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Salei A, El Khudari H, McCafferty BJ, Varma RK. Portal Interventions in the Setting of Venous Thrombosis or Occlusion. Radiographics 2022; 42:1690-1704. [PMID: 36190859 DOI: 10.1148/rg.220020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
Portal vein thrombosis most commonly occurs as a complication of liver cirrhosis and can result in worsening symptoms of portal hypertension, which often can be challenging to treat with conventional decompression therapies. In addition, because complete portal vein thrombosis is associated with higher posttransplant morbidity and mortality, it is regarded as a relative contraindication to liver transplant. Often, the diagnosis of portal vein thrombosis is incidental; hence, imaging remains the mainstay for diagnosing this complication and is used to guide subsequent treatment. Although anticoagulation is the initial approach used to treat acute portal vein thrombosis, endovascular and/or surgical interventions may be necessary when there is concern for impending bowel ischemia. Treatment of chronic portal vein thrombosis is primarily aimed at alleviating the symptoms of portal hypertension and improving the chance of candidacy for liver transplant. Awareness of the portal venous anatomy to differentiate it from the periportal collaterals is key during recanalization of a chronically occluded portal vein. The authors provide an overview of the pathophysiology, acute and chronic imaging findings, and management of portal vein thrombosis, with a specific focus on endovascular management, as well as a summary of the current related literature. An invited commentary by Lopera and Yamaguchi is available online. ©RSNA, 2022.
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Affiliation(s)
- Aliaksei Salei
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Husameddin El Khudari
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Benjamin J McCafferty
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Rakesh K Varma
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
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Liu J, Wang Q, Ding X, Liu Q, Huang W, Gu J, Wang Z, Wu W, Wu Z. The clinical applicability of percutaneous splenic vein stent implantation for pancreatic portal hypertension. BMC Gastroenterol 2022; 22:136. [PMID: 35337294 PMCID: PMC8957150 DOI: 10.1186/s12876-022-02214-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pancreatic portal hypertension (PPH) is a type of extrahepatic portal hypertension. We compared the clinical efficacy of different treatment methods for PPH caused by splenic vein stenosis in chronic pancreatitis. Methods This article retrospectively analyzed the PPH cases that were caused by splenic vein stenosis after chronic pancreatitis. Patients were divided into three groups according to the different treatments: splenic vein stent implantation (stent group), splenectomy, and only medications (conservative group). The treatment effects from each group were compared. Results A total of 33 patients were retrospectively analyzed in this study (9, 12, and 12 patients in each group respectively). All the procedures were successful in the stent and splenectomy groups. During the follow-up, no patient had gastrointestinal bleeding recurrence in the stent and splenectomy groups. However, in the conservative group, the incidence of portal hypertensive gastropathy and upper gastrointestinal bleeding were 50% and 25%. In the stent group, all the varicose veins at the base of the stomach had shrunk by varying degrees, and the red color signs regressed. The stent patency rate was 100%. No major complication occurred. The average platelet count at 1, 3, 6-months postoperatively were all significantly higher than the preoperative value (P < 0.05). The average postoperative hospital stay duration was significantly shorter than that of the splenectomy group (3.1 ± 1.4 days vs. 16.1 ± 8.1 days; P < 0.05). In the splenectomy group, postoperative fever occurred in 4 patients. Postoperative infection occurred in 2 patients (one with abdominal cavity infection and the other with incision infection). Delayed abdominal bleeding occurred in one patient. Portal vein thrombosis occurred in 2 patients during follow up. Conclusion Percutaneous splenic vein stent implantation for PPH treatment reduces the risk of gastrointestinal bleeding with minimal invasive. It has a high safety and reliable efficacy and is worthy of further clinical promotion. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02214-z.
