A retrospective multicentre clinical study on management of isolated splenic vein thrombosis: risks and benefits of anticoagulation.

INTRODUCTION: Isolated splenic vein thrombosis (iSVT) is a common complication of pancreatic disease. Whilst patients remain asymptomatic, there is a risk of sinistral portal hypertension and subsequent bleeding from gastric varices if recanalisation does not occur. There is wide variation of iSVT treatment, even within single centres. We report outcomes of iSVT from tertiary referral hepatobiliary and pancreatic (HPB) units including the impact of anticoagulation on recanalisation rates and subsequent variceal bleeding risk. METHODS: A retrospective cohort study including all patients diagnosed with iSVT on contrast-enhanced CT scan abdomen and pelvis between 2011 and 2019 from two institutions. Patients with both SVT and portal vein thrombosis at diagnosis and isolated splenic vein thrombosis secondary to malignancy were excluded. The outcomes of anticoagulation, recanalisation rates, risk of bleeding and progression to portal vein thrombosis were examined using CT scan abdomen and pelvis with contrast. RESULTS: Ninety-eight patients with iSVT were included, of which 39 patients received anticoagulation (40%). The most common cause of iSVT was acute pancreatitis n = 88 (90%). The recanalisation rate in the anticoagulation group was 46% vs 15% in patients receiving no anticoagulation (p = 0.0008, OR = 4.7, 95% CI 1.775 to 11.72). Upper abdominal vascular collaterals (demonstrated on CT scan angiography) were significantly less amongst patients who received anticoagulation treatment (p = 0.03, OR = 0.4, 95% CI 0.1736 to 0.9288). The overall rate of upper GI variceal-related bleeding was 3% (n = 3/98) and it was independent of anticoagulation treatment. Two of the patients received therapeutic anticoagulation. CONCLUSION: The current data supports that therapeutic anticoagulation is associated with a statistically significant increase in recanalisation rates of the splenic vein, with a subsequent reduction in radiological left-sided portal hypertension. However, all patients had a very low risk of variceal bleeding regardless of anticoagulation. The findings from this retrospective study should merit further investigation in large-scale randomised clinical trials.

A new method to predict venous complications in pediatric liver transplantation: Evaluation of splenic parameters by ultrasonography.

BACKGROUND: Venous complications after pediatric liver transplantation seriously affect the survival rate of patients and grafts. At present, the diagnostic indicators have not been unified. Venous complications may cause portal hypertension, which may lead to splenomegaly and splenic vein dilatation. Therefore, the changes in spleen may be closely related to the venous complications. The purpose of this study was to explore the relationship between ultrasonic splenic parameters and venous complications and to study whether these splenic parameters can be used for the diagnosis of venous complications. METHODS: We retrospectively included pediatric patients who underwent liver transplantation and collected ultrasonic spleen parameters before, and then 1-3 days, 1-3 weeks, 1-3 months, and 4-12 months after liver transplantation. We observed whether there were portal vein or hepatic vein complications within 1 year after liver transplantation. RESULTS: Among 109 pediatric patients after liver transplantation included in our study, 11 of them suffered from portal vein complications and nine hepatic vein complications. Spleen transverse diameter, spleen longitudinal diameter, spleen portal vein diameter, spleen index, spleen transverse diameter ratio, spleen longitudinal diameter ratio, and spleen index ratio were independent risk factors of venous complications. The accuracy of spleen transverse diameter (AUROC: 0.73), spleen index (AUROC: 0.70), spleen transverse diameter ratio (AUROC: 0.71), and spleen index ratio (AUROC: 0.72) in predicting venous complications were higher than other ones. CONCLUSIONS: Ultrasonic examination is a common follow-up method for pediatric patients after liver transplantation and the application of ultrasonic spleen parameters may be helpful to monitor venous complications.

A Case Report of Modified Pancreatic Transplantation With a Limited Splenic Arteriovenous Fistula to Elude Thrombosis.

