An Overview of Splenic Embolization

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1 Vascular and Interventional Radiology Review Ahuja et al. Splenic Embolization Vascular and Interventional Radiology Review FOCUS ON: Chaitanya Ahuja 1 Khashayar Farsad 2 Meghna Chadha 1 Ahuja C, Farsad K, Chadha M Keywords: blunt splenic trauma, hypersplenism, splenic embolization DOI: /AJR Received March 8, 2015; accepted after revision May 29, K. Farsad receives research from Guerbet and Terumo and honoraria from W. L. Gore. 1 Department of Radiology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA Address correspondence to C. Ahuja (drchaitanyaahuja@gmail.com). 2 Department of Radiology, Oregon Health & Sciences University, Portland, OR. AJR 2015; 205: X/15/ American Roentgen Ray Society An Overview of Splenic Embolization OBJECTIVE. The purpose of this article is to define the role of splenic embolization in trauma patients and in patients presenting for treatment of thrombocytopenia and portal hypertension. This article reviews the indications, technical considerations, outcomes, and complications of splenic artery embolization. CONCLUSION. Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries and as an adjunctive procedure in the treatment of thrombocytopenia and portal hypertension. T he spleen constitutes an important part of the body s immune system: It is a site where antibodies, monocytes, and activated lymphocytes are produced [1]. The spleen is highly vascular and is the most commonly injured visceral organ in blunt abdominal trauma [2]. Splenic artery embolization has been used as an adjunct to nonsurgical treatment of blunt splenic injuries. It was first described in 1981 by Sclafani [3] and became more widely used in the late 1990s. The increased susceptibility of patients to infections after splenectomy has led to the use of splenic preservation procedures [4, 5]. In most trauma centers, splenic artery embolization for splenic trauma is now believed to be the treatment of choice to facilitate nonoperative management. The first splenic embolization to treat recurrent gastrointestinal hemorrhage from esophageal varices was performed in 1973 using an autologous blood clot [6]. In 1979, Spigos et al. [7] successfully treated six patients with gastroesophageal varices using partial splenic embolization, antibiotics, and medical therapy for postembolization pain control. Indications Hemodynamically unstable patients are often managed surgically [8, 9]. Hemodynamically stable patients are evaluated with contrast-enhanced CT. Studies have shown that CT has sensitivity of 100% and specificity of 88%, with overall accuracy of 93%, in predicting the need for an intervention [10]. In 1994, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST) developed a grading system for visceral injuries [11]. Generally, the plan for splenic artery embolization is based on the clinical condition of the patient (i.e., hemodynamic stability), imaging findings of ongoing bleeding (i.e., contrast extravasation, grade of injury, and presence of pseudoaneurysm or arteriovenous fistula), and decreasing hematocrit level [12 17]. Active contrast extravasation, splenic vascular injury, AAST III grade or higher injury, and large amount of blood in the peritoneal cavity are indicators for urgent angiography. Embolization should be performed if there are angiographic findings of active bleeding, a pseudoaneurysm, an arteriovenous fistula, or other vascular injury. Nontraumatic Causes Partial splenic embolization is performed to improve the platelet count in patients with hypersplenism from idiopathic thrombocytopenic purpura, thalassemia, idiopathic hypersplenism, and cytopenia induced by anticancer chemotherapy [18 21]. In patients with portal hypertension, splenic embolization is used to improve liver function, decrease variceal hemorrhage, treat hepatic encephalopathy, and improve blood counts [22 25]. Technique Femoral artery access is obtained, and the celiac artery is selected with a 4- or 5-French curved catheter (Cobra C2 or Rosch Celi- 720 AJR:205, October 2015

