DOI: 10.1148/rg.25si055504
Splenic Arterial Interventions: Anatomy, Indications, Technical Considerations, and Potential Complications1
David C. Madoff, MD,
Alban Denys, MD,
Michael J. Wallace, MD,
Ravi Murthy, MD,
Sanjay Gupta, MD,
Edmund P. Pillsbury, BA,
Kamran Ahrar, MD,
Bertrand Bessoud, MD and
Marshall E. Hicks, MD
1 From the Division of Diagnostic Imaging, Interventional Radiology Section, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 325, Houston, TX 77030-4009 (D.C.M., M.J.W., R.M., S.G., E.P.P., K.A., M.E.H.); and Department of Radiology and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (A.D., B.B.). Recipient of a Cum Laude award for an education exhibit at the 2004 RSNA Annual Meeting. Received February 3, 2005; revision requested March 4 and received April 19; accepted April 25. The authors discuss an investigational or unlabeled use of a commercial product, device, or pharmaceutical that has not been approved for such purpose by the FDA. All authors have no financial relationships to disclose.
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Figure 1. Three-dimensional drawing of normal anatomy in the upper abdomen shows the main splenic artery and its branches.
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Figure 2a. Splenic arterial embolization for treatment of splenic laceration due to blunt abdominal trauma in a 26-year-old man. (a) Transverse contrast-enhanced CT scan shows active extravasation (arrow). (b) Splenic arteriogram obtained before intervention shows multiple pseudoaneurysms (arrows) in the upper pole of the spleen. (c) Postprocedural splenic arteriogram shows successful embolization with coils in the splenic artery.
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Figure 2b. Splenic arterial embolization for treatment of splenic laceration due to blunt abdominal trauma in a 26-year-old man. (a) Transverse contrast-enhanced CT scan shows active extravasation (arrow). (b) Splenic arteriogram obtained before intervention shows multiple pseudoaneurysms (arrows) in the upper pole of the spleen. (c) Postprocedural splenic arteriogram shows successful embolization with coils in the splenic artery.
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Figure 2c. Splenic arterial embolization for treatment of splenic laceration due to blunt abdominal trauma in a 26-year-old man. (a) Transverse contrast-enhanced CT scan shows active extravasation (arrow). (b) Splenic arteriogram obtained before intervention shows multiple pseudoaneurysms (arrows) in the upper pole of the spleen. (c) Postprocedural splenic arteriogram shows successful embolization with coils in the splenic artery.
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Figure 3a. Partial splenic arterial embolization in a 45-year-old man with blunt abdominal trauma from a motor vehicle accident. (a) Splenic arteriogram obtained before intervention shows multiple pseudoaneurysms (arrows) and reduced parenchymal blush in the upper pole of the spleen. (b) Splenic arteriogram obtained after embolization of the pseudoaneurysms with gelatin sponge pledgets shows continuation of blood flow to the inferior pole of the spleen (arrowheads).
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Figure 3b. Partial splenic arterial embolization in a 45-year-old man with blunt abdominal trauma from a motor vehicle accident. (a) Splenic arteriogram obtained before intervention shows multiple pseudoaneurysms (arrows) and reduced parenchymal blush in the upper pole of the spleen. (b) Splenic arteriogram obtained after embolization of the pseudoaneurysms with gelatin sponge pledgets shows continuation of blood flow to the inferior pole of the spleen (arrowheads).
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Figure 4a. Splenic arterial embolization in a 48-year-old woman with idiopathic thrombocytopenic purpura and splenomegaly. Because of comorbidity in this patient, embolization was preferred to splenectomy. (a) Splenic arteriogram obtained prior to treatment shows an enlarged spleen. (b) Splenic arteriogram obtained after embolization with microparticles (500–700 µm) and coils shows complete occlusion of the splenic artery. (c) Transverse contrast-enhanced CT scan obtained at follow-up shows a coil within the splenic artery (arrow), as well as complete infarction of the spleen, which is not contrast enhanced. After embolization, the platelet count returned to normal levels; 6 months later, however, symptoms recurred and embolization was repeated. (d) Arteriogram obtained after recurrence of symptoms and before second embolization shows a small pancreatic branch (arrow) that supplies blood to part of the lower pole of the spleen. Repeat embolization was performed with n-butyl-cyanoacrylate.