In classic pancreatic transplantation, the splenic artery and vein are ligated at the tail of the pancreas graft. This leads to slowed blood flow in the splenic vein and may cause thrombosis and graft loss. In this study, a patient received a pancreas after kidney transplantation. A modified surgical technique was used in the pancreatic graft preparation. The donor splenic artery and vein were anastomosed end to end at the tail of the pancreas. The splenic artery near the anastomosis was partially ligated, and an effective diameter of 2 mm was reserved to limit arterial blood pressure and flow. The patient recovered very well. Contrasted computed tomography scans on days 11 and 88 after pancreas transplantation indicated sufficient backflow of the splenic vein. We believe that this procedure may avoid the risk of splenic vein thrombosis after pancreas transplantation. This modified technique has not been reported in clinical cases previously and may help reduce the risk of thrombosis after pancreas transplantation.

Combined transhepatic and transsplenic recanalization of chronic splenic vein occlusion to treat left-sided portal hypertension: A cases report.

RATIONALE: This report describes a unique case of a combination transhepatic and transsplenic recanalization of chronic splenic vein occlusion to treat left-sided portal hypertension (LSPH). PATIENT CONCERNS: In this case report, we report a 49-year-old male who was admitted due to LSPH causing black stools for 2 days and vomiting blood for 1 hour. DIAGNOSES: The patient has a history of multiple episodes of pancreatitis in the past. After admission, abdominal contrast-enhanced CT scan showed the appearance of pancreatitis, with extensive splenic vein occlusion and accompanied by gastric varicose veins, indicating the formation of LSPH. INTERVENTION: The patient received treatment with a combination of splenic and hepatic splenic venoplasty. OUTCOMES: Follow up for 1 year, CT and gastroscopy showed disappearance of gastric varices. LESSONS: Splenic venoplasty is an effective method for treating LSPH. When it is difficult to pass through the occluded segment of the splenic vein through a single approach, percutaneous double approach splenic venoplasty can be attempted for treatment.

Impact of radiological and pathological splenic vein involvement in patients with resectable pancreatic body or tail cancer.

PURPOSE: Several studies have reported a negative impact on survival associated with splenic vessel involvement, especially splenic artery (SpA) involvement, in patients diagnosed with pancreatic body or tail cancer. However, there is limited research on splenic vein (SpV) involvement. Therefore, we aimed to elucidate the significance of splenic vessel involvement, especially SpV involvement, in patients with resectable pancreatic body or tail cancer. METHODS: Between January 2007 and December 2021, 116 consecutive patients underwent distal pancreatectomies for pancreatic body or tail cancer. Among them, this study specifically examined 88 patients with resectable pancreatic body or tail cancer to elucidate prognostic factors using a multivariable Cox proportional analysis. The Kaplan-Meier method evaluated the impact of SpV involvement in terms of both radiological and pathological aspects and the efficacy of neoadjuvant therapy. RESULTS: Higher pre-operative carcinoembryonic antigen levels, larger tumour size, pathological SpV invasion, and non-completion of adjuvant therapy were identified as independent poor prognostic factors for overall survival (OS) and recurrence-free survival (RFS). Additionally, patients with radiological SpV encasement had significantly worse prognoses in terms of OS (p = 0.039) and RFS (p < 0.001). The sensitivity and specificity of multidetector-row computed tomography for detecting pathological SpV invasion were 81.0% and 61.2%, respectively. However, the prognostic impact of neoadjuvant therapy could not be determined, regardless of radiological SpV involvement. CONCLUSION: Radiological and pathological SpV involvement is a poor prognostic factor for patients with resectable pancreatic body or tail cancer. New innovative treatments and effective neoadjuvant therapy regimens are required for patients with SpV involvement.

Laparoscopic spleen-preserving distal pancreatectomy: A novel technique with splenic artery resection and splenic vein preservation.