2 Splenic Embolization ac RC2, Cook Medical). Occasionally, a reversed curve catheter (Simmons 1 or VS1, Cook Medical) is used to select the celiac axis. Celiac angiography is performed to evaluate not only the splenic artery anatomy but also sources of collaterals to the spleen, including the left gastric artery, gastroepiploic arteries, and pancreatic artery branches. Proximal splenic artery embolization, distal splenic artery embolization, or both can be performed. A microcatheter is used to select the splenic artery or its branches. For proximal embolization (Fig. 1), the goal is to decrease perfusion pressure by occluding the main splenic artery, typically with a coil pack just distal to the main pancreatic artery branches [26]. Placement of a coil pack preserves the pancreatic collateral pathway and also preserves splenic perfusion through the collaterals. For distal splenic artery embolization (Fig. 2), the microcatheter is placed as distally as possible in the injured splenic artery branches before embolization to preserve as much of the spleen as possible. Absorbable gelatin (Upjohn), particles ( mm), or coils can be used either alone or in combination. For arterial pseudoaneurysms, coils may be placed across the injury if possible to prevent backflow from the collaterals that may continue to fill the pseudoaneurysm. Nontraumatic Partial Splenic Embolization Distal splenic artery branches are selected (Fig. 3). Embolization is often performed using 300- to 500-μm particles or 500- to 700-μm particles suspended in contrast medium. The suggested volume of embolization is between 50% and 70% because the efficacy is reduced for a volume of less than 50% and the likelihood of complications increases for a volume of more than 70% [25, 27]. Angiography is performed during the procedure to estimate the approximate extent of infarction. Lower pole embolization and midpole embolization are preferred to minimize pleurisy and postprocedure pleural effusions; however, occasionally the upper pole branches draining into the gastric varices are selected for embolization [7]. Coils are avoided because the goal is parenchymal embolization, although proximal coils have been used to decrease splenic perfusion for the treatment of gastroesophageal varices. Patients are often given broad-spectrum preprocedural antibiotics (cefoperazone, 1 g IV). For partial splenic embolization, these antibiotics are continued for at least 5 days after the procedure. Alternatively amoxicillin and clavulanate potassium (3 g/d) and ofloxacin (400 mg/d) can be used [28]. In addition, patients undergoing partial splenic embolization for the treatment of a nontraumatic condition may also receive vaccinations for pneumococcal pneumonia, Haemophilus influenzae type b, and meningococcal infection 2 weeks before the planned procedure; however, these vaccinations are not routinely required. Antiinflammatory medications (methylprednisolone [ Medrol Dosepak, Pfizer]) may be given to mitigate against a postembolization syndrome. When nonoperative management of a splenic injury is successful, repeat CT is not routinely performed. The guidelines proposed by the Eastern Association for the Surgery of Trauma conclude that there are insufficient data to determine whether routine follow-up imaging is needed [29]. Controversies No significant differences in major complications (infection, infarction, or rebleeding requiring splenectomy) were found between proximal and distal embolization techniques in a meta-analysis that included 11 studies and 479 embolizations [30]; however, significantly more minor splenic infarctions not requiring splenectomy occurred in patients who underwent distal embolization than in those who underwent proximal embolization [26, 30 32]. Proximal splenic artery embolization for trauma has not resulted in significant rebleeding distal to the embolization site in the published series to date. Nontraumatic Partial Splenic Embolization The amount of splenic volume reduction required for optimal results remains undefined for hypersplenism. Too small a volume reduction does not improve platelet counts, and too large a volume carries high risks of abscess formation [27]. Experience suggests that between 50% and 70% of splenic infarction balances procedural efficacy with fewer complications [27]. Efficacy and Outcomes of Transcatheter Arterial Embolization Splenic preservation is important because there is a 1 2% lifetime risk of sepsis after splenectomy [33]. Recent data suggest success rates exceeding 90% for nonoperative management using splenic artery embolization [14, 16, 26, 34 40]. For a cohort analysis, Rajani et al. [37] compared outcomes in 222 patients with blunt splenic injury between 1991 and 1998, 3% of whom underwent splenic artery embolization, with outcomes in 408 patients with blunt splenic injury between 1998 and 2005, 23% of whom underwent splenic artery embolization [37]: They found that 61% of patients versus 85% of patients were managed nonoperatively, respectively, and that the success of nonoperative management was 77% versus 96%. With the increased use of arterial embolization for the nonoperative management of splenic trauma, mortality decreased from 12% to 6% and the mean hospital stay decreased from 15 to 9 days. In a retrospective multicenter trial involving 1275 patients, Banerjee et al. [39] also concluded that splenic artery embolization significantly increased the likelihood of splenic salvage (odds ratio, 5; 95% CI, ). Nontraumatic Partial Splenic Embolization Studies in the literature have shown that liver function improves in cirrhotic patients after partial splenic embolization [41 46]. This improvement is likely related to increases in hepatic arterial and superior mesenteric blood flow [46]. Partial splenic embolization also decreases variceal bleeding. Splenic embolization combined with variceal ligation reduced the rate of rebleeding from 39% to 12% in a study performed by Ohmoto et al. [22] of 52 patients. Koconis et al. [27] reviewed the results for 50 patients with portal hypertension from five different studies. Bleeding episodes per year decreased from 2.4 (mean) to 0.48 after partial splenic embolization [27]. In addition, Uflacker et al. [23] reported improvement in hepatic encephalopathy lasting up to 2 years after partial splenic embolization. Partial splenic embolization also increases the blood counts [43]. The platelet count starts rising as early as hours after partial splenic embolization and peaks in 1 2 weeks [47]. The count usually stabilizes in about 2 months at approximately double the value before embolization and then slowly decreases over the next several years. The RBC count increases significantly by 6 months after embolization and stays elevated for years [47]. Complications Splenic Artery Embolization for Trauma A Western Trauma Association multiinstitutional trial assessed complications after AJR:205, October