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Figure 4b. Splenic arterial embolization in a 48-year-old woman with idiopathic thrombocytopenic purpura and splenomegaly. Because of comorbidity in this patient, embolization was preferred to splenectomy. (a) Splenic arteriogram obtained prior to treatment shows an enlarged spleen. (b) Splenic arteriogram obtained after embolization with microparticles (500–700 µm) and coils shows complete occlusion of the splenic artery. (c) Transverse contrast-enhanced CT scan obtained at follow-up shows a coil within the splenic artery (arrow), as well as complete infarction of the spleen, which is not contrast enhanced. After embolization, the platelet count returned to normal levels; 6 months later, however, symptoms recurred and embolization was repeated. (d) Arteriogram obtained after recurrence of symptoms and before second embolization shows a small pancreatic branch (arrow) that supplies blood to part of the lower pole of the spleen. Repeat embolization was performed with n-butyl-cyanoacrylate.
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Figure 4c. Splenic arterial embolization in a 48-year-old woman with idiopathic thrombocytopenic purpura and splenomegaly. Because of comorbidity in this patient, embolization was preferred to splenectomy. (a) Splenic arteriogram obtained prior to treatment shows an enlarged spleen. (b) Splenic arteriogram obtained after embolization with microparticles (500–700 µm) and coils shows complete occlusion of the splenic artery. (c) Transverse contrast-enhanced CT scan obtained at follow-up shows a coil within the splenic artery (arrow), as well as complete infarction of the spleen, which is not contrast enhanced. After embolization, the platelet count returned to normal levels; 6 months later, however, symptoms recurred and embolization was repeated. (d) Arteriogram obtained after recurrence of symptoms and before second embolization shows a small pancreatic branch (arrow) that supplies blood to part of the lower pole of the spleen. Repeat embolization was performed with n-butyl-cyanoacrylate.
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Figure 4d. Splenic arterial embolization in a 48-year-old woman with idiopathic thrombocytopenic purpura and splenomegaly. Because of comorbidity in this patient, embolization was preferred to splenectomy. (a) Splenic arteriogram obtained prior to treatment shows an enlarged spleen. (b) Splenic arteriogram obtained after embolization with microparticles (500–700 µm) and coils shows complete occlusion of the splenic artery. (c) Transverse contrast-enhanced CT scan obtained at follow-up shows a coil within the splenic artery (arrow), as well as complete infarction of the spleen, which is not contrast enhanced. After embolization, the platelet count returned to normal levels; 6 months later, however, symptoms recurred and embolization was repeated. (d) Arteriogram obtained after recurrence of symptoms and before second embolization shows a small pancreatic branch (arrow) that supplies blood to part of the lower pole of the spleen. Repeat embolization was performed with n-butyl-cyanoacrylate.
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Figure 5a. Complete splenic arterial embolization performed in a 45-year-old man with acute myelogenous leukemia and refractory thrombocytopenia (platelet count, <10 x 109/L) after bone marrow transplantation. Embolization was performed immediately before splenectomy, to reduce intraoperative blood loss. (a) Splenic arteriogram obtained before embolization shows normal splenic anatomy. (b) Postembolization arteriogram shows complete occlusion of the splenic artery after infusion of polyvinyl alcohol particles (diameter range, 500–700 µm) and placement of a coil. Within 2 months of treatment, the platelet count returned to normal levels.
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Figure 5b. Complete splenic arterial embolization performed in a 45-year-old man with acute myelogenous leukemia and refractory thrombocytopenia (platelet count, <10 x 109/L) after bone marrow transplantation. Embolization was performed immediately before splenectomy, to reduce intraoperative blood loss. (a) Splenic arteriogram obtained before embolization shows normal splenic anatomy. (b) Postembolization arteriogram shows complete occlusion of the splenic artery after infusion of polyvinyl alcohol particles (diameter range, 500–700 µm) and placement of a coil. Within 2 months of treatment, the platelet count returned to normal levels.