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Affiliation(s)
- Jingjing Liu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qingbing Wang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Xiaoyi Ding
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qin Liu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wei Huang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Junwei Gu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Zhongmin Wang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Wei Wu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Zhiyuan Wu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Liu J, Meng J, Yang M, Zhou C, Yang C, Huang S, Shi Q, Wang Y, Li T, Chen Y, Xiong B. Two-step complete splenic artery embolization for the management of symptomatic sinistral portal hypertension. Scand J Gastroenterol 2022; 57:78-84. [PMID: 34581650 DOI: 10.1080/00365521.2021.1983641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jie Meng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ming Yang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Kushiya H, Noji T, Abo D, Soyama T, Tanaka K, Nakanishi Y, Asano T, Nakamura T, Tsuchikawa T, Okamura K, Hirano S. Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports. Surg Case Rep 2019; 5:128. [PMID: 31396775 PMCID: PMC6687795 DOI: 10.1186/s40792-019-0687-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022] Open
Abstract
Background There is no definitive strategy for gastrointestinal bleeding due to left-sided portal hypertension after pancreaticoduodenectomy (PD) for pancreatic cancer (PC) with concomitant portal vein resection (PVR). Case presentation Case 1: A 70-year-old woman underwent a PD for PC with PVR. Seven years after her surgery, she suffered severe anemia with suspected gastrointestinal bleeding. Computed tomography scan (CT) revealed varices at a portion of the pancreaticojejunostomy (PJ). Angiography revealed that splenic venous flow drained into the varices and then into the portal vein. A diagnosis of bleeding varices of the PJ due to left-sided portal hypertension was made. Following a partial splenic artery embolization, her anemia improved. Case 2: An 80-year-old male underwent a PD for pancreatic head cancer combined with resection of the confluence of the portal and splenic veins with a reconstruction between the portal and superior mesenteric veins. Eighteen months after his surgery, he developed melena with negative endoscopy findings in his large and small bowel. CT revealed varices at the site of the PJ that communicated with the jejunal and portal veins. He underwent obliteration of the varices via a trans-portal-venous approach. As a result, he remained without melena until he died of PC 17 months after the embolization. Conclusions Left-sided portal hypertension following a PD with bleeding varices can be treated by interventional radiology with minimal invasiveness.
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Affiliation(s)
- Hiroki Kushiya
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takeshi Soyama
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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Tang SH, Zeng WZ, He QW, Qin JP, Wu XL, Wang T, Wang Z, He X, Zhou XL, Fan QS, Jiang MD. Repeated pancreatitis-induced splenic vein thrombosis leads to intractable gastric variceal bleeding: A case report and review. World J Clin Cases 2015; 3:920-925. [PMID: 26488031 PMCID: PMC4607813 DOI: 10.12998/wjcc.v3.i10.920] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/25/2015] [Indexed: 02/05/2023] Open
Abstract
Gastric varices (GV) are one of the most common complications for patients with portal hypertension. Currently, histoacryl injection is recommended as the initial treatment for bleeding of GV, and this injection has been confirmed to be highly effective for most patients in many studies. However, this treatment might be ineffective for some types of GV, such as splenic vein thrombosis-related localized portal hypertension (also called left-sided, sinistral, or regional portal hypertension). Herein, we report a case of repeated pancreatitis-induced complete splenic vein thrombosis that led to intractable gastric variceal bleeding, which was treated by splenectomy. We present detailed radiological and pathological data and blood rheology analysis (the splenic artery - after a short gastric vein or stomach vein - gastric coronary vein - portal vein). The pathophysiology can be explained by the abnormal direction of blood flow in this patient. To our knowledge, this is the first reported case for which detailed pathology and blood rheology data are available.
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Wang Q, Xiong B, Zheng C, Liang M, Han P. Splenic Arterial Embolization in the Treatment of Severe Portal Hypertension Due to Pancreatic Diseases: The Primary Experience in 14 Patients. Cardiovasc Intervent Radiol 2015; 39:353-8. [PMID: 26304614 PMCID: PMC4742494 DOI: 10.1007/s00270-015-1199-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 08/04/2015] [Indexed: 12/22/2022]
Abstract
Objective This retrospective study reports our experience using splenic arterial particle embolization and coil embolization for the treatment of sinistral portal hypertension (SPH) in patients with and without gastric bleeding. Methods From August 2009 to May 2012, 14 patients with SPH due to pancreatic disease were diagnosed and treated with splenic arterial embolization. Two different embolization strategies were applied; either combined distal splenic bed particle embolization and proximal splenic artery coil embolization in the same procedure for acute hemorrhage (1-step) or interval staged distal embolization and proximal embolization in the stable patient (2-step). The patients were clinically followed. Results In 14 patients, splenic arterial embolization was successful. The one-step method was performed in three patients suffering from massive gastric bleeding, and the bleeding was relieved after embolization. The two-step method was used in 11 patients, who had chronic gastric variceal bleeding or gastric varices only. The gastric varices disappeared in the enhanced CT scan and the patients had no gastric bleeding during follow-up. Conclusions Splenic arterial embolization, particularly the two-step method, proved feasible and effective for the treatment of SPH patients with gastric varices or gastric variceal bleeding.