3 Ahuja et al. splenic artery embolization in 140 patients [15]: Major complications occurred in 19% patients, whereas minor complications occurred in 23% of patients with some overlap. The most common major complication was persistent hemorrhage in 11%, with half of these patients requiring splenectomy. Splenic infarct not requiring any treatment occurred in 21% of patients, and 3% later developed a splenic abscess. Coil migration was a rare complication. In 2005, Haan and colleagues [37] reported complications in the largest single-center study of splenic artery embolization for blunt splenic trauma. These complications included three splenic abscesses, two symptomatic splenic infarcts, and three coil migrations in 132 patients who underwent splenic artery embolization [37]. Proximal splenic artery embolization has been associated with less frequent and smaller volumes of splenic infarct than distal embolization. Bessoud and colleagues [31] followed 24 patients for 26 months after proximal splenic artery embolization. Only two of the 24 patients had peripheral Howell-Jolly bodies indicating functional impairment of the splenic phagocytic function. All patients assessed for H. influenzae immunity had sufficient immunity. After partial splenic embolization, most patients have postembolization syndrome consisting of fever, nausea, and left upper quadrant pain. Lower pole and midpole splenic embolizations have been reported to cause fewer cases of atelectasis and pneumonia [7]. Koconis et al. [27] assessed 33 studies published between 1990 and 2005, collectively representing 401 patients. Of those patients, 15 (3.7%) had significant complications after splenic embolization, including abscess, large pleural effusion causing dyspnea, ascites, pneumonia, pulmonary embolus, portal vein thrombus, and liver failure, and four (1%) died. The majority of serious complications in this group occurred when the embolization volume was 70% or higher [27]. Conclusions Splenic artery embolization for trauma facilitates nonoperative management for splenic injuries of AAST grade III or higher. Irrespective of proximal or distal embolization technique, splenic artery embolization is effective for both hemorrhage control and preservation of splenic function. The success of the procedure is based on coordination between the trauma surgeon and the interventional radiologist for the correct selection of patients. Partial splenic embolization can be an effective procedure for the treatment of hypersplenism and for the decompression of gastroesophageal varices. Partial splenic embolization can be safely performed when the total embolization volume is between 50% and 70% and when antibiotics are administered before and after the procedure. Embolization can be performed alone or in conjunction with other procedures. References 1. Robertson F, Leander P, Ekberg O. Radiology of the spleen. Eur Radiol 2001; 11: Powell M, Courcoulas A, Gardner M, et al. Management of blunt splenic trauma: significant differences between adults and children. Surgery 1997; 122: Sclafani SJ. The role of angiographic hemostasis in salvage of the injured spleen. Radiology 1981; 141: Bisharat N, Omari H, Lavi I, et al. Risk of infection and death among post-splenectomy patients. J Infect 2001; 43: Holdsworth RJ, Irving AD, Cuschieri A. Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. Br J Surg 1991; 78: Maddison FE. Embolic therapy of hypersplenism. Invest Radiol 1973; 8: Spigos DG, Jonasson O, Mozes M, Capek V. Partial splenic embolization in the treatment of hypersplenism. AJR 1979; 132: Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma. J Trauma 2000; 49: ; discussion, Harbrecht BG. 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Splenic embolization revisited: a multicenter review. J Trauma 2004; 56: Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization. J Trauma 2004; 56: Smith HE, Biffl WL, Majercik SD, et al. Splenic artery embolization: have we gone too far? J Trauma 2006; 61: ; discussion, 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 2002; 179: Miyazaki M, Itoh H, Kaiho T, et al. Partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura. AJR 1994; 163: Kimura F, Ito H, Shimizu H, et al. Partial splenic embolization for the treatment of hereditary spherocytosis. AJR 2003; 181: Thanopoulos BD, Frimas CA. Partial splenic embolization in the management of hypersplenism secondary to Gaucher disease. J Pediatr 1982; 101: Ohmoto K, Yamamoto S. 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Partial splenic embolization in the treatment of patients with portal hypertension: a review of the English language literature. J Vasc Interv Radiol 2007; 18: Moon E, Tam MD, Kikano RN, Karuppasamy K.. Prophylactic antibiotic guidelines in modern interventional radiology practice. Semin Intervent Radiol 2010; 27: Stassen NA, Bhullar I, Cheng JD, et al.; Eastern Association for the Surgery of Trauma. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute 722 AJR:205, October 2015

