Partial splenic embolization as a rescue and emergency treatment for portal hypertension and gastroesophageal variceal hemorrhage

Abstract

Background: Partial splenic embolization (PSE) is a non-surgical procedure which was initially used to treat hypersplenism. Furthermore, partial splenic embolization can be used for the treatment of different conditions, including gastroesophageal variceal hemorrhage. Here, we evaluated the safety and efficacy of emergency and non-emergency PSE in patients with gastroesophageal variceal hemorrhage and recurrent portal hypertensive gastropathy bleeding due to cirrhotic (CPH) and non-cirrhotic portal hypertension (NCPH).

Methods: From December 2014 to July 2022, twenty-five patients with persistent esophageal variceal hemorrhage (EVH) and gastric variceal hemorrhage (GVH), recurrent EVH and GVH, controlled EVH with a high risk of recurrent bleeding, controlled GVH with a high risk of rebleeding, and portal hypertensive gastropathy due to CPH and NCPH underwent emergency and non-emergency PSE. PSE for treatment of persistent EVH and GVH was defined as emergency PSE. In all patients pharmacological and endoscopic treatment alone had not been sufficient to control variceal bleeding, and the placement of a transjugular intrahepatic portosystemic shunt (TIPS) was contraindicated, not reasonable due to portal hemodynamics, or TIPS failure with recurrent esophageal bleeding had occurred. The patients were followed-up for six months.

Results: All twenty-five patients, 12 with CPH and 13 with NCPH were successfully treated with PSE. In 13 out of 25 (52%) patients, PSE was performed under emergency conditions due to persistent EVH and GVH, clearly stopping the bleeding. Follow-up gastroscopy showed a significant regression of esophageal and gastric varices, classified as grade II or lower according to Paquet's classification after PSE in comparison to grade III to IV before PSE. During the follow-up period, no variceal re-bleeding occurred, neither in patients who were treated under emergency conditions nor in patients with non-emergency PSE. Furthermore, platelet count increased starting from day one after PSE, and after one week, thrombocyte levels had improved significantly. After six months, there was a sustained increase in the thrombocyte count at significantly higher levels. Fever, abdominal pain, and an increase in leucocyte count were transient side effects of the procedure. Severe complications were not observed.

Conclusion: This is the first study analyzing the efficacy of emergency and non-emergency PSE for the treatment of gastroesophageal hemorrhage and recurrent portal hypertensive gastropathy bleeding in patients with CPH and NCPH. We show that PSE is a successful rescue therapy for patients in whom pharmacological and endoscopic treatment options fail and the placement of a TIPS is contraindicated. In critically ill CPH and NCPH patients with fulminant gastroesophageal variceal bleeding, PSE showed good results and is therefore an effective tool for the rescue and emergency management of gastroesophageal hemorrhage.

Keywords: Acute-on-chronic liver failure; Cirrhotic portal hypertension; Esophageal varices; Gastric varices; Gastrointestinal hemorrhage; Liver cirrhosis; Non-cirrhotic portal hypertension; Partial splenic embolization; Portal hypertension.

Fig. 1

Esophageal varices grade III (a) and fundal varices (b) before partial splenic artery embolization. Regression of esophageal varices to grade I-II (c) and disappearance of fundal varices (d) after partial splenic artery embolization

Fig. 2

Computed tomography of a patient before (a) and after (b) partial splenic artery embolization. Angiography before (c) and after (d) partial splenic artery embolization. Embolization of the upper branches of the splenic arteries using microcoils and gelatin (marked with arrows); embolization of 60% of the splenic parenchyma d (marked with arrow)

Fig. 3

Leucocytes and CRP levels temporarily rising initially after partial splenic artery embolization, decreasing again after six months (a and b). Significant increase of thrombocyte levels after partial splenic artery embolization, slightly decreasing after 5–7 months, still remaining significantly higher compared to the levels before the intervention (c). Distinction of PSE performed in emergency and non-emergency situations in patients with cirrhotic (CPH) and non-cirrhotic portal hypertension (NCPH) (d)