INTRODUCTION: Laparoscopic spleen-preserving distal pancreatectomy (LSDP) is widely performed to treat benign and low-grade malignant diseases. Although preservation of splenic vessels may be desirable considering the risk of postoperative complications, it is sometimes difficult due to tumor size, inflammation, and proximity of the tumor and splenic vessels. Herein, we present the first case of LSDP with splenic artery resection and splenic vein preservation. MATERIALS AND SURGICAL TECHNIQUE: A 40-year-old woman with a pancreatic tumor was referred to our hospital. Contrast-enhanced computed tomography (CT) revealed a tumor in the pancreatic tail that was in contact with the splenic artery and distant from the splenic vein. The splenic artery and vein were separated from the pancreas near the dissection line. The splenic artery was resected after pancreatic dissection using a linear stapler. After the pancreatic tail was separated from the splenic hilum while preserving the splenic vein, the distal side of the splenic artery was resected, and the specimen was removed. The postoperative course was uneventful and the patient was discharged on postoperative Day 9. Four months after surgery, postoperative follow-up CT findings showed neither splenic infarction nor gastric varices. DISCUSSION: This technique is an alternative method of splenic preservation when there is no attachment of the tumor to the splenic vein or uncontrolled expected bleeding of the splenic artery using the Kimura technique.

Septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum: A case report of an abdominal variant of lemierre syndrome.

RATIONALE: Septic thrombophlebitis of the internal jugular vein also known as Lemierre syndrome occurs secondary to an oropharyngeal infection often leading to septic embolisms to distant sites. Anaerobic gram-negative bacillus, Fusobacterium nucleatum and Fusobacterium necrophorum are commonly isolated organisms. Fusobacterium species has also been reported to complicate an intra-abdominal infection leading to septic thrombophlebitis of portal vein also known as pylephlebitis or abdominal variant of lemierre syndrome. PATIENT CONCERNS: The patient was a middle-aged female patient with chief complaints of abdominal discomfort, intermittent fever and vomiting for one month. DIAGNOSES: The final diagnosis was septic thrombophlebitis of portal and splenic vein secondary to Fusobacterium nucleatum. INTERVENTIONS: Patient was managed with broad spectrum intravenous antibiotics with coverage against gram-negative bacilli, anaerobes, and aerobic streptococcus species with therapeutic anticoagulation. OUTCOMES: Patient gradually improved and was discharged on oral apixaban. She was instructed to follow up with gastrointestinal specialist upon discharge in anticipation of the need for liver transplant in future. LESSONS: Due to its high mortality and associated long term disease morbidity, clinicians should always strive towards early diagnosis and treatment of the condition with involvement of multidisciplinary teams.

Risk factors for portal vein system thrombosis after partial splenic embolisation in cirrhotic patients with hypersplenism.

AIM: To determine risk factors for portal venous system thrombosis (PVST) after partial splenic artery embolisation (PSAE) in cirrhotic patients with hypersplenism. MATERIALS AND METHODS: Between March 2014 and February 2022, 428 cirrhotic patients with hypersplenism underwent partial splenic artery embolisation and from these patients 208 were enrolled and 220 were excluded. Medical records of enrolled patients were collected. Computed tomography (CT) images were reviewed by two blinded, independent radiologists. Statistical analyses were performed by using SPSS. RESULTS: Progressive PVST was observed in 18.75% (39/208) of cirrhotic patients after PSAE. No significant differences in peripheral blood counts, liver function biomarkers, and renal function were observed between the patients with progressive PVST and the patients without progressive PVST. The imaging data showed significant differences in PVST, the diameters of the portal, splenic, and superior mesenteric veins between the progressive PVST group and non-progressive PVST group. Univariate and multivariate analysis demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for progressive PVST. Seventeen of 173 (9.83%) patients showed new PVST; the growth of PVST was observed in 62.86% (22/35) of the patients with pre-existing PVST. Spleen infarction percentage and the diameter of the splenic vein were independent risk factors for new PVST after PSAE. CONCLUSION: The present study demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for PVST after PSAE in cirrhotic patients with hypersplenism.

Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis: A case report and literature review.

BACKGROUND: Splenic vein thrombosis is a known complication of pancreatitis. It can lead to increased blood flow through mesenteric collaterals. This segmental hypertension may result in the development of colonic varices (CV) with a high risk of severe gastrointestinal bleeding. While clear guidelines for treatment are lacking, splenectomy or splenic artery embolization are often used to treat bleeding. Splenic vein stenting has been shown to be a safe option. CASE SUMMARY: A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding. She was anemic with a hemoglobin of 8.0 g/dL. As a source of bleeding, CV were identified. Computed tomography scans revealed thrombotic occlusion of the splenic vein, presumably as a result of a severe acute pancreatitis 8 years prior. In a selective angiography, a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed. The hepatic venous pressure gradient was within normal range. In an interdisciplinary board, transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting, as well as coiling of the aberrant veins was discussed and successfully performed. Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up. CONCLUSION: Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV. However, a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.