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Affiliation(s)
- Qi Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, 430022, People's Republic of China.
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, 430022, People's Republic of China.
| | - ChuanSheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, 430022, People's Republic of China.
| | - Ming Liang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, 430022, People's Republic of China.
| | - Ping Han
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Road, Wuhan, 430022, People's Republic of China.
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7
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A rare case of splenic lymphoma in a patient with polymyositis manifesting as gastric variceal bleeding. Clin J Gastroenterol 2015; 8:92-6. [PMID: 25808874 DOI: 10.1007/s12328-015-0561-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/12/2015] [Indexed: 12/19/2022]
Abstract
We report an unusual case of upper gastrointestinal bleeding due to isolated gastric variceal bleeding in a patient with splenomegaly who was subsequently diagnosed with diffuse large B-cell lymphoma. The patient is a 47-year-old male with a history of polymyositis who presented to the emergency room with complaints of lightheadedness and melena for 2 days. On initial presentation, the patient had positive orthostatic vital signs. He was found to be anemic with presenting hemoglobin of 5.8 g/dl (compared with 13.4 g/dl 4 months prior to presentation). The patient was aggressively resuscitated with intravenous fluid and blood transfusions. An emergency esophagogastroduodenoscopy was performed which showed isolated gastric varices in the fundus of the stomach, with no active bleeding or high-risk stigmata. Abdominal computed tomography revealed focal splenic vein thrombosis and splenomegaly with ill-defined hypodensities. Portal and superior mesenteric veins were patent. Mild edema was seen surrounding the spleen and non-specific abdominal lymphadenopathy was also reported. A surgical consultation recommended an urgent splenectomy. Pathology of the removed spleen revealed diffuse large B-cell lymphoma. Positron emission tomography-computed tomography revealed lymphomatous disease in the thorax, abdomen, pelvis and bone marrow. The patient was subsequently started on chemotherapy.
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8
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Liu Q, Song Y, Xu X, Jin Z, Duan W, Zhou N. Management of bleeding gastric varices in patients with sinistral portal hypertension. Dig Dis Sci 2014; 59:1625-9. [PMID: 24500452 DOI: 10.1007/s10620-014-3048-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 01/23/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Sinistral portal hypertension (SPH) is a rare cause of upper gastrointestinal hemorrhage. Besides splenectomy, there is no consensus on the role of sclerotherapy and splenic embolization for bleeding gastric varices (GVs). This retrospective study summarizes our experience in managing GV bleeding from SPH in patients with pancreatic diseases. METHODS Patients with pancreatic diseases who had bleeding GVs from SPH in two tertiary hospitals were reviewed from January 2001 to December 2011. The etiology, clinical manifestations, diagnostic and therapeutic modalities were analyzed. RESULTS Twenty-one patients (15.2 %) complicating bleeding GVs among 139 patients with SPH secondary to pancreatic diseases were enrolled. The etiologies were acute pancreatitis in one patient, chronic pancreatitis in seven patients, and pancreatic tumors in 13 patients. Emergent endoscopic sclerotherapy was initially performed in five patients, and succeeded in two patients, while one patient died of massive hemorrhage. Initial transcatheter artery embolization using Gianturco coils was successfully performed in six patients. Splenectomy combined with other surgical procedures was undertaken for 15 patients. The patients undergoing artery embolization or splencetomy achieved hemostasis. The survivors had no recurrent bleeding during a median 72-month follow-up period. CONCLUSIONS The incidence of bleeding GVs from SPH is relatively rare. Splenic artery embolization could be selected as a first-line choice for bleeding SPH, especially for patients in poor conditions, and sclerotherapy may not be preferentially recommended. Further studies are required to evaluate the optimum treatment algorithm for bleeding GVs from SPH.
