Splenic Arteriovenous Fistula Accompanied by Splenic Artery Aneurysm Associated with Acute-onset Portal Hypertension and Gastrointestinal Bleeding: Case Report and Literature Review.

Splenic arteriovenous fistula is an uncommon aetiology of portal hypertension, which has definitive treatment effectiveness and good prognosis. We report a case of portal hypertension and gastrointestinal bleeding in the absence of hepatic parenchymal disease in a 50 year-old woman with multiple pregnancies. Abdominal computed tomography and transabdominal arteriography recorded the presence of tortuous and aneurysmal splenic arteries and the premature filling of enlarged splenic veins, which are highly suggestive of splenic arteriovenous fistula. The above vascular abnormalities were successfully treated by transcatheter embolization. No recurrence or other complications were observed. In addition, a literature review concerning splenic arteriovenous fistula published in recent 30 years was performed to further our understanding of the management strategy on this entity.

Splenic Vein Diameter is a Risk Factor for the Portal Venous System Thrombosis After Partial Splenic Artery Embolization.

PURPOSE: Portal venous system thrombosis is a complication of partial splenic artery embolization, and pre-treatment risk assessment is thus important. The purpose of this study was to identify the risk factors for portal venous system thrombosis after partial splenic artery embolization. MATERIALS AND METHODS: We retrospectively analyzed 67 consecutive patients who underwent contrast-enhanced computed tomography before and after first partial splenic artery embolization between July 2007 and October 2018. As risk factors, we investigated age, sex, hematological data, liver function, steroid use, heparin use, and findings from pre- and post-treatment computed tomography. Uni- and multivariate analyses were performed to evaluate the relationship between thrombus appearance or growth and these factors. Values of p < 0.05 were considered significant. RESULTS: Partial splenic artery embolization was technically successful in all 67 patients. Nine patients showed appearance or growth of thrombus. Univariate analysis showed maximum diameter of the splenic vein before treatment (p = 0.0076), percentage of infarcted spleen (p = 0.017), and volume of infarcted spleen (p = 0.022) as significant risk factors. Multivariate analysis showed significant differences in maximum diameter of the splenic vein before treatment (p = 0.041) and percentage of infarcted spleen (p = 0.023). According to receiver operating characteristic analysis, cutoffs for maximum diameter of the splenic vein and percentage of infarcted spleen for distinguishing the appearance or growth of thrombus were 17 mm and 58.2%. CONCLUSION: Large maximum diameter of the splenic vein before partial splenic artery embolization and high percentage of infarcted spleen after partial splenic artery embolization were identified as risk factors for portal venous system thrombosis. LEVEL OF EVIDENCE: Level 4, Case Series.

Hemorrhagic pancreatic pseudocyst: A rare complication.

Pancreatic pseudocysts are seen both in acute and chronic pancreatitis. Prevalence of pancreatic pseudocyst in chronic pancreatitis is 20% to 40% and is most commonly seen in alcoholic chronic pancreatitis. Intracystic hemorrhage from a pseudoaneurysm is a rare and potentially a lethal complication of pancreatic pseudocyst with an incidence of less than 10%. We herein present a case of a 42-year-old male with a past medical history of chronic alcoholic pancreatitis, stable pseudocyst in the tail of pancreas, alcohol abuse and seizures who presented with abdominal pain and acute anemia had this rare complication of hemorrhagic pseudocyst. The diagnostic modalities used to diagnose hemorrhagic pseudocyst are ultrasound with color doppler, CT with contrast, digital subtraction angiography and angiography. Angiographic embolization of the culprit artery is the preferred treatment of choice in the treatment of pseudoaneurysms. It is important for early recognition and treatment of this complication as the mortality can be as high as 40%.

Contribution of Splenic Resistance Arteries to Splanchnic Blood Overflow in Cirrhosis.