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4 Splenic Embolization Care Surg 2012; 73(suppl 4):S294 S Schnüriger B, Inaba K, Konstantinidis A, Lustenberger T, Chan LS, Demetriades D. Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis. J Trauma 2011; 70: Bessoud B, Duchosal MA, Siegrist CA, et al. Proximal splenic artery embolization for blunt splenic injury: clinical, immunologic, and ultrasound- Doppler follow-up. J Trauma 2007; 62: Killeen KL, Shanmuganathan K, Boyd-Kranis R, et al. CT findings after embolization for blunt splenic trauma. J Vasc Interv Radiol 2001; 12: Webb CW, Crowell K, Cravens D. Clinical inquiries: which vaccinations are indicated after splenectomy? J Fam Pract 2006; 55: Davis KA, Fabian TC, Croce MA, et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 1998; 44: ; discussion, Haan J, Scott J, Boyd-Kranis RL, et al. Admission angiography for blunt splenic injury: advantages and pitfalls. J Trauma 2001; 51: Hagiwara A, Yukioka T, Ohta S, et al. Nonsurgical management of patients with blunt splenic injury: efficacy of transcatheter arterial embolization. AJR 1996; 167: Haan JM, Bochicchio GV, Kramer N, et al. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma 2005; 58: Rajani RR, Claridge JA, Yowler CH, et al. Improved outcome of adult blunt splenic injury: a cohort analysis. Surgery 2006; 140: Banerjee A, Duane TM, Wilson SP, et al. Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. J Trauma Acute Care Surg 2013; 75: Miller PR, Chang MC, Hoth JJ, et al. Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved. J Am Coll Surg 2014; 218: Hirai K, Kawazoe Y, Yamashita K, et al. Transcatheter partial splenic arterial embolization in patients with hypersplenism: a clinical evaluation as supporting therapy for hepatocellular carcinoma and liver cirrhosis. Hepatogastroenterology 1986; 33: Murata K, Shiraki K, Takase K, Nakano T, T ameda Y. Long term follow-up for patients with liver cirrhosis after partial splenic embolization. Hepatogastroenterology 1996; 43: Pålsson B, Hallén M, Forsberg AM, Alwmark A. Partial splenic embolization: long-term outcome. Langenbecks Arch Surg 2003; 387: Sakata K, Hirai K, Tanikawa K. A long-term investigation of transcatheter splenic arterial embolization for hypersplenism. Hepatogastroenterology 1996; 43: Tajiri T, Onda M, Yoshida H, Mamada Y, Taniai N, Kumazaki T. Long-term hematological and biochemical effects of partial splenic embolization in hepatic cirrhosis. Hepatogastroenterology 2002; 49: Nishida O, Moriyasu F, Nakamura T, et al. Interrelationship between splenic and superior mesenteric venous circulation manifested by transient splenic arterial occlusion using a balloon catheter. Hepatology 1987; 7: Yoshida H, Mamada Y, Taniai N, Tajiri T. Partial splenic embolization. Hepatol Res 2008; 38: A B Fig. 1 Splenic artery embolization (proximal technique) for blunt trauma in 28-year-old man. A and B, Axial (A) and coronal (B) reformatted contrast-enhanced CT images show grade IV splenic injury and active extravasation (arrow). (Fig. 1 continues on next page) AJR:205, October