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Affiliation(s)
- Quanda Liu
- Department of Hepatobiliary Surgery, Second Artillery General Hospital PLA, Beijing, 100088, China,
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9
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Lee YB, Kim SM, Heo JS, Seok H, Shin IS, Eun YH, Kim DK. Idiopathic Splenic Vein Thrombosis Presenting as Splenic Infarction and Consequent Gastric Variceal Bleeding. J Lipid Atheroscler 2014. [DOI: 10.12997/jla.2014.3.2.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- You-Bin Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeri Seok
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Seub Shin
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeong Hee Eun
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk-Kyung Kim
- Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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10
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Stone PA, Phang D, Richmond B, Gill G, Campbell JE. Splenic artery embolization for the treatment of bleeding gastric varices secondary to splenic vein thrombosis. Ann Vasc Surg 2013; 28:737.e7-11. [PMID: 24495333 DOI: 10.1016/j.avsg.2013.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 06/21/2013] [Accepted: 07/10/2013] [Indexed: 01/10/2023]
Abstract
Splenic vein thrombosis can lead to gastric varices. Subsequent upper gastrointestinal bleeding may ensue related to the change in venous outflow to the portal system. Vascular surgeons are infrequently asked to assist in the management of this entity. However, with many vascular surgeons providing diverse endovascular-based interventions, understanding catheter-based solutions is imperative. This report presents a case in which arterial embolization was used to treat gastric variceal bleeding.
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Affiliation(s)
- Patrick A Stone
- West Virginia University, Charleston Division, Charleston, WV.
| | - David Phang
- West Virginia University, Charleston Division, Charleston, WV
| | - Bryan Richmond
- West Virginia University, Charleston Division, Charleston, WV
| | - Gurpreet Gill
- West Virginia University, Charleston Division, Charleston, WV
| | - John E Campbell
- West Virginia University, Charleston Division, Charleston, WV
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11
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Sankararaman S, Velayuthan S, Vea R, Herbst J. Severe gastric variceal bleeding successfully treated by emergency splenic artery embolization. Pediatr Int 2013; 55:e42-5. [PMID: 23782376 DOI: 10.1111/ped.12014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 08/27/2012] [Accepted: 10/30/2012] [Indexed: 01/26/2023]
Abstract
Bleeding from gastric varices due to splenic vein obstruction is extremely rare in children, but it can be catastrophic. Reported herein is the case of a teenager with splenic vein thrombosis and chronic decompensated liver disease from autoimmune hepatitis who presented with massive gastric variceal bleeding. Standard medical management did not control the bleeding. Due to decompensated liver disease and continuous active bleeding, emergency partial splenic artery embolization was preferred over splenectomy or a shunt procedure. Bleeding was successfully controlled by partial splenic artery embolization by decreasing the inflow of blood into the portal system. It is concluded that emergency partial splenic artery embolization is a safer alternative life-saving procedure to manage severe gastric variceal bleeding due to splenic vein obstruction in a patient with high surgical risk. To our knowledge, only one other patient with similar management has been reported in the pediatric age group.
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Affiliation(s)
- Senthilkumar Sankararaman
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA.
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12
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Allen LM, Behrens G, Patel NH, Ferral H. Splenic artery embolization and balloon occlusion retrograde alcohol embolization in a patient with bleeding gastric varices. Semin Intervent Radiol 2011; 24:53-7. [PMID: 21326737 DOI: 10.1055/s-2007-971186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We present a patient with a large spontaneous splenorenal shunt secondary to isolated splenic vein thrombosis who developed severe bleeding from fundal gastric varices. The patient was managed emergently with splenic artery embolization and balloon occlusion retrograde embolization of the varices with alcohol. We discuss the clinical presentation, embolization techniques, and a potential complication of the use of alcohol for this purpose.
