Download All you need to know about splenic arterial embolisation (or almost)

All you need to know about splenic arterial embolisation (or
almost)
Poster No.:
C-1875
Congress:
ECR 2010
Type:
Educational Exhibit
Topic:
Interventional Radiology
Authors:
A. Zugazaga, P. Bermúdez, A. Darnell, A. Alguersuari, D.
Rodriguez, A. Torremadé, J. Branera, J. R. Fortuño; Sabadell/ES
Keywords:
Spleen, Embolization, Interventional radiology
DOI:
10.1594/ecr2010/C-1875
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Page 1 of 34
Learning objectives
•
To review the anatomy of the splenic artery and the spectrum of indications
for splenic artery embolization.
•
To describe the different techniques for splenic artery embolization and
possible complications.
Background
Splenic artery embolization is becoming increasingly common in interventional radiology.
It is performed to treat different emergent or chronic diseases, including abdominal
trauma, hypersplenism, splenic arterial aneurysm and pseudoaneurysm.
The limitations of each possible management approach have yet to be clearly defined.
We will try to shed some light on the situation.
Splenic vascular anatomy Figure 1, 2 & 3
The spleen plays an important role in the immune system, defending against
microorganisms that enter the circulation. Thus, avoiding splenectomy can help preserve
immune function.
The splenic artery supplies the spleen and distal portions of the stomach and pancreas.
It courses along the superior edge of the pancreas in close relation to the splenic vein.
Near the splenic hilum, the artery usually divides into superior and inferior branches, and
each branch further divides into various intrasplenic branches.
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The inferior polar artery usually gives rise to the left gastroepiploic artery. Numerous short
gastric branches arise from the terminal splenic or left gastroepiploic artery to supply the
gastric cardia and fundus.
The splenic artery has many branches that supply the pancreatic body and tail. The
first large branch is the dorsal pancreatic artery, which arises from the proximal splenic
artery, and the second large branch is the greater pancreatic artery (or arteria pancreatica
magna), which arises from the middle segment of the splenic artery.
When embolization is planned, visualization of the pancreatic arteries and gastric
branches is essential to reduce the risk of their unintended embolization.
Images for this section:
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Fig. 1
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Fig. 2
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Fig. 3
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Imaging findings OR Procedure details
Our experience
Between January 2001 and July 2009, we treated 15 patients (10 men and 5 women;
mean age=58 years, range 33-80) , by splenic artery embolization. All patients
had undergone abdominal CT prior to the procedure. The different diagnoses were:
posttraumatic splenic injuries in 7 patients, splenic artery pseudoaneurysm due to
pancreatitis in 3, hypersplenism in 3, and aneurysms in 2.
Materials used for embolization included gelatin sponge pledgets, polyvinyl alcohol
particles, and coils. We treated 7 patients using only coils, 2 using PVA particles and
coils in combination, 6 using coils and sponge pledgets in combination. We used proximal
embolization in most patients. The procedure was effective in 13 of 15 patients.
Major complications were 1 abscess and 1 pancreatic fistula.
The abscess occurred after coil and sponge pledgets embolization of a pseudoaneurysm
secondary to chronic pancreatitis, and it was treated by percutaneous drainage.
The pancreatic fistula was a postoperative complication in a patient with hypersplenism
who was first treated with proximal splenic artery embolization with coils and particles.
The fistula resolved with conservative management.
Next we will examine the different scenarios where splenic artery embolization plays an
important role.
1.
Trauma
The spleen is the most frequently injured solid organ in blunt abdominal trauma in both
adults and children. Other less common causes of splenic injuries include penetrating
abdominal trauma, iatrogenic injury (surgery, endoscopy or biopsy), and spontaneous
rupture.
Surgery was long the only possible management in patients with traumatic injuries. The
increased susceptibility of patients to infections after splenectomy led to the development
spleen-conserving procedures. This trend is based on experiences in pediatric patients,
where the nonoperative management (NOM) of splenic injuries has gained wide
acceptance. When successful, NOM enables spleen immune function to be preserved
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and avoids the morbidity associated with nontherapeutic laparotomy (theoretical potential
of decreasing hospital length of stay and blood transfusion requirements). As a result,
in most trauma centers, NOM is now the treatment of choice in hemodynamically stable
patients. Failure rates of NOM in most current studies range from 3% to 18%. Splenic
artery embolization (SAE) has played an increasingly important role in this nonoperative
approach, leading to decreased failure rates of NOM.