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Figure 6. Three-dimensional drawing of selective partial splenic arterial embolization shows change in color (brown area) that represents absence of perfusion in the inferior portion of the spleen. PVA/EMBO = polyvinyl alcohol particles/embolization.
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Figure 7a. Partial splenic arterial embolization in a 47-year-old woman with locally advanced pancreatic carcinoma and thrombocytopenia precluding further chemotherapy. (a, b) Arteriograms obtained before embolization show normal splenic anatomy (a) and the superior segment of the splenic artery (b) that was targeted for selective embolization with particles (diameter range, 300–500 µm). (c) Postembolization arteriogram shows complete occlusion of the targeted splenic artery segment. Within 1 month after embolization, the patient’s platelet count had increased to more than 400 x 109/L.
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Figure 7b. Partial splenic arterial embolization in a 47-year-old woman with locally advanced pancreatic carcinoma and thrombocytopenia precluding further chemotherapy. (a, b) Arteriograms obtained before embolization show normal splenic anatomy (a) and the superior segment of the splenic artery (b) that was targeted for selective embolization with particles (diameter range, 300–500 µm). (c) Postembolization arteriogram shows complete occlusion of the targeted splenic artery segment. Within 1 month after embolization, the patient’s platelet count had increased to more than 400 x 109/L.
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Figure 7c. Partial splenic arterial embolization in a 47-year-old woman with locally advanced pancreatic carcinoma and thrombocytopenia precluding further chemotherapy. (a, b) Arteriograms obtained before embolization show normal splenic anatomy (a) and the superior segment of the splenic artery (b) that was targeted for selective embolization with particles (diameter range, 300–500 µm). (c) Postembolization arteriogram shows complete occlusion of the targeted splenic artery segment. Within 1 month after embolization, the patient’s platelet count had increased to more than 400 x 109/L.
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Figure 8. Three-dimensional drawing of nonselective partial splenic arterial embolization with gelatin sponge pledgets shows patchy changes in perfusion (brown areas) throughout the splenic parenchyma.
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Figure 9a. Partial splenic arterial embolization performed to increase the white blood cell and platelet counts before additional chemotherapy in a 48-year-old man with pancreatic cancer and persistent neutropenia and thrombocytopenia. (a) Transverse CT scan of the abdomen shows splenomegaly before embolization. (b) Splenic arteriogram, obtained before embolization, shows normal anatomy and parenchymal enhancement pattern. (c) Splenic arteriogram, obtained after nonselective embolization with gelatin sponge pledgets, shows abrupt occlusion (arrows) of many splenic arterial branches and patchy remnants (10%–20%) of parenchymal blush. (d) Transverse CT scan, obtained 4 months after embolization, shows massive necrosis (arrows) of the splenic parenchyma. Within 2 weeks after embolization, the platelet count returned to a normal level (379 x 109/L).
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Figure 9b. Partial splenic arterial embolization performed to increase the white blood cell and platelet counts before additional chemotherapy in a 48-year-old man with pancreatic cancer and persistent neutropenia and thrombocytopenia. (a) Transverse CT scan of the abdomen shows splenomegaly before embolization. (b) Splenic arteriogram, obtained before embolization, shows normal anatomy and parenchymal enhancement pattern. (c) Splenic arteriogram, obtained after nonselective embolization with gelatin sponge pledgets, shows abrupt occlusion (arrows) of many splenic arterial branches and patchy remnants (10%–20%) of parenchymal blush. (d) Transverse CT scan, obtained 4 months after embolization, shows massive necrosis (arrows) of the splenic parenchyma. Within 2 weeks after embolization, the platelet count returned to a normal level (379 x 109/L).
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Figure 9c. Partial splenic arterial embolization performed to increase the white blood cell and platelet counts before additional chemotherapy in a 48-year-old man with pancreatic cancer and persistent neutropenia and thrombocytopenia. (a) Transverse CT scan of the abdomen shows splenomegaly before embolization. (b) Splenic arteriogram, obtained before embolization, shows normal anatomy and parenchymal enhancement pattern. (c) Splenic arteriogram, obtained after nonselective embolization with gelatin sponge pledgets, shows abrupt occlusion (arrows) of many splenic arterial branches and patchy remnants (10%–20%) of parenchymal blush. (d) Transverse CT scan, obtained 4 months after embolization, shows massive necrosis (arrows) of the splenic parenchyma. Within 2 weeks after embolization, the platelet count returned to a normal level (379 x 109/L).