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13
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Paramythiotis D, Papavramidis TS, Giavroglou K, Potsi S, Girtovitis F, Michalopoulos A, Papadopoulos VN, Prousalidis J. Massive variceal bleeding secondary to splenic vein thrombosis successfully treated with splenic artery embolization: a case report. J Med Case Rep 2010; 4:139. [PMID: 20482817 PMCID: PMC2890017 DOI: 10.1186/1752-1947-4-139] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 05/19/2010] [Indexed: 02/07/2023] Open
Abstract
Introduction Splenic vein thrombosis results in localized portal hypertension called sinistral portal hypertension, which may also lead to massive upper gastrointestinal bleeding. Symptomatic sinistral portal hypertension is usually best treated by splenectomy, but interventional radiological techniques are safe and effective alternatives in the management of a massive hemorrhage, particularly in cases that have a high surgical risk. Case presentation We describe a 23-year-old Greek man with acute massive gastric variceal bleeding caused by splenic vein thrombosis due to a missing von Leiden factor, which was successfully managed with splenic arterial embolization. Conclusions Interventional radiological techniques are attractive alternatives for patients with a high surgical risk or in cases when the immediate surgical excision of the spleen is technically difficult. Additionally, surgery is not always successful because of the presence of numerous portal collaterals and adhesion. Splenic artery embolization is now emerging as a safe and effective alternative to surgery in the management of massive hemorrhage from gastric varices due to splenic vein thrombosis, which often occurs in patients with hypercoagulability.
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Affiliation(s)
- Daniel Paramythiotis
- First Propedeutic Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Cohen DL. Electronic clinical challenges and images in GI. Image 1: Gastric variceal hemorrhage owing to splenic vein thrombosis in a patient with idiopathic retroperitoneal fibrosis. Gastroenterology 2008; 135:e1-2. [PMID: 18851970 DOI: 10.1053/j.gastro.2008.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Daniel L Cohen
- Division of Gastroenterology, New York University Medical Center, New York, New York, USA
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Sato T, Yamazaki K, Akaike J, Toyota J, Karino Y, Ohmura T. Clinical and endoscopic features of gastric varices secondary to splenic vein occlusion. Hepatol Res 2008; 38:1076-82. [PMID: 18498359 DOI: 10.1111/j.1872-034x.2008.00376.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM This study provides a retrospective evaluation of cases with gastric varices secondary to splenic vein occlusion. METHODS Our study group consisted of 14 patients. The clinical manifestations, diagnostic methods and therapeutic modalities were analyzed retrospectively. RESULTS Eleven patients had co-existing pancreatic diseases: seven with chronic pancreatitis, three with cancer of the pancreatic body or tail and one with severe acute pancreatitis. Among the three remaining patients, one had advanced left renal cancer, one had myeloproliferative disease and the third had splenic vein occlusion due to an obscure cause. A diagnosis of gastric varices was made following endoscope gastroduodenoscopy or endoscopic color Doppler ultrasonography (ECDUS), and splenic vein occlusions were diagnosed from enhanced computed tomography in all cases. Specific findings of gastric varices secondary to splenic vein occlusion were based on ECDUS color flow images of gastric variceal flow that clearly depicted round cardiac and fundal regions at the center, with varices expanding to the curvatura ventriculi major of the gastric body. For three cases with gastric variceal bleeding, endoscopic injection sclerotherapy using a mixture of histoacryl and lipiodol (70% histoacryl solution) was performed, after which no further bleeding from gastric varices was detected. Due to a high risk of gastric variceal rupture, splenectomy was performed in two cases and splenic arterial embolization in another two cases. CONCLUSION ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion. Treatment should take into account the diseases underlying these conditions.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
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Madoff DC, Denys A, Wallace MJ, Murthy R, Gupta S, Pillsbury EP, Ahrar K, Bessoud B, Hicks ME. Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications. Radiographics 2006; 25 Suppl 1:S191-211. [PMID: 16227491 DOI: 10.1148/rg.25si055504] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Splenic arterial interventions are increasingly performed to treat various clinical conditions, including abdominal trauma, hypersplenism, splenic arterial aneurysm, portal hypertension, and splenic neoplasm. When clinically appropriate, these procedures may provide an alternative to open surgery. They may help to salvage splenic function in patients with posttraumatic injuries or hypersplenism and to improve hematologic parameters in those who otherwise would be unable to undergo high-dose chemotherapy or immunosuppressive therapy. Splenic arterial interventions also may be performed to exclude splenic artery aneurysms from the parent vessel lumen and prevent aneurysm rupture; to reduce portal pressure and prevent sequelae in patients with portal hypertension; to treat splenic artery steal syndrome and improve liver perfusion in liver transplant recipients; and to administer targeted treatment to areas of neoplastic disease in the splenic parenchyma. As the use of splenic arterial interventions increases in interventional radiology practice, clinicians must be familiar with the splenic vascular anatomy, the indications and contraindications for performing interventional procedures, the technical considerations involved, and the potential use of other interventional procedures, such as radiofrequency ablation, in combination with splenic arterial interventions. Familiarity with the complications that can result from these interventional procedures, including abscess formation and pancreatitis, also is important.
