Background: Portal Hypertension is a common complication of cirrhosis. It leads to splenomegaly which manifests with features of hypersplenism. This results in leucopenia which increases the likelihood of sepsis and prevents treatment with interferon. Thrombocytopenia increases the risk of bleeding including variceal bleeds which make the anemia worse. This study was done to determine the usefulness and safety of partial splenic artery embolization (PSAE) in portal hypertension due to cirrhosis. Methods: Patients with PSAE were identified by using International Classification of Diseases (ICD)-10 coding from medical records and their charts were reviewed retrospectively. 25 patients underwent splenic artery embolization at The Aga Khan University Hospital Karachi from November 2000 to December 2016. 18 patients who underwent PSAE for disabling hypersplenism caused by cirrhosis were included. Patients who were under 18 year of age, or in whom PSAE were performed for reasons other than cirrhosis and those with missing records/incomplete data were excluded (n = 7). Information was collected regarding demographic details, procedure indications, nature, technique, clinical efficacy, repeat embolization and complications along with laboratory and radiological investigations. Results: Eighteen patients of cirrhosis with a mean age of 43.47 ± 10.926 years, of which 14 were males, underwent PSAE (19 procedures). Indications were severe hypersplenism which precluded treatment with interferon and ribavirin (n = 8) and recurrent Gastro-oesophageal variceal (GOV) bleeds due to advanced Child-Pugh grade and thrombocytopenia (n = 10). Hematological parameters improved significantly following PSAE. Three out of eight patients successfully completed interferon + ribavirin treatment for hepatitis C (HCV) infection post PSAE, and GOV bleeds stopped in eight out of 10 patients. Complications included mild Left upper quadrant (LUQ) abdominal pain n = 9 (47.3%), post-embolization syndrome n = 4 (21%), and clinically insignificant pleural effusion n = 4 (21%). One patient developed spontaneous bacterial peritonitis (SBP) which was appropriately managed. One patient needed re-emobilization after 6 months. Conclusion: PSAE is a safe and effective procedure in the treatment of hypersplenism due to cirrhosis.
Ashraf, S. and Naeem, S. (2010) Frequency of Hypersplenism in Chronic Liver Disease Patients Presenting with Pancytopenia. Annals of King Edward Medical University, 16, 108-110.
Smith, M. and Ray, C.E. (2012) Splenic Artery Embolization as an Adjunctive Procedure for Portal Hypertension. Seminars in Interventional Radiology, 29, 135-139. https://doi.org/10.1055/s-0032-1312575
Madoff, D.C., Denys, A., Wallace, M.J., Murthy, R., Gupta, S., Pillsbury, E.P., et al. (2005) Splenic Arterial Interventions: Anatomy, Indications, Technical Considerations, and Potential Complications. RadioGraphics, 25, S191-S211. https://doi.org/10.1148/rg.25si055504
Gaba, R.C., Katz, J.R., Parvinian, A., Reich, S., Omene, B.O., Yap, F.Y., et al. (2013) Splenic Artery Embolization: A Single Center Experience on the Safety, Efficacy, and Clinical Outcomes. Diagnostic and Interventional Radiology, 19, 49-55.
Amin, M.A., El Gendy, M.M., Dawoud, I.E., Shoma, A., Negm, A.M. and Amer, T.A. (2009) Partial Splenic Embolization versus Splenectomy for the Management of Hypersplenism in Cirrhotic Patients. World Journal of Surgery, 33, 1702-1710. https://doi.org/10.1007/s00268-009-0095-2
Spigos, D., Jonasson, O., Mozes, M. and Capek, V. (1979) Partial Splenic Embolization in the Treatment of Hypersplenism. American Journal of Roentgenology, 132, 777-782. https://doi.org/10.2214/ajr.132.5.777
(2011) EASL Clinical Practice Guidelines: Management of hepatitis C Virus Infection. Journal of Hepatology, 55, 245-264. https://doi.org/10.1016/j.jhep.2011.02.023
AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C. http://www.hcvguidelines.org
Child, C.G. and Turcotte, J.G. (1964) Surgery and Portal Hypertension. Major Problems in Clinical Surgery, 1, 1-85.
Pugh, R.N., Murray-Lyon, I.M., Dawson, J.L., Pietroni, M.C. and Williams, R. (1973) Transection of the Oesophagus for Bleeding Oesophageal Varices. British Journal of Surgery, 60, 646-649.
Sakai, T., Shiraki, K., Inoue, H., Sugimoto, K., Ohmori, S., Murata, K., et al. (2002) Complications of Partial Splenic Embolization in Cirrhotic Patients. Digestive Diseases and Sciences, 47, 388-391. https://doi.org/10.1023/A:1013786509418
Outcome
Ahmad, K. (2004) Pakistan: A Cirrhotic State? The Lancet, 364, 1843-1844. https://doi.org/10.1016/S0140-6736(04)17458-8
Fahim, U., Khan, S., Afridi, A.K. and ur Rahman, S. (2012) Frequency of Different Causes of Cirrhosis of Liver in Local Population. Gomal Journal of Medical Sciences, 10, 178-181.
Arisar, F.A.Q., Khan, S.B. and Umar, A. (2014) Hepatic Encephalopathy in Chronic Liver Disease: Predisposing Factors in a Developing Country. Asian Journal of Medical Sciences, 6, 35-42.
