Patients
The study was approved by the local institutional ethics and review committee of our university. Informed consent was obtained from all participants. This study included 30 patients which presented with clinical manifestations of hypersplenism secondary to chronic liver disease; all patients underwent partial splenic embolization to correct thrombocytopenia. All patients were proved clinically and in the laboratory. All were referred from the hepatology departments and outpatient clinics of university hospitals. The study time frame was from January 2015 to December 2017.
All patients were subjected to the following.
Clinical history taking
Clinical history taking includes the following:
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Relevant history, like bilharziasis with previous anti-bilharzial therapy, blood transfusion, and other risk factors that can contribute in the determination of the etiology of liver disease
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History of blood disease (anemia or leukemia) or bleeding tendency
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Presence of portal hypertension, hematemesis, or melena
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History of chronic liver disease or liver cell failure or precoma
Laboratory investigations
Laboratory investigations include the following:
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Complete blood picture with stress on platelet count
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Antiplatelet antibodies
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Liver profile including liver enzymes (ALT and AST), total and direct bilirubin, and serum albumin
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Prothrombin time, concentration, and INR
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Viral markers (HBsAg and HCVAbs)
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Renal function tests (serum creatinine and blood urea)
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Bone marrow aspiration to exclude bone marrow causes of thrombocytopenia
Abdominal ultrasonography with color Doppler study
Color Doppler US examination was done by GE logic P5 and P8, and all patients kept fasting overnight prior to the ultrasonography examination.
Spleen: Size, echogenicity, presence of focal lesions, splenic vein diameter and patency as well as duplex study, with stress upon the splenic maximal length, SV diameter, and blood flow velocity within.
Liver: Size, surface, echogenicity, presence of focal lesions and portal vein ultrasonographic, and duplex examination.
Portal trunk was scanned longitudinally. The portal vein diameter was measured directly about 1.5–2.5 cm before the bifurcation to the right and left branches. The portal flow velocity (PFV) in centimeters per second (cm/s) was averaged by Doppler traces of 2–3 cardiac cycles, as well as direction of portal blood flow; the cross-sectional area of PV was also measured with the calculation of congestion index as well as the presence of ascites and collaterals.
Child-Pugh classifications of the patients in the study
In this study, most of the patients (25 patients) were Child-P A classification with good general condition and good liver function, with no ascites or encephalopathy.
Only few cases (5 cases) were early Child B classification (B7) and were embolized to save the patient’s life; however, no major complications were noted within.
Inclusion criteria
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Cases of hypersplenism secondary to chronic liver disease
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Platelet count less than (50,000\μL)
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Child-P classification A or early B
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Good general performance status
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Absence of ascites
Exclusion criteria
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Child-Pugh C classification
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Moderate and marked ascites
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Portal or splenic vein thrombosis or reversed flow of portal vein on color Doppler US
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Allergy to contrast media
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Aortoiliac or bilateral femoral artery occlusion
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Hypocellular bone marrow
Pre-embolization and patient preparation
The benefits and potential risks of splenic embolization were explained to each patient, and informed consent was obtained.
The participants were asked to fast for 12 h. All patients received broad spectrum antibiotics prophylaxis 6 h before embolization (which consisted of 3rd generation cephalosporins, combined ampicillin-sulbactam and metronidazole). Good sterilization of the patient was routinely done.
Embolization protocol
The patient lies supine in the angiography suite, both groins were prepped by betadine, and percutaneous femoral puncture was performed using cutaneous and perivascular local anesthesia infiltration to induce arterial vasculoplegia and to reduce pain during and post-procedure.
Seldinger’s technique was then used for the 6F femoral sheath insertion. Unilateral femoral artery approach was usually used for partial splenic artery embolization technique (used almost in all patients, only one patient underwent transradial approach).
To catheterize the celiac trunk, a 0.035 hydrophilic guide wire (Radiofocus Inc.) and 5 Fr Cobra catheter (Angiodynamic/Cordis Inc.) were used. Splenic artery was then selectively catheterized; by advancing the catheter over the guidewire, preliminary splenic arteriography was obtained to determine the exact splenic size, configuration of the splenic artery, and location of the pancreatic branches. The catheter was then advanced forward as distal as possible, so that its tip lies distal to the pancreatic branches. Very particular attention was paid to the dorsal pancreatic artery to avoid any potential reflux of the embolic agents.
Approaches for partial splenic artery embolization
The first approach was non-selective approach that was used in the majority of cases (25 patients); it was performed when the splenic artery was tortuous and difficult to selectively catheterize distal splenic branches. In these cases, the catheter tip was positioned more proximally in the main splenic artery as distal as we can, beyond the last major pancreatic branch.
The second approach used was selective approach (done in five patients); in this approach, few distal branches of the splenic artery are selectively catheterized using micro-catheter to reach this position (2.4–3 Fr Renegade ® Hi Flo™ Microcatheter (Boston Scientific, Natick, MA) with a 0.027-in. inner diameter, and embolization is performed to achieve complete stasis in these in the targeted branches.
Embolic particles were mixed with the contrast material and injected slowly until stasis, with the parenchymal blush produced.
Either temporary (Gelfoam) or permanent occluding materials (Microspheres and PVA) were used as embolizing material in the study; Gelfoam particles were the most used embolizing materials in our study, used in 20 patients, while the permanent occluding materials were used only in 10 patients (PVA or Embosphere, Boston Scientific); 355- to 500-μm particles were usually used with size of up to 500 to 700 μm for splenic artery. These particles were mixed with 80 g gentamicin and contrast material, and the mixture was injected slowly. The endpoint of embolization was usually determined when angiography showed that an estimated 50–70% of the splenic parenchyma was successfully embolized, evaluated during the parenchymal phase of serial arteriograms, and then the procedure was terminated.
Post-embolization regimen
All patients were admitted before the procedure and remained in the hospital until the post-embolization syndrome or any significant complications disappear. Analgesic management was followed routinely and combined with an anti-inflammatory agent. Supportive care includes appropriate hydro-electrolytic infusions, broad spectrum antibiotics (3rd generation cephalosporins, amoxicillin-clavulanate (3 g/day) and ofloxacin (400 mg/day) for at least 7 days after the procedure, and analgesics (paracetamol and even morphine if needed). The clinical assessment was performed by the patient’s physician at discharge and consultations at 1 month, 3 months, and 6 months after the procedure.
Follow-up
The post-procedure result and follow-up was analyzed from the medical and radiologic files.
The laboratory tests included CBC stressing on platelet count and liver and renal functions before discharge, and then CBC was repeated at 1, 3, and 6 months after embolization.
Morphologic verification by CT examination took place 1 month after embolization to assess the volume of the infarcted areas and detect any post-embolization complications. In the follow-up visits, CBC and abdominal ultrasonography were done routinely.
Statistical test
The data were coded, entered, and processed on an IBM-PC compatible computer using SPSS (version 19).