Effect of splenic artery embolization for splenic artery steal syndrome in liver transplant recipients: estimation at computed tomography based on changes in caliber of related arteries

Purpose

To estimate the effect of splenic artery embolization (SAE) on blood flow in orthotopic liver transplantation (OLT) recipients with splenic artery steal syndrome (SASS) based on changes in caliber of related arteries upon serial computed tomography (CT) scans.

Methods

Between 2004 and 2007, nine OLT recipients with SASS underwent SAE. They had CT scans before and after SAE: short-, mid-, and long-term, ie, approximately 1 week, 1 month, and 1 year, respectively. The diameters of the celiac axis (CA), common hepatic artery (CHA), and splenic artery (SA) were measured with arterial phase of each CT scan and the ratios of SA to CHA diameter (SA/CHA) calculated to analyze their changes during the follow-up period.

Results

The diameters of celiac axis, CHA, and SA and SA/CHA changed most rapidly during the short-term period. The CHA diameter significantly increased short-term post-SAE by CT and slightly decreased thereafter. However, the mid-term and long-term post-SAE CT values were still significantly greater than those on the pre-SAE CT. The SA diameter steadily decreased throughout the follow-up. The SA/CHA decreased until the mid-term. The SA diameter and SA/CHA were significantly smaller upon mid-term and long-term post-SAE CT compared with those at pre-SAE CT.

Conclusions

The effect of SAE to improve hepatic arterial flow in OLT recipients with SASS might be expected for at least approximately one year. The effect maximally occurred during the short-term after SAE on the basis of changes in the caliber of related arteries upon CT.     

Aneurysm of anomalous splenic artery arising from a splenomesenteric trunk: Review of the literature with a report of a new case

IntroductionAneurysm of splenic artery arising from splenomesentric trunk is an extremely rare condition. The aim of this study is to report a new case with literature review.Presentation of caseA 52-year-old housewife presented with mild central abdominal pain for two month duration. Abdomen was soft. Abdominal ultrasound examination showed a focal aneurysmal dilatation in the splenic artery (SA) near the portal vein. Abdominal computed tomographic angiography (CTA) revealed presence of the splenomesentric trunk with fusiform aneurysm (45 × 33 mm) of the proximal part of the SA. In supine position, through upper midline laparotomy incision, exploration of both superior mesenteric artery (SMA) and SA was performed, total excision of the aneurysm was done, the SMA was side-repaired and SA was ligated. The post-operative period was uneventful.DiscussionIt is interesting to note that orthotopic SA aneurysms, most commonly present in the distal third of the artery, followed by the middle third, while in cases of splenomesentric trunk, all reported cases of anomalous SA aneurysms including the current one, showed the aneurysms to be located in the proximal portion or root of the SA.ConclusionSplenomesentric trunk is a rare anatomical anomaly, aneurysm of which is even rarer. It can be managed either by endovascular intervention or open surgery.     

部分脾动脉栓塞术治疗肝硬化门静脉高压症的临床疗效分析

目的探讨部分脾动脉栓塞术（PSE）治疗肝硬化门静脉高压症的临床疗效。方法选取我院62例肝硬化食管胃底静脉曲张破裂出血和脾功能亢进患者。全组均行PSE,观察手术前后外周血象变化,门静脉、脾静脉管径变化及术后并发症发生情况。结果PSE术后白细胞、血小板计数高于术前（P〈0．05）;门静脉、脾静脉管径较术前缩小（P〈0．05）,全组病例无严重并发症发生。结论PSE治疗肝硬化并脾功能亢进操作简便、创伤较小、疗效稳固,可以抢救和预防再出血,尤适用于高危病重、老年不适于手术治疗者,是值得临床推广和应用的手术方法。     

Giant splenic artery aneurysm

Giant aneurysms of the splenic artery are uncommon. The mean size of splenic artery aneurysms is reported to be 2.1 cm; they are rarely larger than 3 cm. We present two cases in which the splenic artery aneurysm was larger than 8 cm, discuss the management and operative approach to these infrequently encountered entities, and provide a brief review of the relevant literature.     

