Successful splenic artery embolization in a patient with Behçet’s syndrome-associated splenic rupture:A case report

BACKGROUND Splenic rupture associated with Behçet’s syndrome(BS)is extremely rare,and there is no consensus on its management.In this case report,a patient with BSassociated splenic rupture was successfully treated with splenic artery embolization(SAE)and had a good prognosis after the intervention.CASE SUMMARY The patient was admitted for pain in the left upper abdominal quadrant.He was diagnosed with splenic rupture.Multiple oral and genital aphthous ulcers were observed,and acne scars were found on his back.He had a 2-year history of BS diagnosis,with symptoms of oral and genital ulcers.At that time,he was treated with oral corticosteroids for 1 month,but the symptoms did not alleviate.He underwent SAE to treat the rupture.On the first day after SAE,the patient reported a complete resolution of abdominal pain and was discharged 5 d later.Three months after the intervention,a computed tomography examination showed that the splenic hematoma had formed a stable cystic effusion,suggesting a good prognosis.CONCLUSION SAE might be a good choice for BS-associated splenic rupture based on good surgical practice and material selection.

Ruptured Splenic Artery Aneurysm (SAA) in an Elderly Patient with Hypercoagulability: A Very Vague Presentation

Here, we discuss a 78-year-old woman with symptoms of shortness of breath and intermittent productive cough, which worsened over time. She had a history of Factor V Leiden and unprovoked pulmonary embolism (PE) and was on lifelong warfarin. The patient was found to have a widened mediastinum and a small left-sided pleural effusion on chest X-ray, leading to CT aortogram to assess for aortic pathology. While in the CT scanner, she experienced an acute deterioration and went into shock. The initial diagnosis was anaphylactic reaction to the contrast agent, but the CT images revealed an active bleeding in the left upper quadrant, possibly of splenic origin. The patient was stabilized with aggressive resuscitation measures and transferred to a referral hospital for urgent surgery. The surgery revealed a ruptured splenic artery aneurysm (SAA), and the patient was taken to the intensive care unit (ICU) for further management. However, she developed a large infarct in the left occipital lobe and passed away after six days. The case highlights the significance of recognizing the symptoms and signs of SAA and then taking a multidisciplinary approach in managing SAA patients, particularly those with hypercoagulability (Graphic 1).

Total splenic artery embolization for splenic artery aneurysms in patients with normal spleen

AIM: To evaluate total embolization of the main splenic artery in patients with splenic artery aneurysms (SAAs) and normal spleen.

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

PreservaUon of the spleen at distal pancreatectomy has recently attracted considerable attention. Since our first successful trial, spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis has been performed more frequently. The technique for spleenpreserving distal pancreatectomy with conservation of the splenic artery and vein are outlined. The splenic vein is identified behind the pancreas and within the thin connective tissue membrane. The connective tissue membrane is cut longitudinally above the splenic vein. An important issue is to remove the splenic vein from the body of the pancreas toward the spleen, since a different approach may be very difficult. The pancreas is preferably removed from the splenic artery toward the head of the pancreas itself. This procedure is much easier than removing the pancreas from the vein side. One patient had undergone distal gastrectomy for duodenal ulcer, with reconstruction by Billroth Ⅱ tehcnique. If distal pancreatectomy with splenectomy had been performed for the lesion of the distal pancreas at the time, the residual stomach would also have to be resected. The potential damage done to the patient by reconstruction of the gastrointestinal tract in combination with distal pancreatectomy and splenectomy would have been much greater than with distal pancreatectomy only with preservation of the spleen and residual stomach. Benign lesions as well as low-grade malignancy of the body and tail of the pancreas may be a possible indication for this procedure.

Total embolization of the main splenic artery as a supplemental treatment modality for hypersplenism

AIM:To study the safety and feasibility of total embolization of the main splenic artery as a supplemental treatment modality for hypersplenism with thrombocytopenia or leukocytopenia accompanying liver cirrhosis.METHODS:Fifteen consecutive patients with hypersplenism due to cirrhosis were enrolled in this study from January 2006 to June 2010.All patients underwent total embolization of the main splenic artery.Clinical symptoms,white blood cell(WBC) and platelet(PLT) counts,splenic volume,and complications of the patients were recorded.The patients were followed up for 1 and 6 mo,and 1,2,3 years,respectively,after operation.RESULTS:Total embolization of the main splenic artery was technically successful in all patients.Minor complications occurred in 13 patients after the procedure,but no major complications were found.The WBC andPLT counts were significantly higher and the residual splenic volume was significantly lower 1 and 6 mo,and 1,2,3 years after the procedure than before the procedure(P < 0.01).Moreover,the residual splenic volume increased very slowly with the time after embolization.All patients were alive during the follow-up period.CONCLUSION:Total embolization of the main splenic artery is a safe and feasible procedure and may serve as a supplemental treatment modality for hypersplenism with thrombocytopenia or leukocytopenia accompanying liver cirrhosis.

