Percutaneous transsplenic catheterization of the portal venous system

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1 Acta Radiologica ISSN: (Print) (Online) Journal homepage: Percutaneous transsplenic catheterization of the portal veus system H.-L. Liang, C.-F. Yang, H.-B. Pan, C.-K. H. Chen & J.-M. Chang To cite this article: H.-L. Liang, C.-F. Yang, H.-B. Pan, C.-K. H. Chen & J.-M. Chang (1997) Percutaneous transsplenic catheterization of the portal veus system, Acta Radiologica, 38:2, To link to this article: Published online: 04 Jan Submit your article to this journal Article views: 153 Full Terms & Conditions of access and use can be found at

2 Acta Radiologica 38 (1997) Printed in Denmark. All rights reserved Copyright 0 Acta Radiologica I997 A C TA RADIO LOG1 CA ISSN S1 PERCUTANEOUS TRANSSPLENIC CATHETERIZATION OF THE PORTAL VENOUS SYSTEM H.-L. LIANG',~, C.-F. YANG'?~, H.-B. PAN',^, C.-K. H. CHEN'.~ and J.-M. CHANG"~ 'Department of Radiology, Kaohsiung Veterans General Hospital and 'Section of Radiology, National Yang Ming University, Taiwan, Republic of China. Abstract Purpose: To evaluate the safety and feasibility of transsplenic portal vein catheterization. Material and Methods: Under ultrasonic guidance, percutaneous transsplenic splenic vein catheterization was performed in 17 patients. Two of the patients had minimal and 5 moderate ascites. In 11 patients, the platelet counts were over 50000/mm3 and the coagulation time rmal or mildly prolonged, while 6 patients had either platelet counts of less than 50000/mm3 or moderately prolonged coagulation level. Results: Transsplenic portal catheterizations were successfully performed in 16 of the 17 patients (one failed because of small splenic size). Procedure-related complications occurred in 3 patients with 2 requiring one unit of packed RBC transfusion. The third patient accumulated minimal fluid in the left pleural space. Imaging studies.within one week of the procedure were made in 8 patients. These examinations revealed an intrasplenic hematoma in 2 patients. One patient had a small amount of hemoperitoneum. No major complications occurred. Conclusion: Transsplenic portal veus catheterization is a safe and feasible procedure. Key words: Spleen, hypertension; portal; embolization. Correspondence: Chien-Fang Yang, Radiology Department, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd, Kaohsiung, Taiwan 813, Republic of China. FAX Accepted for publication 14 August Spleportography was first introduced in 1951 but soon abandoned because of the risk of bleeding from the splenic puncture site (2). Later PROBST et al. (13) reported a simple way to prevent bleeding complications by plugging the splenic tract with a compressed absorbable gelatin sponge. The safety of spleportography was then widely accepted (1, 4, 10). In 1985, TSANG et al. (16) first reported a case with percutaneous transsplenic catheterization of the splenic vein for balloon dilatation of a stetic surgical splerenal shunt. In 1993 in a veterinarian journal, SCHULZ et al. (14) reported on the transsplenic portal vein catheterization (TSPC) in 2 dogs. Later CHERKASOV & PROKUBOVSKII (3) reported on the application of the technique in clinical use in a Russian journal. We have found previous reports on this in Englishlanguage medical journals and therefore present here our own experiences of TSPC. Material and Methods During a one-year period ending January 1994, we performed TSPC in 17 patients. Thirteen procedures were for variceal studies before or after esophageal variceal ligation therapy, and 4 for adjunctive superselective portal embolization of malignant liver tumors. A summary of the clinical data is presented in Table 1. All patients were men, aged years (mean 63 years), with liver cirrhosis. Eight patients were of Child-Pugh class A, 8 of class B, and one of class C. The imaging studies before TSPC showed ascites in 10 patients, minimal ascites in 2, and moderate ascites in 5. Three patients had platelet counts of less than 50000/mm3, 10 patients /mm3, and 4 patients greater than 80000/mm3. The coagulation data were rmal in 4 patients, mildly pro- 292