Significance of an enlarged splenic artery in patients with splenic vein thrombosis

In an attempt to determine the relationship, if any, between the size of the splenic artery and various clinical aspects of splenic vein thrombosis, including splenomegaly, the clinical and angiographic findings in ten patients with this disorder were reviewed. The size of the splenic artery was found to be unrelated to the nature of the underlying disease, age of the patient, or history of variceal bleeding. An abnormally wide and tortuous splenic artery was identified only in those patients (five) in whom there was also radiographic evidence of splenic enlargement. Since the angiographic finding of an enlarged and tortuous splenic artery is known to correlate closely with increased flow in this vessel, this observation suggests that in patients with isolated splenic vein obstruction an increase in splenic artery flow accompanies splenic enlargement and is probably a critical component of the underlying derangement.     

Hemosuccus pancreaticus from intraductal rupture of a primary splenic artery aneurysm

Hemosuccus pancreaticus—blood entering the gastrointestinal tract through the pancreatic duct—is a rare and elusive form of gastrointestinal bleeding. The most common cause is a splenic artery pseudoaneurysm caused by acute or chronic inflammation of the pancreas. We report the case of an 86-year-old woman who had recurrent gastrointestinal bleeding from erosion of an aneurysm of the splenic artery into the pancreatic duct. The lack of associated symptoms, equivocal endoscopic findings, and the rarity of this entity resulted in a delay in diagnosis. Nonresective treatment by ligation of the splenic artery proximal and distal to the aneurysm prevented any additional bleeding. Postoperative technetium sulfur colloid scanning demonstrated normal perfusion of the spleen. Only 16 cases of hemosuccus pancreaticus from primary splenic artery disease have previously been reported in the English-language literature (15 primary aneurysms, one medial disruption without an aneurysm). In contrast to cases caused by inflammatory pseudoaneurysms, splenic artery - pancreatic duct fistulas caused by primary aneurysms of the splenic artery should be treated without pancreatic or splenic resection, either with surgery or by embolization. In elderly patients with recurrent gastrointestinal bleeding of obscure source, the differential diagnosis should include the possibility of a ruptured aneurysm communicating with a viscus. (J VASC SURG 1994;19:158-64.)     

脾动脉分支血管直径比值法计算脾脏栓塞体积百分比的临床应用

目的探讨脾动脉分支血管直径比值法计算脾脏栓塞体积的临床应用价值。方法回顾性分析20例接受部分脾动脉栓塞术治疗的肝硬化合并脾功能亢进患者的资料。根据术中脾动脉的血管造影图像,测量脾动脉分支血管的直径并计算脾脏栓塞体积百分比。对所有患者均于术后1个月行增强CT检查,并基于VR重建图像计算脾脏栓塞体积百分比。观察术后并发症及不良反应情况,于术前3天、术后1周、1个月、3个月检测外周血红细胞、白细胞及血小板,并进行统计学分析。结果部分脾动脉栓塞术中采用脾动脉分支血管直径比值法计算脾脏栓塞体积百分比[(52.15±3.29)%]与术后1个月CT测量栓塞体积百分比[(49.99±6.02)%]差异无统计学意义(t=-1.630,P=0.120)。所有患者术后均出现中度或中度以下左上腹疼痛,并出现恶心、呕吐、发热症状,均经对症治疗后好转。术前3天、术后1周、1个月、3个月外周血外周血红细胞、白细胞及血小板差异均有统计学意义(P均0.001)。结论部分脾动脉栓塞术中应用脾动脉分支血管直径比值法评估脾脏栓塞体积,简便、实时且较为准确,值得临床推广应用。     

Multiple aneurysms of the splenic artery caused by fibromuscular dysplasia

Splenic artery aneurysms (SAAs) are relatively rare. Moreover, there has been only one previous report of fibromuscular dysplasia (FMD) affecting the splenic artery alone. We describe a 64-year-old man with long, segmental, large, and multiple SAAs in whom the splenic artery branched from the aorta. The patient underwent endoaneurysmorrhaphy and splenectomy, with ligation in the proximal segment of the splenic artery. Histopathological analyses of resected specimens showed characteristics compatible with FMD. To our knowledge, long, segmental, large, and multiple SAAs caused by FMD have not previously been reported.     