Laparoscopic ligation of proximal splenic artery aneurysm with splenic function preservation

Splenic artery aneurysm is one of the most common visceral aneurysms,and patients with this type of aneurysm often present without symptoms.However,when rupture occurs,it can be a catastrophic event.Although most of these aneurysms can be treated with percutaneous embolization,some located in uncommon parts of the splenic artery may make this approach impossible.We present a patient with an aneurysm in the proximal splenic artery,close to the celiac trunk,which was treated by laparoscopic ligation only,without resection of the aneurysm,and with long-term preservation of splenic function.

Diagnostic value of contrast enhanced ultrasound for splenic artery complications following acute pancreatitis

AIM: To assess the value of contrast-enhanced ultrasound (CEUS) in diagnosing splenic artery complications (SACs) after acute pancreatitis (AP). METHODS: One hundred and eighteen patients with AP were enrolled in the study. All patients were examined by CEUS and contrast-enhanced computed tomography (CECT). CECT was accepted as a gold standard for the diagnosis of SACs in AP. The diagnostic accuracy of splenic CEUS and pancreatic CEUS was compared with that of CECT. Splenic infarction was the diagnostic criterion for splenic artery embolism and local dysperfusion of the splenic parenchyma was the diagnostic criterion for splenic arterial stenosis. The incidence of splenic sub-capsular hemorrhage, splenic artery aneurysms, and splenic rupture was all lower than that of SACs. RESULTS: Nine patients were diagnosed as having SACs after AP by CECT among the 118 patients. The patients with SACs were diagnosed with severe acute pancreatitis (SAP). Among them, 6 lesions were diagnosed as splenic artery embolism, 5 as splenic artery aneurysms, and 1 as splenic arterial stenosis. No lesion was diagnosed by pancreatic CEUS and 5 lesions were diagnosed by splenic CEUS. By splenic CEUS, 4 cases were diagnosed as splenic artery embolism and 1 as splenic arterial stenosis. The accuracy of splenic CEUS in diagnosis of SACs in SAP was 41.7% (5/12), which was higher than that of pancreatic CEUS (0%). CONCLUSION: Splenic CEUS is a supplementary method for pancreatic CEUS in AP patients, which can decrease missed diagnosis of SACs. (C) 2014 Baishideng Publishing Group Co., Limited. All rights reserved.

New strategies for prevention and treatment of splenic artery steal syndrome after liver transplantation

AIM: To explore a prophylactic procedure to prevent splenic artery steal syndrome (SASS), as well as a therapeutic intervention to correct it.

Splenic arteriovenous fistula and sudden onset of portal hypertension as complications of a ruptured splenic artery aneurysm: Successful treatment with transcatheter arterial embolization. A case study and review of the literature

Splenic arteriovenous fistula （SAVF） accounts for an unusual but well-documented treatable cause of portal hypertension. A case of a 50-year-old multiparous female who developed suddenly portal hypertension due to SAVF formation is presented. The patient suffered from repeated episodes of haematemesis and melaena during the past twelve days and thus was emergently admitted to hospital for management. Clinical and laboratory investigations established the diagnosis of portal hypertension in the absence of liver parenchymal disease. Endoscopy revealed multiple esophageal bleeding varices. Abdominal computed tomography （CT） and transfemoral celiac arteriography documented the presence of a tortuous and aneurysmatic splenic artery and premature filling of an enlarged splenic vein, findings highly suggestive of an SAVF. The aforementioned vascular abnormality was successfully treated with percutaneous transcatheter embolization. Neither recurrence nor other complications were observed.