Umar, A., Arisar, F.A.Q., Sattar, R.A. and Umar, B. (2014) Non-Invasive Parameters for the Detection of Variceal Bleed in Patients of Liver Cirrhosis, an Experience of a Tertiary Care Hospital in Pakistan. Asian Journal of Medical Sciences, 6, 61-66. https://doi.org/10.3126/ajms.v6i1.9624
Requarth, J.A., D’Agostino Jr., R.B. and Miller, P.R. (2011) Nonoperative Management of Adult Blunt Splenic Injury with and without Splenic Artery Embolotherapy: A Meta-Analysis. Journal of Trauma and Acute Care Surgery, 71, 898-903. https://doi.org/10.1097/TA.0b013e318227ea50
Loffroy, R., Guiu, B., Cercueil, J.-P., Lepage, C., Cheynel, N., Steinmetz, E., et al. (2008) Transcatheter Arterial Embolization of Splenic Artery Aneurysms and Pseudoaneurysms: Short- and Long-Term Results. Annals of Vascular Surgery, 22, 618-626. https://doi.org/10.1016/j.avsg.2008.02.018
Belli, A.-M., Markose, G. and Morgan, R. (2012) The Role of Interventional Radiology in the Management of Abdominal Visceral Artery Aneurysms. CardioVascular and Interventional Radiology, 35, 234-243. https://doi.org/10.1007/s00270-011-0201-3
McDermott, V.G., Shlansky-Goldberg, R. and Cope, C. (1994) Endovascular Management of Splenic Artery Aneurysms and Pseudoaneurysms. CardioVascular and Interventional Radiology, 17, 179-184. https://doi.org/10.1007/BF00571531
Hirai, K., Kawazoe, Y., Yamashita, K., Kumagai, M., Tanaka, M., Sakai, T., et al. (1986) Transcatheter Partial Splenic Arterial Embolization in Patients with Hypersplenism: A Clinical Evaluation as Supporting Therapy for Hepatocellular Carcinoma and Liver Cirrhosis. Hepatogastroenterology, 33, 105-108.
Koconis, K.G., Singh, H. and Soares, G. (2007) Partial Splenic Embolization in the Treatment of Patients with Portal Hypertension: A Review of the English Language Literature. Journal of Vascular and Interventional Radiology, 18, 463-481. https://doi.org/10.1016/j.jvir.2006.12.734
Albadry, A., Elbatea, H.E. and Elfert, A.A. (2010) Long-Term Outcome of Angiographic Partial Splenectomy in Patients with Decompensated Liver Cirrhosis and Hypersplenism. Arab Journal of Gastroenterology, 11, 202-205. https://doi.org/10.1016/j.ajg.2010.09.004
Nassef, A.A., Zakaria, A.A. and ElBary, M.S.A. (2013) Partial Splenic Artery Embolization in Portal Hypertension Patients with Hypersplenism: Two Interval-Spaced Sessions’ Technique. The Egyptian Journal of Radiology and Nuclear Medicine, 44, 531-537. https://doi.org/10.1016/j.ejrnm.2013.04.004
Sundaresan, J.B., Dutta, T., Badrinath, S., Jagdish, S. and Basu, D. (2005) Study of Hypersplenism and Effect of Splenectomy on Patients with Hypersplenism. Journal of Indian Academy of Clinical Medicine, 6, 291-296.
McCormick, P.A. (2007) Hypersplenism. Textbook of Hepatology: From Basic Science to Clinical Practice, 3rd Edition, 771-778.
Hayashi, H., Beppu, T., Masuda, T., Mizumoto, T., Takahashi, M., Ishiko, T., et al. (2007) Predictive Factors for Platelet Increase after Partial Splenic Embolization in Liver Cirrhosis Patients. Journal of Gastroenterology and Hepatology, 22, 1638-1642. https://doi.org/10.1111/j.1440-1746.2007.05090.x
Tajiri, T., Onda, M., Yoshida, H., Mamada, Y., Taniai, N. and Kumazaki, T. (2002) Long-Term Hematological and Biochemical Effects of Partial Splenic Embolization in Hepatic Cirrhosis. Hepatogastroenterology, 49, 1445-1448.
Zhu, K., Meng, X., Qian, J., Huang, M., Li, Z., Guan, S., et al. (2009) Partial Splenic Embolization for Hypersplenism in Cirrhosis: A Long-Term Outcome in 62 Patients. Digestive and Liver Disease, 41, 411-416. https://doi.org/10.1016/j.dld.2008.10.005
Pålsson, B., Hallén, M., Forsberg, A.M. and Alwmark, A. (2003) Partial Splenic Embolization: Long-Term Outcome. Langenbeck’s Archives of Surgery, 387, 421-426.
Hussein, W.M., Ahmed, A.T., Magdy, M., Amer, T.A. and Habba, M.R. (2017) Predictive Factors of Platelet Increase and Complications after Percutaneous Trans-Arterial Partial Splenic Embolization for Hypersplenism in Chronic Liver Disease Patients. The Egyptian Journal of Radiology and Nuclear Medicine, 48, 393-401. https://doi.org/10.1016/j.ejrnm.2017.01.010
Kumar, A., Yoon, J., Thakur, V. and Contractor, S. (2013) Abstract No. 317 Safety and Efficacy of Partial Splenic Embolization for Hypersplenism: A Meta-Analysis. Journal of Vascular and Interventional Radiology, 24, S138. https://doi.org/10.1016/j.jvir.2013.01.342
Hayashi, H., Beppu, T., Okabe, K., Masuda, T., Okabe, H. and Baba, H. (2008) Risk Factors for Complications after Partial Splenic Embolization for Liver Cirrhosis. British Journal of Surgery, 95, 744-750. https://doi.org/10.1002/bjs.6081