•
Diagnosis
The accurate diagnosis of splenic injury is of the utmost importance in the evaluation
of trauma patients. Multidetector computed tomography (MDCT) allows accurate
identification and characterization of splenic injuries.
Hemodynamically unstable patients are not suitable candidates for CT and are typically
evaluated with diagnostic peritoneal lavage (DPL) or ultrasound focused abdominal
sonography in trauma (FAST) to detect hemoperitoneum and enable prompt treatment.
However, in hemodynamically stable patients, MDCT has become the gold standard
for the diagnosis of splenic injuries after trauma. CT has an accuracy exceeding 95%
in the detection of splenic injuries when meticulous CT technique is used. Artifacts
from patients' arms, external wires, or nasogastric tubes should be minimized. The
administration of intravenous contrast is mandatory for the correct evaluation of the
spleen and the rest of the abdomen. Contrast material is routinely administered
intravenously with a power injector, images are obtained 60 to 70 seconds after the
start of the injection to obtain a portal phase. Arterial phase images or delayed images
obtained about 2 to 3 minutes after contrast injection can be useful to demonstrate an
increased volume of extravasation of contrast material.
Assessment of splenic injury should include evaluation for hematoma, laceration,
vascular injuries, and active hemorrhage.
Splenic hematomas are seen as low-density collections of blood, iso/hypodense relative
to spleen in contrast-enhanced CT images. Hematomas can be intraparenchymal,
subcapsular, or perisplenic.
On CT lacerations appear as low-attenuation lines that extend partially or completely
across the spleen; lacerations can be single, multiple, or stellate. Splenic fractures are
defined as lacerations that extend completely across the spleen, commonly involving the
hilum.
Vascular pedicle injuries usually result in significant hemorrhage and cardiovascular
instability, and patients are not referred for CT evaluation. The CT appearance of these
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lesions is nonenhancement of the lower pole of the spleen with preservation of upper
pole perfusion through the short gastric arteries.
Active hemorrhage appears as areas of irregular extravasated contrast that can be
distinguished from blood by its density (> 100 HU).
Table - American Association for the Surgery of Trauma. Splenic Injury Scale. Figure
1&2
Grade
Lesion
Injury Description
I
Hematoma
Subcapsular,
nonexpanding,
surface area
Laceration
<10%
of
Capsular tear, nonbleeding
parenchymal depth < 1 cm
II
Hematoma
Laceration
Subcapsular,
nonexpanding, 10%-50%
of surface area;
Intraparenchymal,
nonexpanding, <5 cm in
diameter
Capsular
tear,
active
bleeding; 1 cm -3 cm
parenchymal
depth that does not involve
a trabecular vessel
III
Hematoma
Laceration
Subcapsular, >50% of
surface area or expanding;
Ruptured
hematoma
bleeding;
subcapsular
with active
Intraparenchymal
hematoma >5 cm
expanding
or
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Parenchymal depth >3
cm or involving trabecular
vessels
IV
Hematoma
Laceration
Ruptured intraparenchymal
hematoma with active
bleeding
Laceration
involving
segmental
or
hilar
vessel producing major
devascularization (>25% of
spleen)
V
Laceration
Completely
spleen
shattered
Vascular
Hilar vascular injury that
devascularizes spleen
Splenic pseudoaneurysms are a rare but life-threatening complication of splenic
injury after blunt abdominal trauma and are defined as well-defined focal contrast
blush. Pseudoaneurysms are differentiated from contrast extravasation because they
appear isodense to the adjacent vascular structures on delayed images, while contrast
extravasation shows no change in density.
•
Indications of SAE
The use of endovascular therapy for controlling hemorrhage from the damaged spleen
was first reported in 1981.
The classic indications for SAE include lesions involving a high risk of secondary rupture
of the spleen, such as splenic trauma with contrast extravasation or pseudoaneurysm on
CT scan. Although more liberal indications have been described, the routine use of SAE
is questioned by other authors.
The addition of SAE to NOM has proven feasible, safe, and effective in increasing rates
of splenic salvage. The procedure is particularly beneficial in severe splenic injuries
that previously required laparotomy and were more likely to lead to the failure of NOM.