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Figure 9d. Partial splenic arterial embolization performed to increase the white blood cell and platelet counts before additional chemotherapy in a 48-year-old man with pancreatic cancer and persistent neutropenia and thrombocytopenia. (a) Transverse CT scan of the abdomen shows splenomegaly before embolization. (b) Splenic arteriogram, obtained before embolization, shows normal anatomy and parenchymal enhancement pattern. (c) Splenic arteriogram, obtained after nonselective embolization with gelatin sponge pledgets, shows abrupt occlusion (arrows) of many splenic arterial branches and patchy remnants (10%–20%) of parenchymal blush. (d) Transverse CT scan, obtained 4 months after embolization, shows massive necrosis (arrows) of the splenic parenchyma. Within 2 weeks after embolization, the platelet count returned to a normal level (379 x 109/L).
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Figure 10a. Splenic abscess in a 64-year-old man after splenic arterial embolization for grade III splenic trauma. (a) Transverse CT scan shows a large fluid collection (arrows) with air pockets in the splenic parenchyma after 2 days of percutaneous drainage. (b) Follow-up transverse CT scan obtained 3 weeks later shows that the fluid collection has almost completely disappeared.
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Figure 10b. Splenic abscess in a 64-year-old man after splenic arterial embolization for grade III splenic trauma. (a) Transverse CT scan shows a large fluid collection (arrows) with air pockets in the splenic parenchyma after 2 days of percutaneous drainage. (b) Follow-up transverse CT scan obtained 3 weeks later shows that the fluid collection has almost completely disappeared.
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Figure 11. Acute pancreatitis in a 62-year-old man after splenic arterial embolization with n-butyl-cyanoacrylate and coils (arrow) for a splenic artery aneurysm. Transverse abdominal CT scan shows moderate thickening (arrowheads) of the pancreatic tail with fat infiltration due to pancreatitis but without necrosis of the pancreas. The patient recovered spontaneously.
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Figure 12a. Splenic arterial embolization for recurrent bleeding from gastric varices in a 58-year-old patient with cirrhosis of the liver after hepatitis C infection. A surgical shunt or transjugular intrahepatic portosystemic shunt could not be created because of the severity of cirrhosis (Child classification C). Since substantial splenomegaly was found at abdominal CT, splenic arterial embolization was performed with simultaneous monitoring of the portosystemic pressure gradient. (a) Angiogram shows balloon catheter (arrow) positioned in the right hepatic vein to monitor wedged hepatic venous pressure during the insertion of a microcatheter in the splenic artery. (b) Splenic arteriogram shows an enlarged splenic arterial trunk with a superior branch that originates at the approximate midpoint of the artery. (c) Follow-up arteriogram obtained after embolization with particles (500–700 µm) and coils shows occlusion of the splenic artery. The hepatic vein pressure decreased from 24 to 16 mm Hg after embolization.
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Figure 12b. Splenic arterial embolization for recurrent bleeding from gastric varices in a 58-year-old patient with cirrhosis of the liver after hepatitis C infection. A surgical shunt or transjugular intrahepatic portosystemic shunt could not be created because of the severity of cirrhosis (Child classification C). Since substantial splenomegaly was found at abdominal CT, splenic arterial embolization was performed with simultaneous monitoring of the portosystemic pressure gradient. (a) Angiogram shows balloon catheter (arrow) positioned in the right hepatic vein to monitor wedged hepatic venous pressure during the insertion of a microcatheter in the splenic artery. (b) Splenic arteriogram shows an enlarged splenic arterial trunk with a superior branch that originates at the approximate midpoint of the artery. (c) Follow-up arteriogram obtained after embolization with particles (500–700 µm) and coils shows occlusion of the splenic artery. The hepatic vein pressure decreased from 24 to 16 mm Hg after embolization.
