and the portal venous system of 31 cirrhotic patients with PHG. The improved group was defined as the amelioration of PHG findings using the McCormack classification. Child–Pugh scores of the improved group (18 of 31 patients) were significantly lower compared with those of the non-improved group (p = 0.018). The changes in the diameters of the portal trunk and those of the spleno-portal junction and spleen hilum in the splenic vein of the improved group were significantly larger than those of the non-improved group (p = 0.007, p = 0.025, and p = 0.003, respectively). The changes in the diameters of the portal vein and splenic hilum of the splenic vein showed significant correlations with Child–Pugh score (r = 0.386, p = 0.039; r = 0.510, p = 0.004). In a multivariate analysis of baseline factors related to the improved group, Child–Pugh grade A was significantly associated with the improvement of PHG (odds ratio 6.875, p = 0.033). PSE could be useful for PHG, especially in patients with Child–Pugh grade A, at least in the short term.

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.

Therapeutic strategies for pseudoaneurysm following blunt liver and spleen injuries: A multicenter cohort study in the pediatric population

BACKGROUND

Little guidance exists for the treatment of pseudoaneurysm (PA) following pediatric blunt liver and/or spleen injuries (BLSIs). We aimed to describe the incidence of delayed PA development and the subsequent clinical course of PA in pediatric BLSIs.

METHODS

This multicenter retrospective cohort study from Japan included pediatric patients (16 years and younger) who sustained BLSIs from 2008 to 2019. The cohort was divided into four groups based on hemostatic intervention within 48 hours of admission, namely, nonoperative management (NOM), NOM with interventional radiology (IR), operative management (OM), and combined IR/OM. Descriptive statistics were used to describe the incidence of delayed PA among the groups and to characterize the clinical course of any PAs.

RESULTS

A total of 1,407 children (median age, 9 years) from 83 institutions were included. The overall number (incidence) of cases of delayed PA formation was 80 (5.7%), and the number with delayed PA rupture was 16 cases (1.1%) in the entire cohort. Patients treated with NOM (1,056), NOM with IR (276), OM (53), and combined IR/OM (22) developed 43 (4.1%), 32 (12%), 2 (3.8%), and 3 (14%) delayed PAs, respectively. Among patients who developed any PAs, 39% of patients underwent prophylactic IR for unruptured PA, while 13% required emergency angioembolization for delayed PA rupture, with one ruptured case requiring total splenectomy. At least 45% of patients experienced spontaneous resolution of PA without any interventions.

CONCLUSION

Our results suggest that the risk of delayed PA still exists even after acute phase IR as an adjunct to NOM for BLSIs in children, indicating the necessity of a period of further observation. While endovascular interventions are usually successful for PA management, including rupture cases, given the high incidence of spontaneous resolution, the ideal management of PA remains to be investigated in future studies.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

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.

Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS

BACKGROUND

This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE).

METHODS

We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE.

RESULTS

In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p < 0.0001); conversely, the number of surgeries decreased from 21 (43.8%) in 2001 to 4 (10.5%) in 2015 (p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p < 0.0001). On angiography, 202 patients who demonstrated vascular injury and 187 achieved hemostasis after SAE with a 92.6% success rate. Six of the 15 patients failed to SAE preserved the spleen after second embolization with a 95.5% salvage rate.

CONCLUSIONS

Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI.

Interventional Management of Portal Hypertension in Cancer Patients

PURPOSE OF REVIEW

To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches.

RECENT FINDINGS

In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.

A case of a pregnant woman with a special splenic artery aneurysm

Visceral artery aneurysm, especially splenic artery aneurysm, is rare and is usually associated with pregnancy. When such aneurysms rupture, they can be fatal, and they often require emergency surgery. This case report includes a review of the literature and describes a effective multidisciplinary approach to managing this type of aneurysm. We describe the treatment of a ruptured splenic artery aneurysm and the careful coordination of obstetric, vascular surgery, and intensive care teams. The uniqueness of this case arose from the metal embolization coil that was found to have fallen off from a recently embolized ruptured splenic artery aneurysm. The management of this ruptured splenic artery aneurysm and iatrogenic foreign body insult required a combination of multiple specialties to provide life-saving treatment. Such cases should be managed by multidisciplinary teams if institutional resources allow for it.

Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma

Background

Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery.

Materials and methods

Retrospective review was performed of PSAE for blunt splenic trauma (2015–2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test.

Results

Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01).

Conclusion

The results support the proposed optimal embolisation location as being between the DPA and GPA.

Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience

BACKGROUND

Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM.

METHODS

A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates.

RESULTS

Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001).

CONCLUSION

ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.

Complications Following Splenic Embolization for Trauma: Have Things Changed Over Time?

INTRODUCTION

Splenic artery embolization (SAE) is a routinely used adjunct in the nonoperative management (NOM) of blunt splenic injury (BSI). The purpose of this study was to evaluate the rate and type of adverse events that occur in patients undergoing SAE and to compare this with the previous data.

METHODS

Patients who had SAE for BSI between 2011 and 2018 were identified. Splenic abscess, splenic infarction, and contrast-induced renal insufficiency were considered major complications. Coil migration, fever, and pleural effusions were regarded minor complications. The results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010.

RESULTS

There were 716 patients admitted with BSI. SAE was performed in 74 (13.3%) of the 557 (78%) NOM patients. The overall complication rate was 33.8%. Major complications occurred in 11 patients (14.9%) and minor in 13 patients (18.9%). There was no association between complications and coil location by logistic regression.

CONCLUSIONS

SAE continues to be a useful adjunct in the NOM of BSI though complications continue to occur. Fewer minor complications were noted in the period studied compared to past similar studies.

Applications of vascular interventions in hypersplenism in liver cirrhosis

Cirrhosis is a common cause of secondary hypersplenism. Hypersplenism often leads to a decrease in peripheral blood cells, and when the numbers of leukocytes and platelets are severely reduced, patients are prone to spontaneous infections and bleeding, which can aggravate the disease and increase the risk of death. The mechanism of hypersplenism in cirrhosis is not well understood, and there is no standard indication or recommended method for the treatment of hypersplenism. Clinical treatment options for hypersplenism include splenectomy, vascular intervention, local thermal ablation, and splenic artery ligation. Vascular interventions mainly involve transjugular intrahepatic portosystemic shunt (TIPS) and partial splenic embolization (PSE). TIPS is an effective method to treat the complications of portal hypertension in cirrhosis, which can effectively reduce portal pressure, but whether it can relieve hypersplenism is still controversial. PSE can relieve hypersplenism to a certain extent. TIPS combined with PSE can effectively reduce portal hypertension and relieve hypersplenism to a certain extent. This article reviews the applications of vascular interventions in hypersplenism in cirrhosis.

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.

Readmission after splenic salvage: How real is the risk?

BACKGROUND

Hemorrhage due to delayed splenic rupture is a potentially fatal complication of nonoperative management of splenic injuries. Suboptimal postdischarge follow-up has made measuring the incidence of failed splenic salvage challenging. We hypothesized that readmission after splenic salvage is rare; however, readmissions for splenic conditions would be associated with a high rate of splenectomy.

METHODS

The National Readmission Database for 2016 and 2017 was queried for trauma admissions with the International Classification of Diseases 10th revision codes for splenic injury. Patients with missing discharge disposition, discharge to a short-term hospital, death during index admission, or admitted in December were excluded. The primary endpoint was nonelective 30-day readmission for splenic diagnoses after nonoperative management during the index admission. Outcomes collected included transfusions, complications, interventions at readmission, and mortality.