Giant splenic artery aneurysm presenting with massive upper gastrointestinal bleeding:A case report and review of literature

BACKGROUND Splenic artery aneurysm(SAA)and pseudoaneurysm are rare vessel’s lesions.Pseudoaneurysm is often symptomatic and secondary to pancreatitis or trauma.True SAA is the most common aneurysm of visceral vessels.In contrast to pseudoaneurysm,SAA is usually asymptomatic until the rupture,with high mortality rate.The clinical onset of SSA’s rupture is a massive life-threatening bleeding with hemodynamic instability,usually into the free peritoneal space and more rarely into the gastrointestinal tract.CASE SUMMARY We describe the case of a 35-year-old male patient,with negative past medical history,who presented to the emergency department for massive upper gastrointestinal bleeding,severe anemia and hypotension.An esophagogastroduodenoscopy performed in emergency showed a gastric bulging in the greater curvature/posterior wall with a small erosion on its surface,with a visible vessel,but no active bleeding.Endoscopic injection therapy with cyanoacrylate glue was performed.Urgent contrast-enhanced computed tomography was carried out due to the clinical scenario and the unclear endoscopic aspect:The radiological examination showed a giant SAA which was adherent to posterior stomach wall,and some smaller aneurysms of the left gastric and ileocolic artery.Because of the high risk of a two-stage rupture of the giant SAA with dramatic outcome,the patient underwent immediate open surgery with aneurysmectomy,splenectomy and distal pancreatectomy with a good postoperative outcome.CONCLUSION The management of a ruptured giant SAA into the stomach can be successful with surgical approach.

Management of splenic artery aneurysm associated with extrahepatic portal vein obstruction

BACKGROUND: Splenic artery aneurysms although rare are clinically significant in view of their propensity for spontaneous rupture and life-threatening bleeding. While portal hypertension is an important etiological factor, the majority of reported cases are secondary to cirrhosis of the liver. We report three cases of splenic artery aneurysms associated with extrahepatic portal vein obstruction and discuss their management. METHODS: The records of three patients of splenic artery aneurysm associated with extrahepatic portal vein obstruction managed from 2003 to 2010 were reviewed retrospectively. The clinical presentation, surgical treatment and outcome were analyzed. RESULTS: The aneurysm was >3 cm in all patients. The clinical symptoms were secondary to extrahepatic portal vein obstruction (hematemesis in two, portal biliopathy in two) while the aneurysm was asymptomatic. Doppler ultrasound demonstrated aneurysms in all patients. A proximal splenorenal shunt was performed in two patients with excision of the aneurysm in one patient and ligation of the aneurysm in another one. The third patient had the splenic vein replaced by collaterals and hence underwent splenectomy with aneurysmectomy. All patients had an uneventful post-operative course. CONCLUSIONS: Splenic artery aneurysms are associated with extrahepatic portal vein obstruction. Surgery is the mainstay of treatment. Although technically difficult, it can be safely performed in an experienced center with minimal morbidity and good outcome.

Congenital absence of the splenic artery and splenic vein accompanied with a duodenal ulcer and deformity

Congenital absence of the splenic artery is a very rare condition.To the best of our knowledge, congenital absence of the splenic artery accompanied with absence of the splenic vein has not been reported.We report a case of the absence of the splenic artery and vein in a 61-year-old woman who presented with postprandial epigastric discomfort. Upper gastrointestinal endoscopy showed a dilated, pulsatile vessel in the fundus and duodenal stenosis. An abdominal computed tomography(CT)scan revealed absence of the splenic vein with a tortuously engorged gastroepiploic vein.Three-dimensional CT demonstrated the tortuously dilated left gastric artery and the left gastroepiploic artery with non-visualization of the splenic artery.After administration of a proton pump inhibitor,abdominal symptoms resolved without any recurrence of symptoms during 6 mo of follow-up.

Massive bleeding from gastric submucosal arterial collaterals secondary to splenic artery thrombosis: A case report

BACKGROUND Gastric submucosal arterial collaterals(GSAC)secondary to splenic artery occlusion is an extraordinary rare and potentially life-threatening cause of acute upper gastrointestinal bleeding.Here,we report a case of massive bleeding from GSAC successfully treated by means of a multidisciplinary minimally invasive approach.CASE SUMMARY A 60-year-old non-cirrhotic gentleman with a history of arterial hypertension was admitted due to hematemesis.Emergent esophagogastroduodenoscopy revealed pulsating and tortuous varicose shaped submucosal vessels in the gastric fundus along with a small erosion overlying one of the vessels.In order to characterize the fundic lesion,pre-operative emergent computed tomography-angiography was performed showing splenic artery thrombosis(SAT)and tortuous arterial structures arising from the left gastric artery and the left gastroepiploic artery in the gastric fundus.GSAC was successfully treated by means of a minimally invasive step-up approach consisting in endoscopic clipping followed by transcatheter arterial embolization(TAE).CONCLUSION This was a previously unreported case of bleeding GSAC secondary to SAT successfully managed by means of a multidisciplinary minimally invasive approach consisting in endoscopic clipping for the luminal bleeding control followed by elective TAE for the definitive treatment.