D, Postembolization angiogram shows coil occlusion of main splenic artery distal to

There is preserved perfusion to spleen via collaterals (arrows). C D E Fig.

A, Axial contrast-enhanced CT image shows grade III splenic injury with active

B, Splenic artery angiogram shows two sites of active contrast extravasation (arrows).

5 Ahuja et al. C Fig. 1 (continued) Splenic artery embolization (proximal technique) for blunt trauma in 28-year-old man. C, Celiac angiogram shows laceration of spleen in lower pole and active extravasation of contrast material (arrow). Note medial displacement of spleen from body wall due to extensive peritoneal hematoma. D, Postembolization angiogram shows coil occlusion of main splenic artery distal to dominant pancreatic branches and no further contrast extravasation. There is preserved perfusion to spleen via collaterals (arrows). C D E Fig. 2 Splenic artery embolization (distal technique) for blunt trauma in 42-year-old man. A, Axial contrast-enhanced CT image shows grade III splenic injury with active extravasation (arrow) and hemoperitoneum. B, Splenic artery angiogram shows two sites of active contrast extravasation (arrows). C, Angiogram with microcatheter advanced into distal splenic artery branch as close as possible to site of arterial injury shows contrast extravasation (arrows). D, Postembolization angiogram shows coils in peripheral splenic artery branches (arrows) and no further contrast extravasation. Perfusion to rest of spleen is preserved. E, Ultrasound image obtained 1 month after D shows blood flow to spleen. A B D 724 AJR:205, October 2015

thrombocytopenia precluding further chemotherapy.

B and C, Arteriograms show catheter tip in lower and midpole splenic artery

D, Splenic artery angiogram obtained after embolization shows occluded distal

6 Splenic Embolization A C B D Fig. 3 Partial splenic embolization in 54-year-old woman with breast cancer and thrombocytopenia precluding further chemotherapy. A, Splenic artery angiogram shows enlarged spleen due to portal hypertension. B and C, Arteriograms show catheter tip in lower and midpole splenic artery branches before embolization was performed with 300- to 500-μm particles. D, Splenic artery angiogram obtained after embolization shows occluded distal branches of lower and midpole splenic artery and preserved perfusion of upper pole. Platelet counts tripled 1 week after procedure. AJR:205, October

Efficacy of Emergent Splenic Artery Embolization in Conservative Treatment of High Grade Splenic Injury

Chin J Radiol 2005; 30: 1-7 1 Efficacy of Emergent Splenic Artery Embolization in Conservative Treatment of High Grade Splenic Injury YU-SAN LIAO YU-FAN CHENG TUNG-LIANG HUANG PAO-CHU YU CHUNG-CHENG HUANG