Hepatic and splenic artery aneurysms

Accounting for 80% of all visceral artery aneurysms, splenic and hepatic artery lesions are rare but potentially life threatening. Although their natural history has not been well-defined, the high mortality associated with emergent repair suggests an aggressive approach is indicated. While repair is clearly mandated in patients with a symptomatic aneurysm or contained rupture, the following asymptomatic lesions also warrant intervention: (1) splenic artery aneurysms in patients with the potential to become pregnant or requiring liver transplantation, (2) hepatic aneurysms in patients with polyarteritis nodosa or fibromuscular dysplasia, (3) splenic or hepatic artery aneurysms greater than 2.0 cm in diameter, and (4) splenic or hepatic pseudoaneurysms. Although open surgical interventions have traditionally been the mainstay of therapy, endovascular techniques have increasingly been applied to this problem. Dictated predominately by the need to maintain distal end-organ perfusion, potential therapies include open surgical ligation, autogenous reconstruction, endovascular coil embolization, or percutaneous endograft placement. While offering alternative approaches, endovascular techniques have not dramatically altered the risk-to-benefit ratio in asymptomatic lesions, and both open and percutaneous approaches present viable options for elective repair. Although explored in only a limited number of patients, the application of endovascular techniques to the symptomatic patient offers the greatest potential for significant improvements in morbidity and mortality.     

部分脾动脉栓塞术治疗重症急性胰腺炎合并胰源性门静脉高压症的临床分析

背景与目的：重症急性胰腺炎（SAP）患者病情危重、进展迅速,具有较多的并发症,其中,胰源性门静脉高压症（PPH）是一种局限性区域性的门静脉高压症。部分患者PPH代偿较好,无明显的临床症状,仅在检查时发现存在脾大等情况,只需内科保守治疗并定期随访即可;对于出现PPH相关症状的患者,目前推荐行脾脏切除术。然而SAP合并PPH的患者,其全身一般情况较差,炎性水肿和腹腔感染较重,行脾脏切除术有加重感染和出血的风险,针对该类患者的治疗方法,目前国内外缺少一定的推荐及共识。因此,本研究主要探讨部分脾动脉栓塞术（PSE）治疗有症状的SAP合并PPH患者的临床效果以及处理的指征、时机和流程方法。方法：回顾性总结2014年1月—2021年12月南京大学医学院附属金陵医院重症医学科收治的15例SAP合并PPH患者的临床资料,分析患者采用PSE治疗PPH的临床诊疗经过及预后,观察患者PPH临床症状缓解情况、实验室血常规检验结果、影像学检查结果、术后并发症情况、是否有PPH症状再发。术后3 d与1、3、6个月进行影像学评估,术前及术后1年进行SF-36生活质量量表评分。结果：15例患者入院后均给予常规补液、抗...     

Multidetector computed tomographic angiography findings of splenic artery steal syndrome in liver transplantation

AIMS: Splenic artery steal syndrome, a common complication in liver transplantation, is diagnosed by conventional angiography showing an enlarged splenic artery and by dynamic findings. The aim of this study was to determine multidetector computed tomographic angiography (MDCTA) findings of splenic artery steal syndrome to develop diagnostic criteria. MATERIALS AND METHODS: Ten patients were diagnosed as displaying splenic artery steal syndrome among 198 liver transplant patients. The diagnosis was confirmed by celiac angiography. In eight of them, MDCTA was performed. Axial and coronal maximum-intensity projection images were obtained in arterial and portal phases. We measured the diameter of the celiac trunk and of the splenic, left gastric, common hepatic, superior mesenteric artery, and transplant hepatic arteries. We also measured the diameter of the proximal and the distal segments of the abdominal aorta, along with the size of the spleen, the ratio of the splenic artery to the common hepatic artery, the ratio of splenic artery to transplant hepatic artery, the diameter of portal vein and superior mesenteric vein. The control group consisted of liver transplant patients with normal liver enzyme levels. We performed Student t test for statistical examination. RESULTS: The diameter of the splenic artery (P<.05), the size of the spleen (P<.01), and the ratio of the splenic to the transplant hepatic arteries (P<.05) was significant between the two groups. The diameter of the splenic artery was larger than 4 mm in all patients in the study group. CONCLUSIONS: Conventional angiography was mandatory for the diagnosis of splenic artery steal syndrome. MDCTA is a noninvasive method. Some computed tomography criteria are important for early diagnosis and treatment.     

Laparoscopic resection of splenic artery aneurysms

Background Laparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently.Methods A laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients.Results One patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 ± 12.6 ml, the mean operative time was 187.6 ± 79.2 min, and the mean postoperative length of hospital stay was 1.8 ± 1.3 days. The mean time to a clear liquid diet was 5.3 ± 0.5 h, and the mean time to a regular diet was 1 ± 0 day. The mean duration of narcotic analgesic use was 5.4 ± 1.5 days, and the mean time to resumption of regular activities was 12.7 ± 1.6 days.Conclusions These cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.     

