Download PDF
CC BY-NC-ND 4.0 · Journal of Clinical Interventional Radiology ISVIR 2019; 03(01): 027-036
DOI: 10.1055/s-0038-1675858
Review Article
Indian Society of Vascular and Interventional Radiology

Role of Splenic Artery Embolization in Gastric Variceal Hemorrhage due to Sinistral Portal Hypertension

Bibin Sebastian
1   Department of Interventional Radiology and Interventional Oncology, BGS Gleneagles Global Hospitals, Bangalore, India
,
Soumil Singhal
1   Department of Interventional Radiology and Interventional Oncology, BGS Gleneagles Global Hospitals, Bangalore, India
,
Rohit Madhurkar
1   Department of Interventional Radiology and Interventional Oncology, BGS Gleneagles Global Hospitals, Bangalore, India
,
Arun Alex
2   Department of Gastroenterology, Government Medical College, Calicut, India
,
M. C. Uthappa
1   Department of Interventional Radiology and Interventional Oncology, BGS Gleneagles Global Hospitals, Bangalore, India
› Author Affiliations
Further Information

Publication History

Received: 16 April 2018

Accepted after revision: 27 July 2018

Publication Date:
27 November 2018 (online)

   Permissions and Reprints

Abstract

Sinistral or left-sided portal hypertension is a localized form of portal hypertension usually due to isolated obstruction of splenic vein. Most commonly, it is secondary to pancreatitis. Rarely this can present as life-threatening gastric variceal bleeding. In such patients, splenectomy is traditionally considered as the treatment of choice to relieve venous hypertension. Unfortunately, a surgical operation may not be safe in most of the patients because of the unfavorable operative field. Splenic artery embolization (SAE) is an effective method, theoretically akin to splenectomy, blocking the direct arterial inflow to the spleen and thereby reducing the outflow venous pressure. The authors demonstrate a case of a 58-year-old man who presented with severe gastric variceal hemorrhage due to sinistral portal hypertension (SPH) secondary to an episode of pancreatitis, which he had 1 month back. He was successfully managed by SAE and remains symptom-free. The authors bring to the fore the potential curability of gastric variceal hemorrhage secondary to SPH using SAE, which is a safe and effective interventional radiologic procedure.

Keywords

sinistral portal hypertension - splenic artery embolization - fundal gastric varices - splenic vein thrombosis
 