Ruptured splenic artery aneurysms in pregnancy and usefulness of endovascular treatment in selective patients:A case report and review of literature

BACKGROUND The rupture of a splenic artery aneurysm(SAA)in pregnancy is an uncommon condition.However,it is associated with high mortality rates in pregnant women and fetuses even after surgical treatment.Though the endovascular treatment of SAAs is currently preferred as it can improve the outcomes even in emergent cases,the endovascular treatment of a ruptured SAA during pregnancy has not been reported until date.CASE SUMMARY We report a case of a 33-year-old woman with the sudden onset of epigastric pain due to a ruptured SAA at the mid-portion of the splenic artery at 18 wk of pregnancy.After emergent initial resuscitation,the patient was diagnosed with a ruptured SAA through digital angiography.Immediately upon diagnosis,she underwent emergent endovascular embolization of the splenic artery for the rupture on the spot.Next,surgery was performed to remove the hematoma under stable conditions.Although the fetus was found to be dead during resuscitation,the woman recovered without complications and was discharged 15 d postoperatively.CONCLUSION Endovascular treatment might be a valuable alternative to surgery/lead to safer surgery for selected pregnant patients with ruptured SAAs.

Diagnosis and surgical treatment of giant splenic artery aneurysms with portal hypertension; report of 4 cases

BACKGROUND:Giant splenic artery aneurysm (GSAA) is a rare but clinically relevant disease. Its importance lies in potential rupture and hemorrhage. Early diagnosis and treatment before rupture of GSAA are crucial to GSAA pa- tients especially to GSAA patients with portal hypertension (PHT). METHODS: Four patients of GSAA with PHT treated at our hospital from December 1999 to September 2001 were retrospectively reviewed. RESULTS: GSAA was found in all patients with digital sub- stracted angiography ( DSA) and/or magnetic resonance angiography (MRA) before operation. Resection of GSAA and treatment of PHT were carried out successfully with no perioperative mortality. CONCLUSIONS: Patients with GSAA are apt to have PHT or segmental PHT because of suppression of the splenic vein or formation of aneurysm-portal vein fistula. Opera- tion should be focused on GSAA, and PHT complica- tions.

Alteration of Levels of Cyclic Nucleotide and Analysis of SDS-PAGE in Autologous Transplanted Spleen and Splenic Artery Ligation

Intracellular levels of cyclic nucleotide were detected and mitogen stimulation assays were performed in young Sprague-Daewley rats and suspension of spleen tissue were separated by SDS-PAGE. Results indicated that intracellular levels of cyclic AMP in transplanted cell were significantly lower compared to the control group(P<0.01), the levels of cyclic GMP in transplant cell and the levels of cyclic nucleotide in splenic artery ligation groups were normal. Immunologic tests showed that the stimulation index by Con A for T cells was drastically decreased in the autotransplant and a normal proliferation of B cells after LPS stimulation in transplants. Electrophoresis showed differences in the protein patterns between both tissues. Mitogen stimulation and the protein patterns were not different between the control and splenic artery ligation groups. There were differences between the normal tissues and the transplants at the functional level, Suggesting simple autotransplant can not prevent overwhelming postsplenectomy infection. The intact cellular function after splenic artery ligation indicated that its anti-infection ability is superior to that of splenic transplants.