RESULTS

There were 22,736 patients admitted for a traumatic splenic injury; 15,596 (68.6%) underwent no intervention, 2,261 (9.9%) were treated with embolization only, and 4,509 (19.8%) underwent splenectomy. The overall 30-day readmission rate was 8.4%, whereas the spleen-related readmission rate was 2.0%. For those treated with embolization or no intervention, the spleen-related 30-day readmission rate was 2.4%, with the majority (69.4%) occurring within 7 days of discharge. The most common complications were pleural effusion (23.0%), sepsis (4.4%), splenic abscess (3.9%), and splenic infarct (3.0%). Those patients readmitted for spleen-related diagnoses after undergoing splenic salvage during the index admission had a 22.3% rate of splenectomy and mortality of 1.6%.

CONCLUSION

Readmission after splenic salvage is rare, with the majority presenting within 1 week of discharge. However, of those readmitted for spleen injury-related diagnoses there was a high rate of splenectomy. Patients managed with splenic salvage should be counseled on the risk of potential failure and need for readmission and operation after discharge.

Evaluation of Splenic Artery Embolization Technique for Blunt Trauma

Introduction:

Evaluate outcomes and radiation exposure across different splenic artery embolization (SAE) techniques for splenic injuries secondary to blunt trauma.

Methods:

This retrospective cohort study included patients 18 years of age or older who underwent SAE for splenic injury after blunt trauma from January 2011 to June 2019.

Results:

Sixty patients underwent angiography for splenic injury after blunt traumatic injury. Forty-four patients were embolized. Seventeen patients underwent proximal SAE, and 23 underwent distal SAE. Four patients had a combination of proximal and distal SAE. Eleven patients had subsequent major complications requiring splenectomy. There was no significant difference in major complication rate when comparing proximal SAE 29.4% versus distal SAE 21.7%. No significant difference was noted across the two groups with respect to age or grade of injury. There was a statistically significant difference (P = 0.004) in fluoroscopy time between the proximal 10.1 ± 4.2 min and distal group 17.8 ± 8.7 min. No statically significant difference was found in major complications when comparing coil versus gel foam embolization.

Conclusion:

Proximal SAE is associated with a significantly lower fluoroscopy time (P = 0.004). Complication rates are similar after proximal and distal SAE. No significant difference was found in major complication rates comparing coil versus gel foam embolization. Minor complications more commonly occurred after proximal embolization with gel-foam.

Splenic artery embolization with N-butyl cyanoacrylate in patients with blunt abdominal trauma

Introduction

Splenic artery embolization (SAE) has been shown to be safe and effective for non-operative management of patients with splenic trauma while preserving splenic function. A variety of coils, plugs, particles and liquid embolics have all been used. NBCA (n-butyl cyanoacrylate) is used less frequently than other modalities but is effective.

Methods

A retrospective review of all patients who underwent SAE with NBCA for blunt abdominal trauma at a single tertiary medical center over a six-year period.

Results

Out of 123 SAE patients, 7 utilized NBCA; 6 patients had intraparenchymal splenic artery pseudoaneurysms, 2 had intraparenchymal arteriovenous fistulas, and 5 had active extravasation from the spleen on CT imaging. There was 100% technical success rate. There were no acute post-op complications or complications at 30-day and 90-day follow up. One patient died 2 days following SAE secondary to worsening subdural hematoma unrelated to SAE.

Conclusions

NBCA is safe and effective in treating patients with splenic injury particularly in patients with high grade splenic injury demonstrating extensive intraparenchymal vascular injury and/or intraprocedural extravasation in distal locations.

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.

Splenic Artery Embolization for Patients with High-Grade Splenic Trauma: Indications, Techniques, and Clinical Outcomes

The spleen is the most commonly injured organ in blunt abdominal trauma. Patients who are hemodynamically unstable due to splenic trauma undergo definitive operative management. Interventional radiology plays an important role in the multidisciplinary management of the hemodynamically stable trauma patient with splenic injury. Hemodynamically stable patients selected for nonoperative management have improved clinical outcomes when splenic artery embolization is utilized. The purpose of this article is to review the indications, technical aspects, and clinical outcomes of splenic artery embolization for patients with high-grade splenic injuries.

Residual Splenic Volume after Main Splenic Artery Embolization is Independent of the Underlying Disease

Purpose:

To assess the safety and efficacy of main splenic artery embolization. To assess the potential difference post-embolization of the residual splenic volume in patients embolized for trauma versus those embolized for (pseudo)aneurysms.