  • References

  • 1 Thompson RJ, Taylor MA, McKie LD, Diamond T. Sinistral portal hypertension. Ulster Med J 2006; 75 (03) 175-177
    PubMedGoogle Scholar
  • 2 Kadir S, Lundell C, Saeed M. Celiac, superior and inferior mesenteric arteries. Atlas of Normal and Variant Angiographic Anatomy. Philadelphia: Saunders; 1991: 204-237
    Google Scholar
  • 3 Weber SM, Rikkers LF. Splenic vein thrombosis and gastrointestinal bleeding in chronic pancreatitis. World J Surg 2003; 27 (11) 1271-1274
    CrossrefPubMedGoogle Scholar
  • 4 Little AG, Moossa AR. Gastrointestinal hemorrhage from left-sided portal hypertension. An unappreciated complication of pancreatitis. Am J Surg 1981; 141 (01) 153-158
    CrossrefPubMedGoogle Scholar
  • 5 Moossa AR, Gadd MA. Isolated splenic vein thrombosis. World J Surg 1985; 9 (03) 384-390
    CrossrefPubMedGoogle Scholar
  • 6 Blendis LM, Banks DC, Ramboer C, Williams R. Spleen blood flow and splanchnic haemodynamics in blood dyscrasia and other splenomegalies. Clin Sci 1970; 38 (01) 73-84
    CrossrefPubMedGoogle Scholar
  • 7 Madsen MS, Petersen TH, Sommer H. Segmental portal hypertension. Ann Surg 1986; 204 (01) 72-77
    CrossrefPubMedGoogle Scholar
  • 8 Sakorafas GH, Sarr MG, Farley DR, Farnell MB. The significance of sinistral portal hypertension complicating chronic pancreatitis. Am J Surg 2000; 179 (02) 129-133
    CrossrefPubMedGoogle Scholar
  • 9 Köklü S, Yüksel O, Arhan M. et al. Report of 24 left-sided portal hypertension cases: a single-center prospective cohort study. Dig Dis Sci 2005; 50 (05) 976-982
    CrossrefPubMedGoogle Scholar
  • 10 Köklü S, Coban S, Yüksel O, Arhan M. Left-sided portal hypertension. Dig Dis Sci 2007; 52 (05) 1141-1149
    CrossrefPubMedGoogle Scholar
  • 11 Okuda K, Yasumoto M, Goto A, Kunisaki T. Endoscopic observations of gastric varices. Am J Gastroenterol 1973; 60 (04) 357-365
    PubMedGoogle Scholar
  • 12 Lewis JD, Faigel DO, Morris JB, Siegelman ES, Kochman ML. Splenic vein thrombosis secondary to focal pancreatitis diagnosed by endoscopic ultrasonography. J Clin Gastroenterol 1998; 26 (01) 54-56
    CrossrefPubMedGoogle Scholar
  • 13 Caletti GC, Brocchi E, Ferrari A, Fiorino S, Barbara L. Value of endoscopic ultrasonography in the management of portal hypertension. Endoscopy 1992; 24 (Suppl. 01) 342-346
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Lo GH, Lai KH, Cheng JS, Huang RL, Wang SJ, Chiang HT. Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy. Gastrointest Endosc 1999; 49 (04) Pt 1 428-436
    CrossrefPubMedGoogle Scholar
  • 15 Rahmouni A, Mathieu D, Golli M. et al. Value of CT and sonography in the conservative management of acute splenoportal and superior mesenteric venous thrombosis. Gastrointest Radiol 1992; 17 (02) 135-140
    CrossrefPubMedGoogle Scholar
  • 16 Kreft B, Strunk H, Flacke S. et al. Detection of thrombosis in the portal venous system: comparison of contrast-enhanced MR angiography with intraarterial digital subtraction angiography. Radiology 2000; 216 (01) 86-92
    CrossrefPubMedGoogle Scholar
  • 17 Illig KA, Spitzer RM, Oates TK. Optimal diagnosis of splenic vein thrombosis: brief clinical report. Am Surg 1997; 63 (11) 1005-1006
    PubMedGoogle Scholar
  • 18 Köklü S, Köksal A, Yolcu OF. et al. Isolated splenic vein thrombosis: an unusual cause and review of the literature. Can J Gastroenterol 2004; 18 (03) 173-174
    CrossrefPubMedGoogle Scholar
  • 19 Babb RR. Editorial: Splenic vein obstruction: a curable cause of variceal bleeding. Am J Dig Dis 1976; 21 (06) 512-513
    CrossrefPubMedGoogle Scholar
  • 20 Evans GR, Yellin AE, Weaver FA, Stain SC. Sinistral (left-sided) portal hypertension. Am Surg 1990; 56 (12) 758-763
    PubMedGoogle Scholar
  • 21 Burbige EJ, Tarder G, Carson S, Eugene J, Frey CF. Colonic varices. A complication of pancreatitis with splenic vein thrombosis. Am J Dig Dis 1978; 23 (08) 752-755
    CrossrefPubMedGoogle Scholar
  • 22 Cakmak O, Parildar M, Oran I, Sever A, Memis A. Sinistral portal hypertension; imaging findings and endovascular therapy. Abdom Imaging 2005; 30 (02) 208-213
    CrossrefPubMedGoogle Scholar
  • 23 Thavanathan J, Heughan C, Cummings TM. Splenic vein thrombosis as a cause of variceal bleeding. Can J Surg 1992; 35 (06) 649-652
    PubMedGoogle Scholar
  • 24 Aranda-Narváez JM, González-Sánchez AJ, Montiel-Casado MC, Titos-García A, Santoyo-Santoyo J. Acute necrotizing pancreatitis: surgical indications and technical procedures. World J Clin Cases 2014; 2 (12) 840-845
    PubMedGoogle Scholar
  • 25 Holdsworth RJ, Irving AD, Cuschieri A. Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. Br J Surg 1991; 78 (09) 1031-1038
    CrossrefPubMedGoogle Scholar
  • 26 Ferrone CR, Konstantinidis IT, Sahani DV, Wargo JA, Fernandez-del Castillo C, Warshaw AL. Twenty-three years of the Warshaw operation for distal pancreatectomy with preservation of the spleen. Ann Surg 2011; 253 (06) 1136-1139
    CrossrefPubMedGoogle Scholar
  • 27 Jones KB, de Koos PT. Postembolization splenic abscess in a patient with pancreatitis and splenic vein thrombosis. South Med J 1984; 77 (03) 390-393
