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Partial splenic embolization for hypersplenism after liver transplantation
Partial Splenic Embolization for Hypersplenism After Liver Transplantation C.S. Sockrider, K.N. Boykin, J. Green, A. Marsala, M. Mladenka, and G.B. Zibari
P
ARTIAL SPLENIC EMBOLIZATION (PSE) has been demonstrated to be an effective alternative to splenectomy for patients with hypersplenism.1 Patients with othotopic liver transplantation (OLTx) present a challenge to physicians due to their complicated medical management and immunosuppresion. Splenectomy in these patients can be associated with an increased risk of perioperative complications.2 In addition, they have the standard risks of overwhelming postsplenctomy sepsis (OPSS), and mortality. Partial splenic embolization has the advantages of
nonoperative intervention and resolution of the complications of hypersplenism. We report the use of this technique
From the Departments of Surgery and Radiology, LSU Health Sciences Center and Willis-Knighton Medical Center, Shreveport, Louisiana. Address reprint requests to G. B. Zibari, L.S.U. Health Sciences Center, Division of Transplantation, 1501 Kings Highway, Shreveport, L.A.
Fig 1. A Splenic angiography preembolization. B Splenic angiography postembolization with microcooils demonstrating lower pole selective embolization. C Nuclear image of liver and spleen in a patient preembolization. D Nuclear image of liver and spleen in a patient after final embolization showing a 62% reduction. 0041-1345/01/$–see front matter PII S0041-1345(01)02496-4
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
3472
Transplantation Proceedings, 33, 3472–3473 (2001)
PARTIAL SPLENIC EMBOLIZATION FOR HYPERSPLENISM
3473
in three patients that have undergone OLTx with persistent hypersplenism posttransplant. MATERIALS AND METHODS Three patients with persistent hypersplenism status post-OLTx were treated during the period 1994 to 1999 at the LSUHSC/Willis Knighton Regional Transplant Center in Shreveport, Louisiana. All patients were female. All three patients had concomitant thrombocytopenia and neutropenia with platelet counts below 50,000. Mean time from OLTx to PSE was 14 months. All patients had bone marrow biopsies reviewed by a hematologist. All patients had steroid treatment without success. Patients underwent selective arterial catheterization and embolization via a percutaneous approach with Cook microcoils or PVA particles. The lower pole of the spleen was selectively embolized in all patients to achieve a 30% to 50% reduction in flow as determined by angiography. Patients were followed with routine computed tomography scans and platelet and WBC counts for a mean of 37 months. The following are the details of the partial splenic embolization procedure. The femoral artery approach was used for diagnostic angiography and embolization an all patients. A 6 French sheath was placed in the groin using sterile technique, and a diagnostic angiogram, including the celiac and superior mesenteric angiography, was performed along with selective splenic angiography (Fig 1A). Films were taken in the AP projection with extended filming to include the capillary and portal venous phases of the angiogram. Digital subtraction angiography was used on all cases. Embolization was performed on the first two cases utilizing Cook microcoils delivered through a target tracker catheter (Fig 1B). Microcatheters were used because of the severe tortuosity in all splenic arteries encountered in this study. Microcoils provided satisfactory occlusion on the first case. However, on subsequent cases, the microcoils provided inadequate long-term occlusion. Therefore, PVA particles (contour) were utilized, resulting in more reliable occlusion. Particle sizes in the range of 355 to 500 microns were used exclusively. Particles smaller than this are not recommended because of the possibility of a more intense necrosis. The diagnostic splenic angiogram was studied to choose target vessels with the intention of embolizing no more than 25% to 30% of the spleen at one time. Following the procedure, intravenous antibiotics were continued for 3 to 5 days and then oral antibiotic prophylaxis was continued for a variable period. Liver/spleen scans were obtained in the nuclear medicine department prior to the procedure, at 24 hours, and a 1 to 4 weeks (Fig 1C and 1D).3– 6
RESULTS
All three patients had persistent resolution of thrombocytopenia and neutropenia after embolization (Fig 2). One patient had persistent splenomegaly and required splenectomy for pain control after 11 months. No procedurerelated complications occurred in any patient. Postembolization syndrome included symptoms of fever, left upper
Fig 2. Resolution of leukopenia and thrombocytopenia after embolization.
quadrant pain, small left pleural effusion, and leukocytosis. These were controlled with oral or intravenous analgesics. DISCUSSION
Hypersplenism and the resulting thrombocytopenia and leukopenia are common in transplant candidates with portal hypertension and cirrhosis.7 Severe thrombocytopenia increases the risks of complications in these patients; patients with persistent hypersplenism previously went on to splenectomy.8 In liver transplant recipients, many immunosuppressive medications are required that complicate the clinical picture. In addition, operative procedures in these patients have a higher morbidity and mortality. The use of selective arterial embolization in these patients provides a less invasive treatment for severe thrombocytopenia.2 Furthermore, the concern of overwhelming postsplenectomy sepsis is avoided. In this small review of a limited number of patients, the patients did benefit and have resolution of thrombocytopenia and leukopenia. Although one patient did have persistent pain from splenomegaly and required splenectomy after 11 months, it does appear to be a logical first choice with its decreased risks to the patient. REFERENCES 1. Gerlock AJ: Am J Radiol 138:451, 1982 2. Ignacio Herrero J: Transplantation.63:484, 1997 3. Kadir S: Current Practice in interventional radiology. St. Louis, Mo: Mosby Year Book; 1991, p 493 4. Grassi CJ: Cardio Inter Radiol. 10:291, 1987 5. Mozes MF: Surgery 96:694, 1984 6. Yoshioka H: Am J Radiol 144:1269, 1985 7. Villaiazan Perez C: Arch Dis Child 72:243, 1995 8. Altaca G: Transplantation 64:1481, 1997
P
ARTIAL SPLENIC EMBOLIZATION (PSE) has been demonstrated to be an effective alternative to splenectomy for patients with hypersplenism.1 Patients with othotopic liver transplantation (OLTx) present a challenge to physicians due to their complicated medical management and immunosuppresion. Splenectomy in these patients can be associated with an increased risk of perioperative complications.2 In addition, they have the standard risks of overwhelming postsplenctomy sepsis (OPSS), and mortality. Partial splenic embolization has the advantages of
nonoperative intervention and resolution of the complications of hypersplenism. We report the use of this technique
From the Departments of Surgery and Radiology, LSU Health Sciences Center and Willis-Knighton Medical Center, Shreveport, Louisiana. Address reprint requests to G. B. Zibari, L.S.U. Health Sciences Center, Division of Transplantation, 1501 Kings Highway, Shreveport, L.A.
