Partial spleen embolization reduces the risk of portal hypertension-induced upper gastrointestinal bleeding in patients not eligible for TIPS implantation

Abstract

Introduction: Upper gastrointestinal bleeding (UGIB) is a severe and life-threatening complication among patients with portal hypertension (PH). Covered transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for patients with refractory or recurrent UGIB despite pharmacological and endoscopic therapy. In some patients, TIPS implantation is not possible due to co-morbidity or vascular disorders. Spleen embolization (SE) may be a promising alternative in this setting.

Materials and methods: We retrospectively analyzed 9 patients with PH-induced UGIB who underwent partial SE between 2012 and 2016. All patients met the following criteria: (i) upper gastrointestinal hemorrhage with primary or secondary failure of endoscopic interventions and (ii) TIPS implantation not possible. Each patient was followed for at least 6 months after embolization.

Results: Five patients (56%) suffered from cirrhotic PH, 4 patients (44%) from non-cirrhotic PH. UGIB occured in terms of refractory hemorrhage from gastric varices (3/9; 33%), hemorrhage from esophageal varices (3/9; 33%), and finally, hemorrhage from portal-hypertensive gastropathy (3/9; 33%). None of the patients treated with partial SE experienced re-bleeding episodes or required blood transfusions during a total follow-up time of 159 months, including both patients with cirrhotic- and non-cirrhotic PH.

Discussion: Partial SE, as a minimally invasive intervention with low procedure-associated complications, may be a valuable alternative for patients with recurrent PH-induced UGIB refractory to standard therapy.

Fig 1. Partial coilembolization of the spleen.

Angiographic images of the spleen with 5F-Sidewinder catheter in celiac trunk showing (a) the tortuous splenic artery (arrow) and the branching vessels before embolization and (b) the perfusion defect of approximately 60% (arrows) after coil embolization (arrow heads) of multiple peripheral arteries to the caudal pole of the spleen.

Fig 2. Partially devascularized spleen after coilembolization.

Postinterventional CT images of the spleen in (a) transverse orientation with demarcation of parenchymal infarction (arrow) at the level of coil embolization (arrow head) and (b) in coronal orientation showing the demarcation zone (arrows) in correlation with the angiographic image (Fib 1b).

Fig 3

Esophagogastroduodenoscopy showing (a) large-sized gastric varices in the gastric fundus before partial splenic embolization (SE) and (b) distinct regression of varices (arrows) six months after partial SE.

Fig 4

Esophagogastroduodenoscopy showing (a) large-sized esophageal varices before partial splenic embolization (SE) and (b) distinct regression of varices (arrows) with scarring of the squamous epithelium eight months after partial SE in combination with endoscopic variceal ligation.