Materials and Methods:

A retrospective analysis was performed on a cohort of 65 patients (36 males) who underwent pre- and post-embolization computed tomography. Patients’ demographics, pre- and post-interventional medical and radiological data were gathered. Splenic volume calculations were semi-automatically performed via a workstation. Patients with splenic aneurysms or pseudoaneurysms of the main splenic artery (group 1) were compared to those with splenic rupture (group 2) using Wilcoxon rank tests.

Results:

The main indications for splenic artery embolization were splenic rupture (n = 22; 34%) and splenic pseudoaneurysm (n = 19; 29%). The technical success rate was n = 63; 97%. The procedure-related complication rate was n = 7; 11%, including abscess formation (n = 5; 8%), re-bleeding (n = 1; 1.5 %) and pseudoaneurysm re-opening (n = 1; 1.5%). The overall 30-day mortality was n = 7; 11%.

Median follow-up for groups 1 and 2 was 1163 days (61–3946 days) and 702 days (43–2095 days) respectively. When processable (n = 23), the splenic volume in group 1 (n = 7) was 311 cm³ and 257 cm³ (p = 0.1591) before and after embolization respectively, and in group 2 (n = 16) it was 261 cm³ and 215 cm³ (p = 0.4688), respectively.

Conclusions:

Main splenic artery embolization is efficacious, with low procedure-related complication and 30-day mortality rates. No significant differences in residual post-embolization splenic volume were found between patients treated for splenic rupture versus those treated for splenic arterial (pseudo)aneurysm.

Luspatercept: A Gigantic Step in the Treatment of Transfusion-Dependent β-Thalassemia Patients-a Quick Review

INTRODUCTION

Some studies have indicated that the use of luspatercept may be a novel and efficient treatment for β-thalassemia patients. In this article, we aimed to review the current evidence related to luspatercept prescription and its clinical effectiveness in patients with β-thalassemia.

METHODS

PubMed, Web of Science, Scopus, Trip and CENTRAL were searched up to June 2020. The inclusion criteria were English-language articles that studied the effects of luspatercept on improving anemia severity in patients with β-thalassemia in a clinical setting.

RESULTS

The search strategy yielded 273 potentially relevant articles. After searching the databases, scanning of titles, abstracts and full texts for relevancy was performed to identify suitable articles. A total of 77 articles were confirmed for full text analysis. The estimated number of patients needed to treat (NNT) for luspatercept treatment, using data derived from conducted clinical trials, according to a reduction in transfusion need of ≥ 33% or ≥ 50 from baseline, during week 13-24/week 37-48/any 12- and 24-week intervals as outcomes, was 3-5 in patients with β-thalassemia.

CONCLUSION

Based on the conducted studies, the effectiveness of luspatercept on transfusion burden and hemoglobin levels was outstanding in β-thalassemia patients. Further large and well-designed clinical studies are needed to identify any unforeseen complications subsequent to use of luspatercept, particularly when used with other treatments with potentially serious adverse effects such as anti-osteoporotic and iron chelator agents.

Autosomal Recessive Polycystic Kidney Disease-The Clinical Aspects and Diagnostic Challenges

Autosomal recessive polycystic kidney disease (ARPKD) is one of the most common ciliopathies with kidney (nephromegaly, hypertension, renal dysfunction) and liver involvement (congenital hepatic fibrosis, dilated bile ducts). Clinical features also include growth failure and neurocognitive impairment. Plurality of clinical aspects requires multidisciplinary approach to treatment and care of patients. Until recently, diagnosis was based on clinical criteria. Results of genetic testing show the molecular basis of polycystic kidneys disease is heterogeneous, and differential diagnosis is essential. The aim of the article is to discuss the role of genetic testing and its difficulties in diagnostics of ARPKD in children.