3 PERCUTANEOUS TRANSSPLENIC CATHETERIZATION OF THE PORTAL VENOUS SYSTEM Table 1 Clinical data in 17 TSPCpatients PatienVAge Child-Pugh Ascites Platelet, Splenic span, class m3~ cm coagulation* 1140 A 110K(+) A 79K(+) /73 A minimal 145K(+) A 61 K(+) 13 5/62 A 72K(+) /67 A 106K(+) /59 A 340 K (+) 7.2 8/65 A 78K(+) 11 9/68 B 65 K(++) B moderate 55 K (++) /47 B moderate 63 K (+) /66 B moderate 42 K (+) B minimal 50J(++) /75 B 55 K(+) /68 B 45 K(+) /48 B moderate 67 K(+) 16 17/66 C moderate 41 K (++) 14.5 Fig. 1. Under ultrasonic guidance, the first tributary of the intrasplenic vein (+) is chosen for puncture. * Coagulation levels: Normal - Prothrombin time (PT) (International rmalized ratio (INR)): 4.25; Activated partial thrombin time (ATPP) (Pt-control) <8 s. + Mild prolongation - FT (INR): ; APTT (Pt-control) 8-14 s. ++ Moderate prolongation - FT (INR): ; APTT (Pt-control) s. longed in 8, and moderately prolonged in 5 patients. Most patients had splemegaly secondary to liver cirrhosis. Thirteen patients had a splenic length greater than 12 cm and 4 less than 12 cm. The clinical condition of each patient was retrospectively reviewed through the medical records. Technique Under ultrasonic guidance with local anesthesia, a 20-cm-long 1.3-mm-diameter needle was used to puncture subcostally a splenic vein near the splenic hilum (usually the first intrasplenic tributary of the splenic vein as in Fig. 1). The patients were positioned supine in most cases. By the Seldinger technique a curved hydrophilic 0.9-mm guidewire (Terumo) and a 1.35-mm Cobra catheter were advanced into the splenic vein (Fig. 2). If necessary, further superselective catheterization was done (Fig. 3). The number of needle passes were restricted to 2. Before the catheter was pulled out, the splenic parenchymal tract was embolized by 2-4 pieces of gelfoam (2x10 mm) injected by a 1-ml tuberculin syringe. After this procedure, the patient was kept in a left lateral decubitus position with sand-bag com- Fig. 2. Transsplenic portograms. A) In a patient with portal hypertension and large collaterals. B) In a patient with splenic vein occlusion. pression for one hour. In ascitic patients, the supine position was applied. Thereafter, absolute bed-rest and monitoring of vital signs for 4 h were required. Results TSPC was performed successfully in 16 of the 17 patients. One attempt failed because of small splenic size (10.9 cm in patient 13). No major complications occurred. The results of imaging and clinical follow-up are summarized in Table 2. Eight patients had CT or US examinations within one week of TSPC. Five of these patients showed intrasplenic hematoma or hemoperitoneum. One patient had a 1-cm intrasplenic hematoma at CT 6 293

4 H.-L. LIANG ET AL. Fig. 3. Superselective portal catheterization. A) In the paraumbilical vein. B) In the segmental branch of s4 (+) for adjunctive portal embolization after hepatic artery embolization. Fig, 4. CT image on the second day after TSPC in case 2. A 5- cm intrasplenic hematoma (+). days later. He was clinically stable. In ather 2 patients, CT revealed a 5-cm intrasplenic hematoma in one patient (Fig. 4), and a small hemoperitoneum in the other. Due to complaints of dizziness, both of them had received one unit of packed RBC transfusion. One patient complained of pain in the left upper quadrant of the abdomen after TSPC. Chest radiography revealed minimal left pleural effusion, which had subsided spontaneously 4 days later. Ather patient had a drop in blood pressure during the procedure. Immediate and 4-h follow-up US examination showed intra-abdominal bleeding. The episode was attributed to hypoglycemia. Discussion With recent advances in imaging, the indications for direct portography are limited. However, in some cases spleportography or direct portography may still be necessary for definite diagsis of spleportal thrombosis or for better delineation of portal collaterals. The clinical applications of portal catheterization include: 1) variceal embolization (although a. transjugular intrahepatic portosystemic shunt is more efficient for the immediate control of variceal bleeding, its long-term results (6, 8) are still unkwn); 2) veus sampling for localization of hormone-secreting pancreatic tumors; and 3) portal Table 2 Clinical follow-up and complications after TSPC Pat. Imaging* follow-up Blood transfusion Other complications Modality/days/result 1 tdone pleural effusion 2 CT/2nd dayl5-cm intrasplenic hematoma 1 U packed red blood cell transfusion 3 tdone 4 tdone 5 CT/2nd dayhegative 6 tdone 7 tdone 8 tdone 9 CT/2nd dayhegative 10 CT/6th day/l-cm intrasplenic hematoma 11 CTl7th dayhegative 12 CT/2nd daykmall hemoperitoneum 1 U packed red blood cell transfusion 13 CT/2nd dayhegative technical failure 14 tdone 15 US/4th dayhegative blood pressure drop 16 tdone 17 tdone * Negative - intrasplenic hematoma or hemoperitoneum. 294