BACKGROUND: In liver cirrhosis, a marked splanchnic vasodilation causes an increase in portal blood flow, contributing to the development of portal hypertension. AIM: To evaluate if, in experimental cirrhosis, a different vascular reactivity exists between splenic and mesenteric components of the splanchnic circulation. METHODS: Liver cirrhosis was induced in Sprague Dawley rats by common bile duct ligation. In sections of splenic and superior mesenteric arteries, cumulative dose-response curves were obtained. mRNA expression of endothelial nitric oxide synthase (eNOS), inducible NOS (iNOS), and prostaglandin I2 synthase (PTGIS) was evaluated. RESULTS: In cirrhotic rats, mesenteric but not splenic arteries showed a significant increase in endothelium-dependent relaxation to acetylcholine. In control and cirrhotic rats, COX inhibition alone did not significantly change the response of mesenteric arteries to acetylcholine; after inhibiting also NOS, the relaxation was completely abolished in control but only partially decreased in cirrhotic rats. After the inhibition of COX and NOS, the relaxation to acetylcholine was similarly decreased in splenic arteries from control and cirrhotic animals. The contraction induced by phenylephrine of both mesenteric and splenic arteries was decreased in cirrhotic rats. PTGIS mRNA expression did not differ in splenic and mesenteric arteries from control and cirrhotic rats; in cirrhotic rats, eNOS and iNOS mRNA expression was increased in mesenteric but not in splenic vascular bed. CONCLUSION: In cirrhotic rats, a decreased splenic arterial response to vasoconstrictors, rather than an increased response to vasodilators, contributes to splanchnic vasodilation, while in mesenteric arteries also an increased response to vasodilators secondary to, but not only, eNOS and iNOS overexpression, plays a role.

Laparoscopic splenic artery ligation in a patient with immune thrombocytopenia with intracranial haemorrhage (two clips that stopped a timebomb).

Intracranial haemorrhage (ICH) in a patient with relapse of idiopathic thrombocytopaenic purpura (ITP) can be lethal. The site of haemorrhage, compounded by low platelets in this disease, makes its management extremely challenging, especially when a neurosurgical procedure is warranted. We report a case report of an unconventional way of increasing platelet counts in ITP rapidly in an emergency setting.

Effect of kallikrein on microcirculation of rats with pancreatic ischemia reperfusion injury (IRI).

The common pathway for pancreatitis onset is pancreatic ischemia reperfusion injury (IRI), which plays an especially significant role in the evolution process from acute edematous pancreatitis (AP) towards severe acute pancreatitis (SAP). This study explored the effect of Kallikrein (PK) on pancreatic ischemia reperfusion injury (IRI). Male Wistar rats were taken as study objects, and a SAP -IRI combined model was established through retrograde infusion of 5% sodium taurocholate in biliopancreatic duct combining 30 min splenic artery clipping; drug intervention was carried out by pumping PK into rat caudal vein. Pancreatic microcirculation blood flow, pancreatic micro vascular permeability, hemorheological change and levels of adherence factors CD18 and CD54 were determined respectively. PK can obviously improve pancreatic microcirculation blood flow volume and velocity of IRI rats and expand arteriole; expand diameter of pancreatic blood capillary so that perfusion state tends to be stable; decrease pancreatic micro vascular permeability, reduce rat whole blood viscosity, erythrocyte deformation index and rigidity index; SAP-IRI combination reduces expression levels of white cell adhesion factor CD18 and vascular endothelial cell adhesion cell CD54 in rats. In conclusion, PK is an effective method of improving SAP pancreatic IRI microcirculation.

Management strategies for true and dissecting visceral artery aneurysms.