The following algorithm is currently recommended by the American Association for the
Surgery of Trauma (AAST): Figure 3 on page 19
In summary, angiography is indicated in hemodynamically stable patients with grade III-V
splenic lesions on CT and/or active contrast extravasation and/or splenic vascular injury
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on CT. Of course, the final decision and the success of the treatment will depend on good
teamwork between surgeons and radiologists.
•
Technique
The success rate of splenic embolization ranges from 75% to 100%.
Two primary techniques of splenic artery embolization have been described:
1. Proximal
2. Super selective distal embolization.
In proximal embolization, the splenic artery is selectively catheterized; the tip of the
catheter must be placed beyond the origin of the dorsal pancreatic artery. Then, embolic
coils (the size of which is very important) are placed to occlude blood flow. The surgical
equivalent of this procedure is splenic artery ligation.
Proximal embolization performed exclusively with coils decreases the volume of splenic
arterial blood flow and thereby produces relative hypotension in the splenic bed, which
allows the spleen to repair itself without infarction. By reducing splenic blood flow and
arterial pressure, bleeding ceases and the collateral supply from the left gastric artery,
short gastric branches, dorsal pancreatic artery, and pancreatic or duodenal arcades,
as well as omental gastroepiploic collaterals, will provide an alternative blood flow
maintaining the viability of the spleen. The endpoint of embolization is still controversial,
but it is clear that the objective of embolization is to reduce the pressure in the splenic
parenchyma to decrease its risk of bleeding and help the spleen heal and reconstitute
the blood supply through collateral vessels.
In super selective distal embolization, a microcatheter is advanced as close as possible
to the site or sites of vascular injury. Then, embolic agents are used with or without
small coils. This achieves hemostasis in the injured spleen while preserving perfusion
to the remaining. However, subsequent bleeding may occur because some vascular
injuries may initially go unnoticed due to vasospasm. Reportedly, approximately 70% of
pseudoaneurysms are missed on initial CT examination and discovered on follow-up CT.
Moreover, there is some evidence suggesting that distal embolization may be associated
with more frequent splenic infarcts.
For all these reasons, proximal embolization is the technique of choice for the
management of blunt splenic injuries.
At angiography, frank extravasation is rare, and abrupt vessel truncation, arteriovenous
fistula, or pseudoaneurysm are more common findings.
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Here there some examples: Figure 4 on page 20, Figure 5 on page 21, Figure 6
on page 22
2. Hypersplenism
Splenectomy or transcatheter ablation of splenic parenchyma are often performed
for the management of hypersplenism, a pathologic condition that is characterized
by increased pooling or destruction of the corpuscular elements of the blood by the
spleen. It may be seen in many disorders, including cirrhosis with portal hypertension,
hematological abnormalities, and diffuse splenic infiltration from primary malignancies
such as leukemia and lymphoma. Signs of hypersplenism include splenomegaly,
thrombocytopenia, leukopenia, and anemia.
Total splenectomy may be an effective treatment for hypersplenism, but it impairs
the body's ability to produce antibodies against encapsulated microorganisms and
predisposes patients to sepsis.
After splenectomy, the treated condition may recur, with the possible result that a
second surgery or additional transfusion will be needed. Furthermore, patients who
have comorbid conditions and severe cytopenia are not considered candidates for
surgery. However, the removal of functional splenic tissue may improve hematological
abnormalities related to bone marrow suppression from systemic chemotherapeutic
and immunosuppressive agents, so that optimal doses of such medications can be
maintained.
In 1973, Madison reported the initial clinical experience with splenic arterial embolization.
•
Indications:
1. Preoperative
2. Definitive treatment
1. Although proximal arterial occlusion is ineffective for the management of
hypersplenism, it is useful as a preoperative technique for reducing intraoperative blood
loss in patients undergoing open or laparoscopic splenectomy. Moreover, in laparoscopic
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splenectomy, splenic artery embolization can lead to a reduction in splenic size, which
may help improve the surgical view and intraoperative exposure. Presently, laparoscopic
splenectomy is the treatment of choice in the surgical management of splenomegaly.
Many reports suggest the clinical benefit of preoperative splenic artery embolization,
especially in patients with severe splenomegaly (larger than 20 cm). The most widely
accepted technique in these cases is proximal embolization (the same as described
above for traumatic lesions).