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Figure 12c. Splenic arterial embolization for recurrent bleeding from gastric varices in a 58-year-old patient with cirrhosis of the liver after hepatitis C infection. A surgical shunt or transjugular intrahepatic portosystemic shunt could not be created because of the severity of cirrhosis (Child classification C). Since substantial splenomegaly was found at abdominal CT, splenic arterial embolization was performed with simultaneous monitoring of the portosystemic pressure gradient. (a) Angiogram shows balloon catheter (arrow) positioned in the right hepatic vein to monitor wedged hepatic venous pressure during the insertion of a microcatheter in the splenic artery. (b) Splenic arteriogram shows an enlarged splenic arterial trunk with a superior branch that originates at the approximate midpoint of the artery. (c) Follow-up arteriogram obtained after embolization with particles (500–700 µm) and coils shows occlusion of the splenic artery. The hepatic vein pressure decreased from 24 to 16 mm Hg after embolization.
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Figure 13a. Drawings show techniques for splenic arterial embolization with multiple coils placed in the aneurysmal sac (a) and in splenic artery segments proximal and distal to the aneurysmal neck (the so-called sandwich method) (b).
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Figure 13b. Drawings show techniques for splenic arterial embolization with multiple coils placed in the aneurysmal sac (a) and in splenic artery segments proximal and distal to the aneurysmal neck (the so-called sandwich method) (b).
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Figure 14a. Treatment of splenic artery aneurysm secondary to atherosclerosis in a 68-year-old woman. (a) Celiac arteriogram shows a 2.4-cm-diameter saccular aneurysm (arrow) that arises from the splenic artery. (b) Fluoroscopic image shows multiple coils (arrow) deployed inside the aneurysmal sac. (c) Follow-up arteriogram shows treatment success; blood flow to the spleen (arrowheads) is preserved.
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Figure 14b. Treatment of splenic artery aneurysm secondary to atherosclerosis in a 68-year-old woman. (a) Celiac arteriogram shows a 2.4-cm-diameter saccular aneurysm (arrow) that arises from the splenic artery. (b) Fluoroscopic image shows multiple coils (arrow) deployed inside the aneurysmal sac. (c) Follow-up arteriogram shows treatment success; blood flow to the spleen (arrowheads) is preserved.
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Figure 14c. Treatment of splenic artery aneurysm secondary to atherosclerosis in a 68-year-old woman. (a) Celiac arteriogram shows a 2.4-cm-diameter saccular aneurysm (arrow) that arises from the splenic artery. (b) Fluoroscopic image shows multiple coils (arrow) deployed inside the aneurysmal sac. (c) Follow-up arteriogram shows treatment success; blood flow to the spleen (arrowheads) is preserved.
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Figure 15a. Splenic arterial embolization for a splenic artery aneurysm of unknown origin in a 47-year-old man. (a) Splenic arteriogram shows a 2.5-cm-diameter aneurysm (arrow) that involves the midportion of the main splenic artery. (b) Arteriogram shows a microcatheter that was successfully inserted into the aneurysmal sac but that could not be advanced to the splenic artery downstream of the aneurysm. (c) Arteriogram shows embolization with placement of coils (arrow) in the bifurcation of the splenic artery to avoid retrograde filling from the splenic hilum via gastroepiploic collateral vessels and with deployment of n-butyl-cyanoacrylate and coils in the aneurysm. (d) Follow-up arteriogram shows exclusion of the aneurysm.
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Figure 15b. Splenic arterial embolization for a splenic artery aneurysm of unknown origin in a 47-year-old man. (a) Splenic arteriogram shows a 2.5-cm-diameter aneurysm (arrow) that involves the midportion of the main splenic artery. (b) Arteriogram shows a microcatheter that was successfully inserted into the aneurysmal sac but that could not be advanced to the splenic artery downstream of the aneurysm. (c) Arteriogram shows embolization with placement of coils (arrow) in the bifurcation of the splenic artery to avoid retrograde filling from the splenic hilum via gastroepiploic collateral vessels and with deployment of n-butyl-cyanoacrylate and coils in the aneurysm. (d) Follow-up arteriogram shows exclusion of the aneurysm.
