A Review of Transsplenic Access for Portal Vein Interventions

History

Transsplenic portography was one of the first procedures performed in the developing specialty of interventional radiology. The technique was first described by Abeatici and Campi in 1951.[1] The procedure continued with various techniques until a standardized approach to these procedures was developed by Kreel in 1970 to increase the safety of the procedure and consistency of results.[2] Transsplenic portography had a relatively high rate of complications but was an important diagnostic tool until computed tomography (CT) rendered the procedure obsolete for diagnostic purposes.[3] Portography from this approach allowed the characterization of portal anatomy, direct measurement of portal pressure, characterization of varices, treatment of variceal bleeding, evaluation of infections, and diagnosis of hepatic tumors. The general procedure involved blind insertion of a 19-gauge needle into the 9th to 10th intercostal space with a slightly upward and posterior trajectory. The trajectory was adjusted until blood dripping from the needle indicated intravascular placement. A splenic pressure measurement was then taken (normal: 8–14 mm Hg from a transsplenic 19-gauge needle). 50 mL of 50% contrast was then injected and imaging was performed with cut-film. At the end of the procedure, the needle was removed without any maneuvers to aid hemostasis (as these embolic techniques were relatively unknown at that time). There was significant bleeding risk with these early procedures, and as such, the procedure was largely abandoned in the late 1970s with the wide adoption of abdominal CT. It was not until the early 2000s that renewed interest in transsplenic access led to series entering the literature with a new focus on therapeutic interventions from a splenic vein approach. Of note, these procedures had a significantly lower complication rate compared with the early studies in part owing to the ability to use advanced hemostatic maneuvers. Since 2009, there have been several small studies demonstrating safe and effective transsplenic interventions. In a series of 46 patients who underwent endovascular portal vein interventions via a transsplenic approach, technical success was achieved in 44 procedures, major bleeding complicated 3 procedures, and 6 patients experienced minor bleeding.[4] In a series of 22 pediatric patients who underwent successful transsplenic procedures, there was 1 major bleed and 1 minor bleed.[5] In another series on pediatric patients, 12 of 44 had significant bleeding.[3] In a series of 11 adults in which transsplenic access was performed to allow portal venous reconstruction (PVR) with transjugular intrahepatic portosystemic shunt (TIPS) placement in chronically thrombosed portal veins, 11 of 11 had TIPS placed successfully with no bleeding complications.[6] The available series are small but do give useful data on method of access and hemostasis given the variability in outcomes. In the series with the highest bleeding complications, 12 of 44 (27%), gel foam alone was used for tract embolization.[3] In Habib's TIPS-PVR series in which coils were utilized, there were no bleeding complications.[6]

Although the transjugular and transhepatic approaches are more widely applied in clinical practice, developing skills with transsplenic approaches allows treatment to a broader set of patients.

Publikationsverlauf

Artikel online veröffentlicht:
17. November 2022

• References

• 1 Campi L, Abeatici S. [Portography by splenic route]. J Sci Med Lille 1951; 69 (25) 676-678
• 2 Kreel L. Radiology of the portal system. Gut 1970; 11 (07) 620-626
• 3 Pimpalwar S, Chinnadurai P, Hernandez A, Kukreja K, Siddiqui S, Justino H. Trans-splenic access for portal venous interventions in children: Do benefits outweigh risks?. Cardiovasc Intervent Radiol 2018; 41 (01) 87-95
• 4 Zhu K, Meng X, Zhou B. et al. Percutaneous transsplenic portal vein catheterization: technical procedures, safety, and clinical applications. J Vasc Interv Radiol 2013; 24 (04) 518-527
• 5 Monroe EJ, Speir EJ, Hawkins CM, Shivaram G, Koo KSH, Gill AE. Transsplenic splenoportography and portal venous interventions in pediatric patients. Pediatr Radiol 2018; 48 (10) 1441-1450
• 6 Habib A, Desai K, Hickey R. et al. Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis. J Vasc Interv Radiol 2015; 26 (04) 499-506