2. Splenic arterial embolization has also been advocated for the intentional infarction of
splenic tissue to reduce its consumptive activity. Initial experiences with this modality
of treatment led to severe complications of complete splenic infarction, preventing its
acceptance as a viable treatment option. However, many authors recommend incomplete
or partial splenic arterial embolization, in which a portion of the splenic parenchyma is left
viable, to preserve the spleen's immunologic function. Partial splenic arterial embolization
was first considered a viable option when initial attempts to treat hypersplenism with
proximal splenic arterial occlusion were unsuccessful. Treatment failures were attributed
to abundant collateral circulation (especially through short gastric and gastroepiploic
arteries) that re-entered around the occluded segment of the splenic artery reestablishing
the splenic blood supply.
Partial splenic embolization may be performed with one of two methods:
In the first approach, a few distal branches of the splenic artery are selectively
catheterized and embolized to achieve complete stasis in these branches while several
other branches are left untreated. Parenchymal phase angiograms may be used to
estimate the volume of the remaining viable splenic tissue. Additional branches then may
be catheterized, and embolization may be repeated, until the desired effect is achieved.
In the second approach, nonselective partial embolization, the working catheter tip is
positioned more proximally in the main splenic artery but beyond the origin of the
major pancreatic branches. Embolic particles are injected until the parenchymal blush
is reduced.
We can use different embolic agents, most frequently gelfoam pledgets and PVA
particles. The Spigos technique to minimize complications includes
1. Aseptic technique
2. Antibiotic coverage
3. Avoidance of excessive infarction of splenic mass. Hematological response and the
severity of complications correlate with the amount of infarcted splenic tissue. Most
interventionalists aim to achieve infarction in 60% to 70% of the plenic mass.
Page 13 of 34
4. Effective postembolization analgesia
Here is an example: Figure 7 on page 23
3. Portal hypertension
Endoscopic obliteration of gastroesophageal varices and creation of a transjugular
intrahepatic portosystemic shunt are the two most common options used to manage
variceal hemorrhage in cirrhotic patients with portal hypertension. Open or laparoscopic
splenectomy has been proposed, but it has not gained wide acceptance because of the
high risk of complications.
Partial splenic embolization appears to be efficacious in reducing episodes of variceal
bleeding, improving hematologic parameters, enhancing hepatic protein synthesis, and
reducing the severity of hepatic encephalopathy. The reduction of splenic volume results
in a decrease in venous drainage and, thus, in a reduction in portal venous flow and
pressure. Associated morbidity and mortality appear to be acceptable.
Embolization may be performed alone or in combination with other therapeutic
interventions, such as endoscopic ligation.
The literature, however, is limited. Given the potential benefits of partial splenic
embolization, further investigation is warranted to allow evidence-based evaluation of its
use.
We do not have any experience in splenic artery embolization to treat portal hypertension.
4. Splenic artery aneurysm
The splenic artery is the most frequent site of visceral arterial aneurysms with a
prevalence of 0.8%. Most of them are small (<2 cm), saccular, and located in the
intermediate or distal segment of the splenic artery. They are multiple in 20% of cases.
Most splenic artery aneurysms are detected incidentally during diagnostic imaging
performed for other indications. Rupture is rare but associated with a high mortality rate.
Page 14 of 34
•
Indications for treatment
Cases with specific symptoms (e.g., back or epigastric or left upper quadrant pain),
female sex and childbearing age, planned liver transplantation, portal hypertension, and
aneurysms with a diameter of greater than 2.5 cm should be treated.
Various therapeutic options are available to treat splenic artery aneurysms. Traditional
surgical management is the recommended repair in low-risk patients with asymptomatic
aneurysms greater than 20 mm in diameter or with rapidly growing aneurysms. During
the past decade, endovascular techniques have been advocated as an alternative to
treat these aneurysms. Percutaneous interventional techniques are associated with lower
morbidity and mortality compared to surgical modalities.
•
Technique
Packing of the aneurysmal sac with embolic agents (most commonly with coils, but
also with detachable balloons and inert particles) and exclusion of the aneurysmal
neck with the "sandwich" method are the recommended techniques for treating splenic
artery aneurysms. Precise selection of the occlusion site is necessary to preserve
collateral blood flow to the spleen via the gastric, omental, and pancreatic vessels. The
"remodeling" technique used to treat intracranial aneurysms has also been used for widenecked aneurysms.