Partial splenic embolization. An effective alternative to splenectomy for hypersplenism

Splenectomy for massive splenomegaly and hypersplenism carries a significant morbidity and mortality. We have used partial splenic embolization (PSE) as an effective alternative to splenectomy. Ten PSE procedures were performed on nine patients without mortality and with minimal morbidity. The age of the patients ranged from 8 months to 32 years (mean 14 years). The causes of splenomegaly and hypersplenism included cystic fibrosis with cirrhosis (2), tyrosinemia and cirrhosis (1); thalassemia (1), hemophilia with Human Immune Deficiency Virus infection (2), chronic hepatitis with portal hypertension (1), malignant histiocytosis (1), and Wiskott-Aldrich Syndrome (1). All procedures were performed under local anesthesia with sedation. A percutaneous femoral artery approach to the splenic artery was used to deliver Ivalon sponge particles (280-800 microns) into the spleen. Splenic infarction was assessed by postembolization angiograms. All of the patients except one demonstrated improvement of hematologic parameters. In one patient, however, cytopenia improved only after a second embolization. In the total series, there was an early mean rise of 8,600/mm3 in the leukocyte count (range 2,900-14,900) and 212,000/mm3 in the platelet count (range 30,000-718,000). Follow-up ranged from 4 months to 7 years. Improvement of the blood picture has been persistent in seven of the eight patients who showed initial improvement. Transient procedural complications included fever (5), pleural effusion (2), pneumonia (1), and splenic abscess (1). One patient had paralytic ileus lasting for 10 days and one patient developed a streptococcal peritonitis 3 weeks after embolization. No patient developed pancreatitis or vascular compromise of other abdominal viscera.(ABSTRACT TRUNCATED AT 250 WORDS)     

Endovascular management of a splenic artery aneurysm

Splenic artery aneurysms represent the third most common aneurysm in the abdomen. The majority are asymptomatic and discovered incidentally by abdominal imaging. The overall rupture rate is low but the associated mortality rate is high, especially in pregnant women and patients with portal hypertension. Traditionally, open surgical modalities represented the only viable treatments. More recently, laparoscopic and endovascular techniques have been applied to these vascular lesions. We report a case of a giant splenic artery aneurysm that was diagnosed incidentally and managed successfully by percutaneous splenic artery embolization. The case is presented and general considerations regarding the presentation, diagnosis, and management of splenic artery aneurysms are reviewed.     

Successful surgical treatment for aneurysm of splenic artery with anomalous origin.

The splenic artery is the third common site of an infrarenal abdominal arterial aneurysm after the abdominal aorta and iliac arteries, and the most common site of a visceral artery aneurysm. It is a rare, but clinically important form of vascular disease with the potential for life-threatening rupture. We report a 64-year-old woman with a splenic artery aneurysm. Though she was asymptomatic, calcification around the left upper quadrant was incidentally detected. A saccular aneurysm with calcification located in the proximal portion of the splenic artery was detected by computed tomography (CT). Anomalous origin of the splenic artery, from the superior mesenteric artery (SMA), was also detected. Aneurysmal resection without splenectomy was carried out successfully. A suitable approach to aneurysms must be selected in each case, because the splenic artery exhibits congenital anomaly in 10% of all the people.     

经导管弹簧圈栓塞治疗脾动脉瘤

目的探讨经导管弹簧圈栓塞治疗脾动脉瘤的临床应用价值。方法回顾性分析接受经导管弹簧圈栓塞治疗的18例脾动脉瘤患者的资料,其中真性脾动脉瘤14例,假性脾动脉瘤4例;近端型6例,中间型4例,脾门型8例。根据患者脾动脉造影情况,选择普通弹簧圈、微弹簧圈或机械可脱式弹簧圈进行栓塞。术后1周及1、3、9个月行CT增强或CTA复查,随后每月行电话随访。结果对18例均顺利完成手术,11例采用隔绝旷置术,4例采用瘤腔填塞术,3例采用隔绝旷置术+瘤腔填塞术。术后12例出现栓塞后综合征,其中8例出现不同程度的脾梗死,梗死体积约10%~35%;余4例为轻微并发症。随访中无瘤体增大、破裂或复发及相关并发症。结论经导管弹簧圈栓塞治疗脾动脉瘤简单可行、安全有效。     