Anatomical basis for pancreas transplantation via isolated splenic artery perfusion:A literature review

The variability of vascular anatomy of the pancreas underlines the difficulty of its transplantation.Research regarding the consistency of anatomical variations shows splenic arterial dominance in most cases.This can significantly improve transplantation success.A systematic literature review was performed according to the quality standards described in the AMSTAR measurement tool and the PRISMA guidelines.We valuated existing literature regarding the vascularization and blood perfusion patterns of the pancreas in terms of dominance and variability.The collected data was independently analyzed by two researchers.Variance of vascular anatomy was seen to be underreported in literature,though significant findings have been included and discussed in this study,providing valuable insight into the dynamics of pancreatic perfusion and feasibility of transplantation on several different supplying arteries.The splenic artery(SA)has a high percentage of consistency in all found studies(over 90%).High frequency of anastomoses between arterial pools supplying the pancreas can mediate sufficient blood supply through a dominant vessel,such as the SA,which is present in most cases.Pancreatic transplantation with isolated SA blood supply can provide sufficient arterial perfusion of the pancreas for stable transplant viability due to high anatomical consistency of the SA and vast communications with other arterial systems.

Indocyanine green fluorescence imaging for spleen preservation in laparoscopic splenic artery aneurysm resection:A case report

BACKGROUND Splenic artery aneurysm(SAA)is a rare vascular lesion conventionally treated by resection or interventional therapy.The surgical procedure usually involves splenectomy,and interventional therapy may cause post-embolization syndromes.Preservation of the spleen and its function is rarely reported during the management of SAA.CASE SUMMARY We report a patient with an asymptomatic SAA(3.5 cm in diameter),which was en-bloc resected laparoscopically using indocyanine green(ICG)fluorescence imaging to preserve the spleen and its function.CONCLUSION ICG fluorescence imaging for spleen preservation in laparoscopic SAA resection is safe and may be beneficial in avoiding splenectomy and maintaining splenic function.

Successful Treatment of Spontaneous Rupture of the Spleen by Embolization of Splenic Artery in a Patient with Acute Promyelocytic Leukaemia and COVID-19 Infection

Spontaneous rupture of the spleen (SRS) is a rare clinical entity with a potentially poor medical outcome. In most cases, SRS is caused by neoplastic disorder. Acute promyelocytic leukaemia is a rare but important cause of SRS that physicians are required to assess for. We present a 28-year-old woman with APL and COVID-19 pneumonia, who successfully underwent embolisation of the splenic artery for spontaneously occurring splenic rupture during induction chemotherapy. After the intervention the patient completed induction chemotherapy and achieved complete remission. Our case demonstrates that emergent transcatheter arterial embolisation can be lifesaving even in the unfavourable condition of a patient with severe immune deficiency.

Simultaneous portal vein thrombosis and splenic vein thrombosis in a COVID-19 patient:A case report and review of literature

BACKGROUND It is well-described that the coronavirus disease 2019(COVID-19)infection is associated with an increased risk of thrombotic complications.While there have been many cases of pulmonary emboli and deep vein thrombosis in these patients,reports of COVID-19 associated portal vein thrombosis(PVT)have been uncommon.We present a unique case of concomitant PVT and splenic artery thrombosis in a COVID-19 patient.CASE SUMMARY A 77-year-old-male with no history of liver disease presented with three days of left-sided abdominal pain.One week earlier,the patient was diagnosed with mildly symptomatic COVID-19 and was treated with nirmatrelvir/ritonavir.Physical exam revealed mild right and left lower quadrant tenderness,but was otherwise unremarkable.Significant laboratory findings included white blood cell count 12.5 K/μL,total bilirubin 1.6 mg/dL,aminoaspartate transferase 40 U/L,and alanine aminotransferase 61 U/L.Computed tomography of the abdomen and pelvis revealed acute PVT with thrombus extending from the distal portion of the main portal vein into the right and left branches.Also noted was a thrombus within the distal portion of the splenic artery with resulting splenic infarct.Hypercoagulable workup including prothrombin gene analysis,factor V Leiden,cardiolipin antibody,and JAK2 mutation were all negative.Anticoagulation with enoxaparin was initiated,and the patient’s pain improved.He was discharged on apixaban.CONCLUSION It is quite uncommon for PVT to present simultaneously with an arterial thrombotic occlusion,as in the case of our patient.Unusual thrombotic manifestations are classically linked to hypercoagulable states including malignancy and hereditary and autoimmune disorders.Viral infections such as Epstein-Barr virus,cytomegalovirus,viral hepatitis,and COVID-19 have all been found to increase the risk of splanchnic venous occlusions,including PVT.In our patient,prompt abdominal imaging led to early detection of thrombus,early treatment,and an excellent outcome.This case is unique in that it is the second known case within the literature of simultaneous PVT and splenic artery thrombosis in a COVID-19 patient.