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Affiliation(s)
- David C Madoff
- Division of Diagnostic Imaging, Interventional Radiology Section, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 325, Houston, TX 77030-4009, USA.
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Cakmak O, Parildar M, Oran I, Sever A, Memis A. Sinistral portal hypertension; imaging findings and endovascular therapy. ACTA ACUST UNITED AC 2005; 30:208-13. [PMID: 15654577 DOI: 10.1007/s00261-004-0231-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2003] [Revised: 04/07/2004] [Indexed: 12/11/2022]
Abstract
Sinistral portal hypertension, a rare and localized form of portal hypertension, is the result of splenic vein thrombosis or obstruction and may cause gastrointestinal hemorrhages from the esophageal and gastric varices. This report presents two cases (69- and 10-year-old females) of bleeding gastric varices. The patients were diagnosed as having sinistral portal hypertension. Splenic artery embolization was performed in both patients to overcome intractable bleeding, and the clinical outcome was good.
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Affiliation(s)
- O Cakmak
- Department of Radiology, Faculty of Medicine, Ege University, Bornova, Izmir, Turkiye Izmir, Turkey.
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18
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Abstract
OBJECTIVE Regional portal hypertension (RPH) results from splenic vein thrombosis/occlusion, with emergence of gastric varices and severe upper gastrointestinal bleeding. Its diagnosis and management are summarized below. METHODS We reviewed our experience in 16 consecutive patients with RPH at Chinese PLA General Hospital between 2001 and 2004. The clinical manifestations, diagnostic methods and therapeutic modalities were analyzed retrospectively. RESULTS Among the 16 patients with RPH, 12 had co-existing pancreatic diseases and 4 were of obscure origin. The main clinical findings were splenomegaly in 16 (100%), epigastric pain (mainly left upper abdomen) in 10 (63%), gastrointestinal bleeding in 7 (44%) and abdominal mass in 3 (19%). All had normal liver function tests. The main diagnostic methods used were ultrasound (US), computerized tomography (CT) and endoscopy. Splenic vein thrombosis could be identified by color Doppler ultrasound (7/7), enhanced CT could show its enlarged and tortuous short gastric vein, gastroepiploic vein, and collateral vessels around the splenic hilum (16/16). Isolated gastric varices (4/5) were mainly shown by esophagogastroscopy. Splenectomy was effective in controlling the variceal bleeding, but portal vein thrombosis occurred in 1 case. Endoscopic sclerotherapy had been carried out repeatedly in 2 cases, but was less effective (1/2, 50%). CONCLUSIONS Precise diagnosis of RPH can be achieved by clinical manifestations, US and CT. Therapeutic options should be individualized basing on the underlying diseases, however, splenectomy is more preferable for patients with bleeding varices, and endoscopic sclerotherapy can be tried.
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Affiliation(s)
- Quan Da Liu
- Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China.
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Hasan RA, Inoue S, Bruch SW, Onwuzurike N, Golladay ES. Variceal hemorrhage 13 years after nephrectomy for Wilms tumor. J Pediatr Gastroenterol Nutr 2005; 40:600-2. [PMID: 15861023 DOI: 10.1097/01.mpg.0000155564.87150.c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Rashed A Hasan
- Michigan State University College of Human Medicine, Hurley Medical Center, Flint, Michigan, USA
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Maier JP, Weiss WM. Variceal hemorrhage 18 years after pancreatectomy for nesidioblastosis: a case report and discussion. J Pediatr Surg 2003; 38:1102-5. [PMID: 12861551 DOI: 10.1016/s0022-3468(03)00204-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Nesidioblastosis is a rare condition that requires near-total pancreatectomy in a minority of cases. Splenic vein thrombosis resulting in gastric variceal hemorrhage has not been a previously reported complication from 95% pancreatectomy for this indication. A case is presented and the management of this unusual complication discussed.
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Affiliation(s)
- Joel Patrick Maier
- Department of Surgery, The Mary Imogene Bassett Hospital, Cooperstown, NY, USA
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