脾动脉瘤的传统手术和腔内治疗的比较

目的:比较脾动脉瘤的传统手术方法与血管腔内微创治疗。方法:回顾性总结1999年7月至2009年10月收治的46例脾动脉瘤病例,其中20例采用传统手术方法,包括近、远端动脉结扎加脾动脉瘤旷置术,动脉瘤切除加脾动脉重建术,脾动脉瘤切除加脾脏切除术等3种术式;26例采用血管腔内治疗方法,即脾动脉介入栓塞术。比较两组的手术时间、术后并发症、术后死亡率及近期随访的结果。结果:腔内治疗组的平均手术时间和住院天数明显少于传统手术组,差异有统计学意义[(47.3±14.5)min比(108.7±16.4)min,P=0.037;(3.6±1.3)d比(9.2±1.6)d,P=0.025]。传统手术组术中术后需输血的有3例,1例合并亚急性心内膜炎病人术后因心功能不全引发多脏器功能衰竭而死亡;而血管腔内治疗组术中、术后无输血病例,无围手术期死亡病例。血管腔内治疗组术后平均随访14个月,1例术后12个月瘤体仍有少量内漏,但瘤体直径未增大;其余病例瘤体均缩小。结论:与传统手术相比,血管腔内治疗具有安全、微创、恢复快等特点,应成为脾动脉瘤治疗方法的首选。     

Splenic conservation and the management of splenic artery aneurysm

We report two patients with splenic artery aneurysm diagnosed by CT, treated by proximal and distal ligation of the splenic artery and followed for two years by CT to assess splenic size and pitted erythrocyte counting to assess function. Literature review shows that excision of the aneurysm and splenectomy is usual but with growing regard for conservation of splenic tissue we suggest that proximal and distal ligation of the artery is a preferable alternative as shown by splenic function tests in these patients.     

脾动脉瘤的诊断和治疗

目的：总结16例脾动脉瘤的外科诊治经验。方法：回顾性分析收治的16例脾动脉瘤患者的临床资料。其中男4例,女12例,经超声多普勒、CT血管造影（CTA）等检查发现脾动脉瘤15例,另1例术中探查发现。手术治疗11例,其中脾动脉瘤破裂行急诊手术4例,择期性手术7例,手术包括脾动脉瘤及脾切除9例,同时切除胰尾3例,脾动脉瘤切除、脾动脉重建1例,脾动脉瘤切除、近远端脾动脉结扎1例。另外行脾动脉瘤介入栓塞3例,非手术治疗2例。结果：手术及介入治疗的14例患者治疗后未发生严重的并发症,无死亡,均康复出院。术后随访0.5~19.0年,平均8.4年。11例手术及介入治疗者中,2例分别手术后3,7年死于其他疾病,另9例情况良好。2例非手术治疗者已分别随访3,5年,脾动脉瘤无变化。结论：脾动脉瘤女性多发;CT血管造影和多普勒超声等可明确诊断;早期切除动脉瘤或介入栓塞术是防止破裂出血导致死亡的有效方法。     

Improved graft function in liver‐transplanted patients after partial splenic embolization: reversal of splenic artery steal syndrome?

AIM: To describe the functional effect of partial splenic embolization (PSE) in liver-transplanted (LT) patients with hypersplenism and hepatitis C virus (HCV) recurrence. PATIENTS AND METHODS: From May 2002 to May 2005, five LT patients with persistent hypersplenism, viral recurrence and graft dysfunction underwent PSE prior to pegylated interferon/ribavirin (peg-IFN/RBV). RESULTS: The mean splenic size was 19.5 cm (16-21) and there was evidence of an enlarged splenic artery (10.7+/-1 mm). PSE produced a median splenic infarction of 90% and a significant reduction in the splenic artery diameter to 5.8+/-0.4 mm (p=0.04). PSE significantly improved hematologic parameters, bilirubin levels, prothrombin activity, international normalized ratio and the Model for End-stage Liver Disease (MELD) score despite high HCV-RNA (6.2 log10 IU/mL). It was demonstrated histologic amelioration of ischemic changes in all subjects. PSE allowed the safe use of full-dose peg-IFN plus RBV in all subjects. CONCLUSIONS: In HCV LT patients with chronic graft dysfunction and cholestasis the improvement in the liver function following PSE might be due to the reversal of an undiagnosed splenic artery steal syndrome related to chronic hypersplenism masked by HCV recurrence.