Pediatric hypereosinophilic syndrome associated with liver damage, portal vein, splenic vein and superior mesenteric vein thromboses: a case report.

BACKGROUND: The hypereosinophilic syndrome (HES) is a group of rare blood disorders characterized by persistent eosinophilia and damage to multiple organs. HES can be either primary, secondary or idiopathic. Secondary HES are commonly caused by parasitic infections, allergic reactions or cancer. We described a pediatric case of HES associated with liver damage and multiple thrombi. A 12-year-old boy with eosinophilia was complicated with severe thrombocytopenia, liver damage, portal vein, splenic vein, and superior mesenteric vein thromboses. The thrombi recanalized after treatment with methylprednisolone succinate and low molecular weight heparin. No side effects appeared after 1-month. CONCLUSIONS: Corticosteroids should be used at an early stage of HES to prevent further damage to vital organs. Anticoagulants should be recommended only in cases with thrombosis which should be actively screened as a part of evaluation of end organ damage.

Drainage pattern of the splenic flexure vein and its accompanying arteries using three-dimensional computed tomography angiography: a single-centre study of 600 patients.

AIM: The splenic flexure has variable vascular anatomy, and the details of the venous forms are not known. In this study, we report the flow pattern of the splenic flexure vein (SFV) and the positional relationship between the SFV and arteries such as the accessory middle colic artery (AMCA). METHODS: This was a single-centre study using preoperative enhanced CT colonography images of 600 colorectal surgery patients. CT images were reconstructed into 3D angiography. SFV was defined as a vein flowing centrally from the marginal vein of the splenic flexure visible on CT. AMCA was defined as the artery feeding the left side of the transverse colon, separate from the left branch of the middle colic artery. RESULTS: The SFV returned to the inferior mesenteric vein (IMV) in 494 cases (82.3%), the superior mesenteric vein in 51 cases (8.5%) and the splenic vein in seven cases (1.2%). The AMCA was present in 244 cases (40.7%). The AMCA branched from the superior mesenteric artery or its branches in 227 cases (93.0% of cases with existing AMCA). In the 552 cases in which the SFV returned to the IMV, superior mesenteric vein or splenic vein, the left colic artery was the most frequent artery accompanying the SFV (42.2%), followed by the AMCA (38.1%) and the left branch of the middle colic artery (14.3%). CONCLUSIONS: The most common flow pattern of the vein in the splenic flexure is from the SFV to IMV. The SFV is frequently accompanied by the left colic artery or AMCA.

The effect of splenic vein diameter on the diagnosis of portal vein thrombosis.

BACKGROUND: It was still controversial that whether the increase of splenic vein (SV) diameter increased the risk of portal vein thrombosis (PVT), which was a severe disease with high mortality, in the clinic. PURPOSES: This study, using computational fluid dynamics method, aimed to investigate how the increase of SV diameter affects the portal vein hemodynamics under different anatomical and geometric features of the portal venous system, thus how it induced to PVT. METHODS: The ideal models of the portal system, including different anatomical structures according to the location of left gastric vein (LGV) and inferior mesenteric vein (IMV), and different geometric morphological parameters models were established to carry out numerical simulation in this study. In addition, the morphological parameters of real patients were measured to verify the numerical simulation results. RESULTS: First, the wall shear stress (WSS) and helicity intensity, which were closely related to the occurrence of thrombosis, gradually decreased with the increase of SV diameter in all models. However, the degree of decrease was bigger in following models: (1) the models with LGV and IMV linking to SV compared with them linking to PV; (2) the models with big angle of PV and SV compared with small angle. In addition, the morbidity of PVT was higher when LGV and IMV linked to SV rather than them linked to PV in the real patients. Moreover, the angle of PV and SV was also different between PVT and non-PVT patients (125.53° ± 16.90° vs. 115.03° ± 16.10°, p = 0.01). CONCLUSION: Whether the increase of SV diameter will result in PVT is depended on the anatomical structure of portal system and the angle between PV and SV, this is also the reason leading to the clinical controversy that the increase of SV diameter is the risk factor of PVT.