Success rates of embolization are between 80% and 90%. Stent-graft placement to
exclude the aneurysm and preserve blood flow through the splenic artery has also been
reported. Percutaneous needle puncture of the aneurysm and administration of thrombin
into the aneurysm may be another therapeutic option when embolization is not possible
or has failed.
Imaging follow-up (Doppler ultrasonography or CT, which is more sensitive) is
recommended to determine whether the aneurysm is completely occluded.
Here is an example: Figure 8 on page 24
5. Splenic artery pseudoaneurysm
Chronic pancreatitis causes vascular complications, including pseudoaneurysms of the
peripancreatic arteries. Splenic artery pseudoaneurysms are the most common visceral
artery pseudoaneurysms. They have been reported to develop in about 10% of cases
Page 15 of 34
of pancreatitis. Splenic pseudoaneurysms appear to develop as a consequence of
inflammatory processes adjacent to the splenic artery, particularly acute and chronic
pancreatitis with associated pseudocysts. Proteolytic pancreatic enzymes may digest the
arterial wall and cause pseudoaneurysms. They are often asymptomatic. Complications
include rupture with retroperitoneal or intraperitoneal hemorrhage. They can rarely
rupture into the gastrointestinal tract.
The clinical presentation of pseudoaneurysm rupture includes acute abdominal pain,
hematemesis, and melena. When such symptoms are present in a patient with
pancreatitis, a vascular complication should be suspected and a prompt diagnosis is
essential because treatment is mandatory. Color duplex sonography and especially
contrast-enhanced MDCT are essential for the detection of vascular complications.
Although surgical treatment traditionally played the major role, recent advances
in interventional radiology have made arterial embolization well suited for treating
splenic artery pseudoaneurysms. Identification of the bleeding vessel during surgery is
problematic due to peripancreatic inflammation, necrosis, and friability, which can make
it impossible to control bleeding.
•
Technique
Several techniques (mostly the same as in splenic artery aneurysms) have been
described for the interventional radiology treatment of splenic pseudoaneurysms.
Although theoretically all modalities could be effective, the great fragility of the
pseudoaneurysmatic wall contraindicates most of them. Therefore, embolization of
both distal and proximal vessels (the "sandwich technique" Figure 9 on page 25)
is generally believed to be the best procedure. Coils, which achieve permanent
embolization without increasing the intravascular pressure, are the most common
embolic materials in the treatment of pseudoaneurysms. In this context, temporary
occlusion of the splenic artery using a balloon catheter can be useful for controlling
splenic arterial flow and preventing distal coil migration. A gelatin sponge is also an option.
However, because it might induce rupture by increasing intravascular pressure during
infusion, it must be applied in specific situations: (1) in combination with coils, where it
would function as an adjuvant to stimulate thrombus formation by increasing blood flow
stagnation; (2) to embolize small vessels in which deployment of coils is difficult; and (3)
when treating multiple bleeding sites.
Here is another example: Figure 10 on page 26
Complications of embolization
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The use of total splenic infarction has been limited because of the high incidence and
severity of complications such as splenic abscess (Figure 10 on page 26), splenic
rupture, bacteremia, splenic vein thrombosis, and unremitting bronchopneumonia.
Unlike in other organ systems, the presence of air in the spleen does not always indicate
abscess formation. Splenic abscesses occur in a small percentage of patients and may
be successfully managed percutaneously or intraoperatively. Salvage rates are similar
whether embolization is performed in an arterial segment distal or proximal to the origin
of the splenic artery.
Several mechanisms may cause complications after complete splenic infarction: induced
immunosuppression, anaerobic bacterial growth in the hypoxic tissue, percutaneous
introduction of exogenous bacteria, and retrograde transport of enteric pathogens via
reversed portal flow. Like complete splenic ablation, partial splenic arterial embolization
and proximal embolization (for splenic artery aneurysm) may entail complications and
adverse effects, but these procedures are better tolerated than complete splenic ablation.
In addition, patients may develop pleural effusions that require thoracentesis; paralytic
ileus; pancreatitis (likely a result of nontarget embolization of the dorsal pancreatic
or greater pancreatic artery); or postembolization syndrome, which consists of fever,
leukocytosis, and abdominal pain.
In general, major complications are rare and it is difficult to quantify them because of the
inhomogeneous data from the different series.
