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

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.

Percutaneous Transsplenic Balloon-Assisted Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Portal Vein Obliteration for Portal Vein Recanalization: Feasibility, Safety and Effectiveness.

PURPOSE: To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)-transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. MATERIALS AND METHODS: In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR-TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose-area product (DAP) and air kerma (AK) were evaluated. RESULTS: Transsplenic PVR-TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. CONCLUSIONS: Transsplenic PVR-TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT.

Trans-splenic Access for Portal Venous Interventions in Children: Do Benefits Outweigh Risks?

BACKGROUND: The primary concern of trans-splenic access for portal interventions is the risk of life-threatening intraperitoneal bleeding. OBJECTIVE: To review the clinical indications and efficacy and evaluate the risk factors for intraperitoneal bleeding during trans-splenic portal interventions in children. MATERIALS AND METHODS: A retrospective review of consecutive patients who underwent trans-splenic portal interventions at a tertiary care pediatric institution between March 2011 and April 2017 was performed. Forty-four procedures were performed in 30 children with a median age of 5 (0.3-18) years. Clinical indications, technical success, procedural success, and incidence of complications were recorded. Potential risk factors for intraperitoneal bleeding were evaluated using Wilcoxon rank and Fisher's exact tests. RESULTS: Trans-splenic access was 100% successful. In 35/44 (79%) procedures, the subsequent intervention was successful including recanalization of post-transplant portal vein occlusion in 10/13, embolization of bleeding Roux limb varices in 8/8, recanalization of chronic portal vein thrombosis in native liver in 7/13, splenoportography and manometry in 6/6, and occlusion of portosystemic shunts in 4/4 procedures. Intraperitoneal bleeding occurred during 12/44 (27%) procedures and was managed with analgesics, blood transfusion, and peritoneal drainage without the need for splenectomy or splenic artery embolization. Statistically significant correlation of bleeding was found with intraprocedural anticoagulation, but not with patient age, weight, platelet count, INR, ascites, splenic length, splenic venous pressure, vascular sheath size, or tract embolization technique. CONCLUSION: Trans-splenic access is a useful technique for successful pediatric portal interventions. Although it entails a substantial risk of intraperitoneal bleeding, this can be managed conservatively.

Trans-Splenic Portal Vein Embolization: A Technique to Avoid Damage to the Future Liver Remnant.

Portal vein embolization (PVE) induces hypertrophy of the future liver remnant (FLR) in patients undergoing extensive hepatic resection. Portal vein access for PVE via the ipsilateral hepatic lobe (designated for resection) places veins targeted for embolization at acute angles to the access site requiring reverse curve catheters for access. This approach also involves access close to tumors in the ipsilateral lobe and requires care to avoid traversing tumor. Alternatively, a contralateral approach (through the FLR) risks damage to the FLR due to iatrogenic trauma or non-target embolization. Two patients successfully underwent PVE via trans-splenic portal vein access, allowing easy access to the ipsilateral portal veins and eliminating risk of damage to FLR. Technique and advantages of trans-splenic portal vein access to perform PVE are described.