Non-operative management of blunt splenic trauma: The role of splenic artery embolization depending on the severity of parenchymal injury

PURPOSE

To address the disagreement about the need for splenic artery embolization (SAE) in medium grade blunt splenic trauma this retrospective study evaluates the clinical outcome of non-operative management (NOM) and the possible impact of a more liberal indication for primary SAE.

METHOD

From 01/2010 to 12/2019 186 patients presented with splenic injury on computed tomography (CT) after blunt abdominal trauma. The extent of splenic injuries according to Marmery, vascular pathologies, active bleeding as well as clinical and laboratory parameters were recorded and analyzed with regard to the success rates of NOM and SAE. Procedural complications and clinical outcome were noted. The number needed to treat (NNT) was determined for a possible extension of the indication for SAE to grade 3 injuries.

RESULTS

Of 186 patients 126 were managed non-operatively, 47 underwent primary SAE and twelve splenectomy. NOM was successful in 119/126 (94 %) patients. Conversion rate was significantly higher in patients with active bleeding or vascular pathology. Patients with failed NOM had a significantly greater decrease in haemoglobin and haematocrit levels. Primary SAE was successful in 45/47 (96 %) cases. Major complications occurred in four cases (9%), all managed without sequela. The NNT in grade 3 splenic injuries equals 13.

CONCLUSIONS

NOM of low to medium-grade blunt splenic trauma has a low failure rate. Presence of active haemorrhage is the most important predictor for failure of NOM. SAE should be reserved for high-grade injuries and visible vascular pathology or active bleeding to avoid a disproportionate increase in the NNT.

Small-diameter TIPS combined with splenic artery embolization in the management of refractory ascites in cirrhotic patients

PURPOSE

Maximally decreasing portal pressures with transjugular intrahepatic portosystemic shunt (TIPS) is associated with improved ascites control but also increased encephalopathy incidence. Since splenic venous flow contributes to portal hypertension, we assessed if combining small-diameter TIPS with splenic artery embolization could improve ascites while minimizing encephalopathy.

METHODS

Fifty-five patients underwent TIPS creation for refractory ascites. Subjects underwent creation of 8 mm TIPS followed by proximal splenic artery embolization (group A, n=8), or of 8 mm (group B, n=6) or 10 mm TIPS (group C, n=41) without splenic embolization. Data were retrospectively reviewed.

RESULTS

In group A, median portosystemic gradient decreased from 19 mmHg to 9 mmHg after TIPS, and 8 mmHg after subsequent splenic artery embolization. In groups B and C, gradient decreased from 15 mmHg to 8 mmHg and 16 mmHg to 6 mmHg. All patients except for one in group A and two in C had greater than 50% reduction in the number of paracenteses in 3 months. Any postprocedural encephalopathy incidence was 62%, 50%, 83% in groups A, B, and C, respectively. Overall, 20% of subjects with 10 mm TIPS required TIPS reduction/closure compared to 7% of subjects with 8 mm TIPS.

CONCLUSION

We found that 8 mm diameter TIPS provided similar ascites control compared to 10 mm TIPS regardless of splenic embolization. While more patients with 10 mm TIPS required reduction/closure for severe encephalopathy, the study was underpowered for definitive assessment. Splenic embolization might have the potential to further decrease portosystemic gradient and ascites as an alternative to dilation of TIPS to 10 mm minimizing the risk of encephalopathy, but larger studies are warranted.

Management of portal hypertension severe complications

Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review were to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discussed the indications and contraindications of transjugular intra-hepatic portosystemic shunt and for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section); we reviewed the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari Syndrome) and in those with portal vein thrombosis (second section); and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section).

[Interventional radiology as emergency therapy]

CLINICAL ISSUE

Both the progress of surgical techniques and the demographic development with increasing numbers of multimorbid patients demand and also encourage radiology in the setting of trauma and acute emergencies. In addition to a fast and precise diagnostics, this also includes image-guided, minimally invasive therapy to control and treat several acute pathologies.