Splenic function after embolization has not been thoroughly evaluated. Several small
studies have demonstrated preserved splenic function after surgical splenic artery ligation
based on pathological findings. Thus, as proximal embolization mimics surgical splenic
artery ligation, it is reasonable to theorize that it also preserves splenic function.
Although there are some encouraging findings, large prospective studies are needed.
Page 17 of 34
Images for this section:
Fig. 1: A: splenic laceration (grade II), B: subcapsular and perisplenic hematoma (grade
III), C: splenic fracture (grade IV)
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Fig. 2: D: shattered spleen (grade V) with post-traumatic pseudoaneurysm, E: splenic
laceration with perisplenic hematoma and active bleeding (grade IV)
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Fig. 3: Algorithm of the AAST
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Fig. 4: A 36-year-old man injured in a head-on automobile accident. A: CT shows
laceration (grade IV) with perisplenic hematoma and active bleeding (arrow), B:
DSA shows an extensive hypovascular lesion, C: proximal embolization with coils to
reduce the pressure, D: CT postembolization shows a normal sized-spleen with small
hypoattenuating areas that correspond to infarcts. No surgery was needed in this patient.
Page 21 of 34
Fig. 5: A 41-year-old man involved in a bicycle accident. A: CT shows a splenic laceration
(grade II) with perisplenic hematoma, B: CT two days after A shows the formation of
a posttraumatic pseudoaneurysm (arrow). Note that the hyperenhancing nodular image
seen in the arterial phase disappears in the portal phase, C: DSA with multiple nodular
images secondary to pseudoaneurysms, D: proximal embolization of the splenic artery,
E: CT postembolization shows resolution of the pseudoaneurysms and a residual splenic
hematoma. No surgical measures were taken in this patient
Page 22 of 34
Fig. 6: A 64-year-old woman involved in an automobile accident. A: CT shows
splenic lacerations (grade III) and hyperenhancing nodular images that correspond to
pseudoaneurysms (arrow), B: DSA shows multiple pseudoaneurysms (note that no active
extravasation is visualized), C: proximal embolization of the splenic artery. No surgical
measures were taken in this patient
Page 23 of 34
Fig. 7: A 57-year-old man with lymphoproliferative disease and splenomegaly. A:
CT shows a giant splenomegaly, with peripheral triangular, hypoattenuating images
that correspond to infarcted areas (arrow), B: DSA shows the same as the CT, C:
proximal embolization D: macroscopic specimen. Embolization was performed before
splenectomy to reduce the risk of bleeding
Page 24 of 34
Fig. 8: An asymptomatic 71-year-old woman with an incidentally found splenic artery
aneurysm. US (A) and MR angiogram (B) show a splenic artery aneurysm, C: DSA
confirms MR findings, D: DSA post-coling the aneurysm, E: Postembolization CT shows
a splenic infarct.
Page 25 of 34
Fig. 9: "Sandwich technique"
Page 26 of 34
Fig. 10: A 59-year-old man with chronic pancreatitis. Pseudoaneurysm formation after
a relapse of acute disease. A: CT shows a hypodense collection in the pancreatic tail
associated with splenic infarction, B: CT one week after A shows a hyperattenuating
nodular image inside the collection that was due to the formation of a splenic
pseudoaneurysm (red arrow), C: DSA shows a pseudoaneurysm, D: embolization by
packing 2 coils to sandwich the pseudoaneurysm, E: CT after embolization, shows an
splenic abscess due to splenic necrosis that was managed with percutaneous drainage.
Page 27 of 34
Conclusion
•
Splenic arterial embolization may be used to treat a wide range of
pathologic entities, so interventional radiologists require a thorough
knowledge of the common indications, techniques, and complications.
•
We also believe that specific interdisciplinary protocols for each
condition are mandatory.
Personal Information
#
#
A. Zugazaga , P. Bermúdez*, A. Darnell**, A. Alguersuari*, D. Rodriguez , A.
#
Torremadé , J. Branera*, J. R. Fortuño*
#
Radiology Resident
* Vascular and Interventional Radiology Staff
** Abdominal Radiology Staff
UDIAT-CD, Institut Universitari Parc Taulí - UAB
Parc Taulí, 1
Page 28 of 34
08208 Sabadell
SPAIN
[email protected]
[email protected]
Images for this section:
Page 29 of 34
Fig. 1
Page 30 of 34
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Images for this section:
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Fig. 1
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