Fig 1. A Splenic angiography preembolization. B Splenic angiography postembolization with microcooils demonstrating lower pole selective embolization. C Nuclear image of liver and spleen in a patient preembolization. D Nuclear image of liver and spleen in a patient after final embolization showing a 62% reduction. 0041-1345/01/$–see front matter PII S0041-1345(01)02496-4
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
3472
Transplantation Proceedings, 33, 3472–3473 (2001)
PARTIAL SPLENIC EMBOLIZATION FOR HYPERSPLENISM
3473
in three patients that have undergone OLTx with persistent hypersplenism posttransplant. MATERIALS AND METHODS Three patients with persistent hypersplenism status post-OLTx were treated during the period 1994 to 1999 at the LSUHSC/Willis Knighton Regional Transplant Center in Shreveport, Louisiana. All patients were female. All three patients had concomitant thrombocytopenia and neutropenia with platelet counts below 50,000. Mean time from OLTx to PSE was 14 months. All patients had bone marrow biopsies reviewed by a hematologist. All patients had steroid treatment without success. Patients underwent selective arterial catheterization and embolization via a percutaneous approach with Cook microcoils or PVA particles. The lower pole of the spleen was selectively embolized in all patients to achieve a 30% to 50% reduction in flow as determined by angiography. Patients were followed with routine computed tomography scans and platelet and WBC counts for a mean of 37 months. The following are the details of the partial splenic embolization procedure. The femoral artery approach was used for diagnostic angiography and embolization an all patients. A 6 French sheath was placed in the groin using sterile technique, and a diagnostic angiogram, including the celiac and superior mesenteric angiography, was performed along with selective splenic angiography (Fig 1A). Films were taken in the AP projection with extended filming to include the capillary and portal venous phases of the angiogram. Digital subtraction angiography was used on all cases. Embolization was performed on the first two cases utilizing Cook microcoils delivered through a target tracker catheter (Fig 1B). Microcatheters were used because of the severe tortuosity in all splenic arteries encountered in this study. Microcoils provided satisfactory occlusion on the first case. However, on subsequent cases, the microcoils provided inadequate long-term occlusion. Therefore, PVA particles (contour) were utilized, resulting in more reliable occlusion. Particle sizes in the range of 355 to 500 microns were used exclusively. Particles smaller than this are not recommended because of the possibility of a more intense necrosis. The diagnostic splenic angiogram was studied to choose target vessels with the intention of embolizing no more than 25% to 30% of the spleen at one time. Following the procedure, intravenous antibiotics were continued for 3 to 5 days and then oral antibiotic prophylaxis was continued for a variable period. Liver/spleen scans were obtained in the nuclear medicine department prior to the procedure, at 24 hours, and a 1 to 4 weeks (Fig 1C and 1D).3– 6
RESULTS
All three patients had persistent resolution of thrombocytopenia and neutropenia after embolization (Fig 2). One patient had persistent splenomegaly and required splenectomy for pain control after 11 months. No procedurerelated complications occurred in any patient. Postembolization syndrome included symptoms of fever, left upper
Fig 2. Resolution of leukopenia and thrombocytopenia after embolization.
quadrant pain, small left pleural effusion, and leukocytosis. These were controlled with oral or intravenous analgesics. DISCUSSION
Hypersplenism and the resulting thrombocytopenia and leukopenia are common in transplant candidates with portal hypertension and cirrhosis.7 Severe thrombocytopenia increases the risks of complications in these patients; patients with persistent hypersplenism previously went on to splenectomy.8 In liver transplant recipients, many immunosuppressive medications are required that complicate the clinical picture. In addition, operative procedures in these patients have a higher morbidity and mortality. The use of selective arterial embolization in these patients provides a less invasive treatment for severe thrombocytopenia.2 Furthermore, the concern of overwhelming postsplenectomy sepsis is avoided. In this small review of a limited number of patients, the patients did benefit and have resolution of thrombocytopenia and leukopenia. Although one patient did have persistent pain from splenomegaly and required splenectomy after 11 months, it does appear to be a logical first choice with its decreased risks to the patient. REFERENCES 1. Gerlock AJ: Am J Radiol 138:451, 1982 2. Ignacio Herrero J: Transplantation.63:484, 1997 3. Kadir S: Current Practice in interventional radiology. St. Louis, Mo: Mosby Year Book; 1991, p 493 4. Grassi CJ: Cardio Inter Radiol. 10:291, 1987 5. Mozes MF: Surgery 96:694, 1984 6. Yoshioka H: Am J Radiol 144:1269, 1985 7. Villaiazan Perez C: Arch Dis Child 72:243, 1995 8. Altaca G: Transplantation 64:1481, 1997