STANDARD RADIOLOGICAL PROCEDURES

Computed tomography (CT) is not only important for the diagnosis of abscesses, active bleeding or other acute pathologies, but also allows minimally invasive therapy. While digital subtraction angiography (DSA) guides catheter-based procedures, e.g., to control bleedings or to place percutaneous transhepatic cholangiodrain (PTCD), fluoroscopy allows the 3D-visualization to drain abdominal and thoracic abscesses.

METHODOLOGICAL INNOVATION AND EVALUATION

Radiology has established itself in the treatment of acute emergencies or acute complications through gentle and usually fast minimally invasive procedures. Presumably, MRI interventions will become increasingly important in the near future and, thus, complement the portfolio.

PRACTICAL RECOMMENDATIONS

Every clinical radiologist who works on night shifts should be able to safely carry out some basic interventional techniques in order to stabilize the patient and at least ensure medically safe bridging to the next routine workday. Due to the diversity of materials and the rarity and difficulty of some procedures, the full portfolio requires years of expertise and will therefore remain restricted to specialized interventional radiologists.

Predictors of surgical management of high grade blunt splenic injuries in adult trauma patients: a 5-year retrospective cohort study from an academic level I trauma center

Backgrounds

Splenic injury accounts for 40% of all injuries after blunt abdominal trauma. Blunt splenic injury in hemodynamically unstable patients is preferably treated by splenectomy. Nowadays hemodynamically stable patients with low grade splenic injuries are mostly treated by non-operative management (NOM). However no consensus exists about the management of high grade splenic injuries in hemodynamically stable patients. Therefore the aim of this study was to analyze patients with high grade splenic injuries in our institution.

Methods

We retrospectively included all patients with a splenic injury presented to our level I trauma center during the 5-year period from January 1, 2012, until December 31, 2017. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on splenic injury and the treatment they received.

Results

A total of 123 patients were included, of which 93 (75.6%) were male with a median age of 31 (24–52) and a median injury severity score of 27 (17–34). High grade injuries (n = 28) consisted of 20 Grade IV injuries and 8 grade V injuries. Splenectomy was required in 15/28 (53.6%) patients, of whom all remained hemodynamically unstable after resuscitation, including all grade V injuries. A total of 13 patients with high grade injuries were treated with spleen preserving therapy. Seven of these patients received angio-embolization. One patient went for laparotomy and the spleen was treated with a hemostatic agent. Secondary hemorrhage was present in 3 of these patients (initial treatment: 1 embolization/ 2 observational), resulting in a success rate of 76.9%. There is no mortality seen in patient with high grade splenic injuries.

Conclusion

Non-operative treatment in high grade splenic injuries is a safe treatment modality in hemodynamically stable patients. Hemodynamic status and peroperative bleeding, not injury severity or splenic injury grade were the drivers for surgical management by splenectomy. This selected cohort of patients must be closely monitored to prevent adverse outcomes from secondary delayed bleeding in case of non-operative management.

Expert consensus on interventional therapy for traumatic splenic bleeding

This study aims to introduce the diagnosis and treatment processes of traumatic splenic bleeding and explain its emergency, medical, interventional, and surgical treatments. Furthermore, this study aims to summarize the indications and contraindications of splenic artery embolization, interventional procedures, and precautions of complications.

Metalophagia: Splenic artery pseudoaneurysm after foreign body ingestion and retrieval

Persistent eating of non-nutritive, nonfood substances (Pica) is seen in children and adult patients with psychiatric problems. Ingestion of multiple metallic FBs with resultant bezoar formation is rare. While many FBs are passed without complication, mucosal injury, bleeding, obstruction or perforation can occur in some cases. Endoscopic FB removal is performed in 20% of patients following FB ingestion. Generally, these are safe procedures, and very effective in extracting ingested FBs. We report, a 25-year-old male patient with a metal ingestion predominant Pica, requiring multiple prior extraction procedures (including open gastrostomy). He developed a splenic artery pseudoaneurysm following his latest endoscopic FB removal, that was successfully treated with transarterial coil embolization. The unique circumstances leading to this rare complication and its successful endovascular management make this case worthy of report.