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Figure 15c. Splenic arterial embolization for a splenic artery aneurysm of unknown origin in a 47-year-old man. (a) Splenic arteriogram shows a 2.5-cm-diameter aneurysm (arrow) that involves the midportion of the main splenic artery. (b) Arteriogram shows a microcatheter that was successfully inserted into the aneurysmal sac but that could not be advanced to the splenic artery downstream of the aneurysm. (c) Arteriogram shows embolization with placement of coils (arrow) in the bifurcation of the splenic artery to avoid retrograde filling from the splenic hilum via gastroepiploic collateral vessels and with deployment of n-butyl-cyanoacrylate and coils in the aneurysm. (d) Follow-up arteriogram shows exclusion of the aneurysm.
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Figure 15d. Splenic arterial embolization for a splenic artery aneurysm of unknown origin in a 47-year-old man. (a) Splenic arteriogram shows a 2.5-cm-diameter aneurysm (arrow) that involves the midportion of the main splenic artery. (b) Arteriogram shows a microcatheter that was successfully inserted into the aneurysmal sac but that could not be advanced to the splenic artery downstream of the aneurysm. (c) Arteriogram shows embolization with placement of coils (arrow) in the bifurcation of the splenic artery to avoid retrograde filling from the splenic hilum via gastroepiploic collateral vessels and with deployment of n-butyl-cyanoacrylate and coils in the aneurysm. (d) Follow-up arteriogram shows exclusion of the aneurysm.
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Figure 16. Drawing shows complete exclusion of an aneurysmal sac with a stent-graft while blood flow through the splenic artery is maintained.
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Figure 17a. Stent-graft placement for a splenic artery aneurysm in a 69-year-old woman with duodenal adenocarcinoma and gastric outlet obstruction. (a) Transverse unenhanced CT scan shows a 2-cm-diameter splenic artery aneurysm (arrow) that required exclusion from the arterial lumen before duodenal resection. (b) Transverse CT scan obtained with intravenous contrast material shows contrast enhancement of the splenic artery aneurysm (arrow). (c) Transverse CT scan, obtained 4 months after placement of an 8 x 50-mm stent-graft (Viabahn; Gore, Flagstaff, Ariz) (white arrow) for exclusion of the aneurysm, shows a thrombus (black arrow) in the aneurysmal sac.
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Figure 17b. Stent-graft placement for a splenic artery aneurysm in a 69-year-old woman with duodenal adenocarcinoma and gastric outlet obstruction. (a) Transverse unenhanced CT scan shows a 2-cm-diameter splenic artery aneurysm (arrow) that required exclusion from the arterial lumen before duodenal resection. (b) Transverse CT scan obtained with intravenous contrast material shows contrast enhancement of the splenic artery aneurysm (arrow). (c) Transverse CT scan, obtained 4 months after placement of an 8 x 50-mm stent-graft (Viabahn; Gore, Flagstaff, Ariz) (white arrow) for exclusion of the aneurysm, shows a thrombus (black arrow) in the aneurysmal sac.
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Figure 17c. Stent-graft placement for a splenic artery aneurysm in a 69-year-old woman with duodenal adenocarcinoma and gastric outlet obstruction. (a) Transverse unenhanced CT scan shows a 2-cm-diameter splenic artery aneurysm (arrow) that required exclusion from the arterial lumen before duodenal resection. (b) Transverse CT scan obtained with intravenous contrast material shows contrast enhancement of the splenic artery aneurysm (arrow). (c) Transverse CT scan, obtained 4 months after placement of an 8 x 50-mm stent-graft (Viabahn; Gore, Flagstaff, Ariz) (white arrow) for exclusion of the aneurysm, shows a thrombus (black arrow) in the aneurysmal sac.
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Figure 18a. Drawings show (a) splenic artery steal syndrome after liver transplantation, with substantial blood flow via the splenic artery to the spleen and with reduced blood flow to the transplanted liver, and (b) improved blood flow to the liver transplant after splenic arterial embolization.
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Figure 18b. Drawings show (a) splenic artery steal syndrome after liver transplantation, with substantial blood flow via the splenic artery to the spleen and with reduced blood flow to the transplanted liver, and (b) improved blood flow to the liver transplant after splenic arterial embolization.
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Copyright © 2005 by the Radiological Society of North America.