5 PERCUTANEOUS TRANSSPLENIC CATHETERIZATION OF THE PORTAL VENOUS SYSTEM veus embolization, either as an adjunctive therapy for transcatheter arterial embolization (12, 17) or as a preoperative procedure before liver resection (9, 11, 15) in the treatment of malignant liver tumors. Several techniques for direct portal catheterization are available. 1) The transhepatic approach is widely adopted by most radiologists. However, there may be some disadvantages to this technique: a) it may be difficult to pass through a thrombosed segment of the portal or splenic vein; b) it may be impossible to catheterize intrahepatic segmental portal vein branches for selective embolization therapy. 2) Direct catheterization through a mesenteric vein via minilaparotomy is a relatively safe procedure but much more invasive than the percutaneous techniques (5). 3) The transsplenic approach provides the straightest pathway for entering branches of the portal vein, but few reports on experience with this technique have appeared (3, 14, 16). Spleportography is w accepted as a safe procedure (1, 2, 4, 10, 13), even in pediatric patients (7). In TSPC, the initial step is the same as in spleportography. The only difference is that, under ultrasonic guidance, we advance the needle tip further in order to enter a large splenic vein. We believe that with only one puncture hole in the splenic capsule and need for injection of contrast medium into the splenic parenchyma, the risk of bleeding may be even less than at conventional spleportography. We conclude that TSPC is a safe and feasible procedure. The technique is t recommended as a routine replacement for transhepatic portography as the risk of bleeding complications might be higher in TSPC. The method does, however, provide an alternative route for portography in patients in whom the traditional transhepatic approach is difficult. REFERENCES 1. BRAUN S. D., NEWMAN G. E. & DUNNICK N. R.: Digital spleportography. AJR 144 (1985), BRAZZINI A., HUNTER D. W. & DARCY M. D.: Safe spleportography. Radiology 162 (1987), CHERKASOV V. A. & PROKUBOVSKII V. I.: Transcutaneous transsplenic catheterization of the splenic vein. (Abstract, p. 46.) Vestn. Rentgel. Radiol. 4 (1993). 4. DILAWARI J. B., CHAWLA Y. K. & RAKJ G. S.: Spleportovegraphy in portal hypertension. A safe out-patient procedure. Can. Ass. Radiol. J. 41 (1990), DURHAM J. D., KUMPE D. A. & STIEGMANN G. V.: Direct catheterization of the mesenteric vein. Combined surgical and radiological approach to the treatment of variceal hemorrhage. Radiology 177 (1990), ECHENACUSIA A. J., CAMUNEZ F. & SIMO G.: Variceal hemorrhage. Efficacy of transjugular intrahepatic portosystemic shunts created with Strecker stents. Radiology 192 (1994), FARID N., BALKANCI F. & GURAN S.: A digital spleportography. More sensitive method of detecting spontaneous splerenal shunt. Angiology 42 (1991), LABERGE J. M., RING E. J. & GORDON R. L.: Creation of transjugular intrahepatic portosystemic shunts with the Wallstent endoprosthesis. Results in 100 patients. Radiology 187 (1993), MAKAUUCHI M., THAI B. L. & TAKAYASU K.: Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcima. A preliminary report. Surgery 107 (1990), MISRA S., SARIN S. K. & GULATI P. K.: Spleportography. Safety, success rate and hemodynamic changes, and incidence and natural history of splenic hematoma. (Abstract, p. 49.) Indian J. Gastroenterol. 10 (1991). 11. NAGINO M., NIMURA Y. & KAMIYA J.: Right or left trisegment portal vein embolization before hepatic trisegmentectomy for hilar bile duct carcima. Surgery 117 (1995), NAKAO N., MIURA K. & TAKAHASHI H.: Hepatocellular carcima. Combined hepatic arterial and portal veus em-.bolization. Radiology 161 (1986), PROBST P., RYSAVY J. A. & AMPLATZ K.: Improved safety of spleportography by plugging of the needle tract. AJR 131 (1978), SCHULZ K. S., MARTIN R. A. & HENDERSON R. A,: Transsplenic portal catheterization. Surgical technique and clinical use in two dogs with portosystemic shunts. Vet. Surg. 22 (1993), TANAKA H., KINOSHITA H. & HIROHASHI K.: Preoperative transhepatic portal vein embolization to extend the indication for hepatectomy and to increase the safety of extended hepatectomy for hepatocellular carcima. (Abstract, p ) J. Jpn Surg. SOC. 93 (1992), TSANG Y. M., Au W. Y. & CHEN C. M.: Percutaneous transsplenic balloon dilatation for stetic distal splerenal shunt. (Abstract, p. 395.) J. Jpn Surg. 15 (1985), YAMAKADO K., HIRANO T. & KATO N.: Hepatocellular carcima. Ttreatment with a combination of transcatheter arterial chemoembolization and transportal ethal injection. Radiology 193 (1994),