Intra-abdominal Hemorrhage Due to Splenic Vein Aneurysm Rupture Caused by Invasive Aspergillosis during Treatment for Advanced Non-small-cell Lung Cancer.

A 71-year-old man was admitted for left-sided chest pain. He had a history of diabetes, treatment with epidermal growth factor receptor-tyrosine kinase inhibitor for advanced non-small-cell lung cancer, and corticosteroid treatment for underlying lung diseases. Chest computed tomography showed consolidations in the bilateral lower lobes, and Aspergillus fumigatus was detected by bronchoscopy. Invasive pulmonary aspergillosis was suspected, and antifungal therapy with voriconazole was initiated; however, the patient passed away suddenly. Autopsy revealed disseminated Aspergillus infection and intra-abdominal hemorrhage due to the rupture of a splenic vein aneurysm caused by Aspergillus necrotizing vasculitis, which was considered the cause of death.

Treatment of refractory hepatic encephalopathy induced by spontaneous portosystemic shunt: Selective splenic vein embolization versus shunt embolization.

BACKGROUND AND AIMS: Spontaneous portosystemic shunt (SPSS) can cause refractory hepatic encephalopathy (HE) in cirrhotic patients. The embolization of the shunt (ES) can resolve the HE, while the selective embolization of the splenic vein (SESV) can treat splenorenal shunts related HE. The aim of this study was to compare the clinical outcomes of ES and SESV when applied for the treatment of SPSS-induced refractory HE in cirrhotic patients. METHODS: Patients with refractory HE who were treated with ES or SESV were retrospectively identified. The clinical outcomes were compared and analyzed. RESULTS: The 6-month mortality after the ES procedure was significantly higher than that after the SESV procedure. During the 6-month follow-up, both the white blood cell and the platelet counts were significantly lower after the ES procedure than after the SESV procedure. There was a significant increase in aspartate aminotransferase levels after ES. However, the albumin levels as well as the Child-Pugh score and grade were found to be significantly improved at 6 months after the undertaking of an SESV (as compared with baseline). CONCLUSION: The 6-month mortality was improved after SESV (as compared with ES) in the treatment of SPSS-induced refractory HE. A prospective multicenter study for validation is warranted.

Successful Treatment of Splenic Vein Thrombosis Secondary to Acute Pancreatitis with Oral Anticoagulants: A Pediatric Case Series.

BACKGROUND Two Pediatric Patients with Splanchnic Venous Thrombosis as a Complication of Acute Pancreatitis Successfully Treated with Low-Molecular-Weight Heparin and Rivaroxaban CASE REPORT Case 1: A 13-year-old girl presented with a second attack of acute pancreatitis. She developed a non-occlusive splenic vein thrombosis diagnosed by CT scan on the sixth day of hospitalization. Injectable low-molecular-weight heparin was started during hospitalization and switched to oral rivaroxaban at discharge. Imaging at follow-up showed resolution of thrombosis. Case 2: A 9-year-old girl with history of acute recurrent pancreatitis presented with a third attack of acute pancreatitis. An occlusive splenic vein thrombosis with extension into the portal vein and superior mesenteric vein and necrotizing pancreatitis was seen on CT scan on the third day of hospitalization. Low-molecular-weight heparin was initiated during hospitalization and was switched to oral rivaroxaban at discharge. Imaging at follow-up demonstrated nearly complete resolution of the extensive thrombosis. CONCLUSIONS Splanchnic venous thrombosis remains a rare complication of pediatric pancreatitis. Anticoagulant use in patients with these complications remains controversial. Direct oral anticoagulants are as safe and effective as low-molecular-weight heparin and should be considered for use in children instead of low-molecular-weight heparin due to its advantages, including the availability of enteral forms of administration.