    CrossrefPubMedGoogle Scholar
  • 28 Madoff DC, Denys A, Wallace MJ. et al. Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications. Radiographics 2005; 25 (Suppl. 01) S191-S211
    CrossrefPubMedGoogle Scholar
  • 29 He X-H, Gu J-J, Li W-T. et al. Comparison of total splenic artery embolization and partial splenic embolization for hypersplenism. World J Gastroenterol 2012; 18 (24) 3138-3144
    CrossrefPubMedGoogle Scholar
  • 30 Madison FE. Embolic therapy of hypersplenism. Invest Radiol 1973; 8: 280-281
    PubMedGoogle Scholar
  • 31 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 2014; 28 (03) 737.e7-737.e11
    CrossrefPubMedGoogle Scholar
  • 32 Sankararaman S, Velayuthan S, Vea R, Herbst J. Severe gastric variceal bleeding successfully treated by emergency splenic artery embolization. Pediatr Int 2013; 55 (03) e42-e45
    CrossrefPubMedGoogle Scholar
  • 33 Kandarpa K, Machan L, Janette D Durham. Splenic and renal embolisation. South Asian edition of Handbook of Interventional Radiologic Procedures. 5th ed.. New Delhi, India: Wolters Kluwer; 2017: 283-284
    Google Scholar
  • 34 Spigos DG, Jonasson O, Mozes M, Capek V. Partial splenic embolization in the treatment of hypersplenism. AJR Am J Roentgenol 1979; 132 (05) 777-782
    CrossrefPubMedGoogle Scholar
  • 35 Zhang CQ, Liu FL, Xu HW. et al. [Treatment of esophageal varicose bleeding by percutaneous transhepatic varices obliteration and partial spleen embolization]. Zhonghua Gan Zang Bing Za Zhi 2007; 15 (10) 742-745
    PubMedGoogle Scholar
  • 36 Sclafani SJ, Shaftan GW, Scalea TM. et al. Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. J Trauma 1995; 39 (05) 818-825 discussion 826–827
    CrossrefPubMedGoogle Scholar
  • 37 Link DP, Seibert JA, Gould J, Lantz BM. On-line monitoring of sequential blood flow reduction during splenic embolization. Acta Radiol 1989; 30 (01) 101-103
    CrossrefPubMedGoogle Scholar
  • 38 Dehdashti AR, Muster M, Reverdin A, de Tribolet N, Ruefenacht DA. Preoperative silk suture embolization of cerebral and dural arteriovenous malformations. Neurosurg Focus 2001; 11 (05) e6
    PubMedGoogle Scholar
  • 39 Hickman MP, Lucas D, Novak Z. et al. Preoperative embolization of the spleen in children with hypersplenism. J Vasc Interv Radiol 1992; 3 (04) 647-652
    CrossrefPubMedGoogle Scholar
  • 40 Kim HJ, Park EK, Hur YH, Koh YS, Cho CK. Splenic artery embolization for the treatment of gastric variceal bleeding secondary to splenic vein thrombosis complicated by necrotizing pancreatitis: report of a case. Case Rep Med [Internet]. 2016 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116513/ Accessed June 13, 2018
    PubMedGoogle Scholar
  • 41 Coldwell DM, Stokes KR, Yakes WF. Embolotherapy: agents, clinical applications, and techniques. Radiographics 1994; 14 (03) 623-643 quiz 645–646
    CrossrefPubMedGoogle Scholar
  • 42 Chao CP, Nguyen JH, Paz-Fumagalli R, Dougherty MK, Stockland AH. Splenic embolization in liver transplant recipients: early outcomes. Transplant Proc 2007; 39 (10) 3194-3198
    CrossrefPubMedGoogle Scholar
  • 43 Piffaretti G, Tozzi M, Lomazzi C. et al. Splenic artery aneurysms: postembolization syndrome and surgical complications. Am J Surg 2007; 193 (02) 166-170
    CrossrefPubMedGoogle Scholar
  • 44 Mozes MF, Spigos DG, Pollak R. et al. Partial splenic embolization, an alternative to splenectomy–results of a prospective, randomized study. Surgery 1984; 96 (04) 694-702
    PubMedGoogle Scholar
  • 45 N'Kontchou G, Seror O, Bourcier V. et al. Partial splenic embolization in patients with cirrhosis: efficacy, tolerance and long-term outcome in 32 patients. Eur J Gastroenterol Hepatol 2005; 17 (02) 179-184
    CrossrefPubMedGoogle Scholar
  • 46 Haan J, Bochicchio G, Kramer M, Scalea T. Air following splenic embolization: infection or incidental finding?. Am Surg 2003; 69 (12) 1036-1039 discussion 1039–1040
    CrossrefPubMedGoogle Scholar
  • 47 Kimura F, Itoh H, Ambiru S. et al. Long-term results of initial and repeated partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura. AJR Am J Roentgenol 2002; 179 (05) 1323-1326
    CrossrefPubMedGoogle Scholar
  • 48 Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR. Pneumococcal polysaccharide vaccine efficacy. An evaluation of current recommendations. JAMA 1993; 270 (15) 1826-1831
    CrossrefPubMedGoogle Scholar
  • 49 Bisno AL, Freeman JC. The syndrome of asplenia, pneumococcal sepsis, and disseminated intravascular coagulation. Ann Intern Med 1970; 72 (03) 389-393
    PubMedGoogle Scholar
  • 50 Wahl WL, Ahrns KS, Chen S, Hemmila MR, Rowe SA, Arbabi S. Blunt splenic injury: operation versus angiographic embolization. Surgery 2004; 136 (04) 891-899
    CrossrefPubMedGoogle Scholar
  • 51 Bessoud B, Duchosal MA, Siegrist C-A. et al. Proximal splenic artery embolization for blunt splenic injury: clinical, immunologic, and ultrasound-Doppler follow-up. J Trauma 2007; 62 (06) 1481-1486
    CrossrefPubMedGoogle Scholar