Transsplenic tract closure after transsplenic portalvenous access using gelfoam-based tract plugging

Abstract

Background: To assess the feasibility and safety of a gelfoam torpedo plugging technique for embolization of the transsplenic access channel in adult patients following transvenous portal vein interventions.

Materials and methods: Between 09/2016 and 08/2021, an ultrasound guided transsplenic portalvenous access (TSPVA) was established in twenty-four adult patients with a 21-G needle and 4-F microsheath under ultrasound guidance. Afterwards, sheaths ranging from 4-F to 8-F were inserted as needed for the procedure. Following portal vein intervention, the splenic access tract was embolized with a gelfoam-based tract plugging (GFTP) technique. TSPVA and GFTP were performed twice in two patients. Patients' pre-interventional and procedural characteristics were analyzed to assess the feasibility and safety of the plugging technique according Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. Values are given as median (minimum;maximum). Subgroup analysis of intercostal vs. subcostal puncture site for TSPVA was performed using the two-sided Mann-Whitney-U test or Student's t-test and Fisher's exact test. Level of significance was p < 0.05.

Results: The study population's age was 56 (29;71) years and 54% were female patients. Primary liver disease was predominantly liver cirrhosis with 62% of the patients. Pre-interventional model for end-stage liver disease score was 9 (6;25), international normalized ratio was 1.15 (0.86;1.51), activated partial thromboplastin time was 33s (26s;52s) and platelet count was 88.000/µL (31.000;273.000/µL). Ascites was present in 76% of the cases. Craniocaudal spleen diameter was 17cm (10cm;25cm). Indication for TSPVA was assisted transjugular intrahepatic portosystemic shunt placement in 16 cases and revision in two cases, portal vein stent placement in five cases and variceal embolization in three cases. TSPVA was successfully established in all interventions; interventional success rate was 85% (22/26). The splenic access time was 33min (10min;133min) and the total procedure time was 208min (110min;429min). Splenic access was performed with a subcostal route in 11 interventions and with an intercostal route in 15 interventions. Final sheath size was 4-F in 17 cases, 5-F in three cases, 6-F in five cases, 7-F in two cases and 8-F in one case. A median of two gelfoam cubes was used for GFTP. TSPVA- and GFTP-related complications occurred in 4 of 26 interventions (15%) with a subcapsular hematoma of the spleen in two patients (CIRSE grade 1), access-related infection in one patient (CIRSE grade 3) and both in one patient (CIRSE grade 3). In detail, one access-related complication occurred in a patient with subcostal TSPVA (CIRSE grade 1 complication) and the other three complications occurred in patients with intercostal TSPVA (one CIRSE grade 1 complication and two CIRSE grade 3 complication) (p = 0.614). No patient required interventional or surgical treatment due to puncture tract bleeding.

Conclusion: Gelfoam-based plugging of the puncture tract was feasible and safe for transsplenic access in adult patients undergoing percutaneous portal vein interventions. The lack of major bleeding complications and complete absorption of the gelatine sponge make it a safe alternative to transjugular and transhepatic access and re-interventions via the splenic route.

Keywords: Cavernous transformation; Embolization; Gelfoam; Portal hypertension; Portal vein reconstruction; Portal vein stent; Portal vein thrombosis; Splenic access; Transjugular intrahepatic portosystemic shunt; Transsplenic; Variceal embolization.

Fig. 1

A Contrast media was injected through the access sheath transsplenic tract and intraparenchymal splenic vein branch in the patient while the access sheath was pulled backwards (red arrow) until a parenchymal tract is visible. Then, a gelfoam plug (gray) was loaded in the tip of a second sheath, the insertion sheath (green arrow). Of note, two dilators were shown in this image (blue). One dilator was shortened concisely to the end of the sheath with an incision scalpel, the insertion dilator. B Then, the tip of the gelfoam-loaded insertion sheath was introduced through the membrane of the access sheath in the splenic tract (both sheaths were the same size). C Pushing the normal length dilator into the insertion sheath (red arrow), we transferred the gelfoam plug in the access sheath. D After successful transfer of the gelfoam plug in the access sheath, the insertion sheath and the normal length dilator were removed. The insertion dilator was introduced in the access sheath to advance the gelfoam plug. E The insertion dilator is almost loaded in the access sheath. F Finally, the access sheath is gently pulled backward (red arrow) while the insertion dilator is held in position to release the gelfoam plug in the tract (“withdrawal technique”)