BACKGROUND: Visceral artery aneurysms (VAA) are rare and the literature regarding management strategies is limited. The study aim was to evaluate our 13-year experience with VAA treatment including conservative, open surgical and endovascular therapy. METHODS: This retrospective single-center study included 37 patients (31 male, median age 70 years [46-79 years]) with true and dissecting VAA treated between January 2006 and December 2018. Indications for invasive therapy were ruptured (N.=1) and symptomatic (N.=8) VAA or asymptomatic VAA>20 mm (N.=15). The decision on the treatment type was made after interdisciplinary (vascular surgeons/radiologists) discussion. RESULTS: The aneurysms affected the celiac trunk (N.=18, 49%), the splenic artery (N.=11, 30%), the superior mesenteric artery (SMA, N.=6, 16%), the hepatic artery (N.=5, 14%) and proximal SMA side branches (N.=2, 5%). Six patients had multiple VAA, one had an intrahepatic artery aneurysm and one had peripheral mesocolic artery aneurysms plus a VAA. 46% of the patients (N.=17) had coexisting aneurysms in other vascular territories. Thirteen patients were managed conservatively (median VAA diameter 15 [14-25] mm), 18 underwent open surgery with venous or prosthetic bypass or interposition graft implantation and 6 were treated by endovascular means (coiling [N.=3] or endograft [N.=3]). Median follow-up (FU) was 21 months (4-123 months). In-hospital mortality was 0%. Median length of hospital stay was 11 days (5-28 days) after surgical and 3 days (2-71 days) after endovascular treatment. Complications included an early type I endoleak, 3 secondary open abdominal surgeries for bleeding/peritonitis after endovascular treatment of a ruptured intrahepatic aneurysm, an asymptomatic aorto-truncal bypass occlusion and aneurysm recurrence after a venous SMA interposition graft. None of the conservatively treated VAA required invasive treatment during FU. CONCLUSIONS: Small (<20 mm) asymptomatic VAA can be managed conservatively. Whenever invasive treatment is indicated, both open and endovascular treatments can be performed with low complication rates. In order to choose the optimal therapeutic approach, anatomical features and patient comorbidities should be considered and, ideally, discussed interdisciplinarily.

Endovascular Repair Using a 7-Branch Stent-Graft for a Thoracoabdominal Aortic Aneurysm With Variant Renovisceral Artery Anatomy.

Purpose: To present a case of endovascular repair using a custom-made 7-branch stent-graft for a thoracoabdominal aortic aneurysm (TAAA) in a patient with variations in the renovisceral artery anatomy. Case Report: A 70-year-old asymptomatic man presented with a 60-mm-diameter type IV TAAA. Due to severe coronary artery disease, an endovascular approach was elected. In the preoperative computed tomography angiography (CTA) scans, variations in the renovisceral artery anatomy included the common hepatic and splenic arteries deriving separately from the aorta and bilateral double renal arteries (RAs). A custom-made 7-branch stent-graft was manufactured to preserve all renovisceral arteries. The 7 branches were catheterized and connected with a steerable sheath from a femoral access. All branches were bridged to the target vessel (TV) with a self-expanding covered stent; 4 TVs also had balloon-expandable covered stents implanted. Final angiography and predischarge CTA showed patency of all 7 target vessels and corresponding visceral organs, with no endoleak. The patient was discharged on postoperative day 8 without complications. Six-month follow-up CTA demonstrated exclusion of the TAAA and patency of all 7 target vessels. Conclusion: Successful treatment of a TAAA in a patient with multiple variant renovisceral arteries was feasible with a custom-made 7-branch stent-graft, achieving a good early outcome.

Patterns of splenic arterial enhancement on computed tomography scan are related to portal venous hypertension.

OBJECTIVES: We have previously shown that patterns of splenic arterial enhancement on computed tomography scan change following liver transplantation. We suggested that this is related to changes in portal venous pressure. The aim of this study was to see if similar patterns occur in patients with and without portal hypertension and in patients before and after portal systemic shunts (transjugular portosystemic shunts). METHODS: We evaluated contrast enhanced computed tomography scans in patients being evaluated for liver disease and compared those from patients with and without portal hypertension. In addition we evaluated patients who had computed tomography scans before and after transjugular portosystemic shunts shunts. Splenic arterial enhancement was evaluated using Hounsfield units (pixel counts). RESULTS: Twenty-four patients with clinically significant portal hypertension were compared to 91 without. Mean splenic pixel count was significantly lower in patients with clinically significant portal hypertension (88.2 ± 17.7 vs. 115.2 ± 21.0; m ± SD, P < 0.01). Computed tomography scans were available in 18 patients pre- and post-transjugular portosystemic shunts. Pixel counts were significantly higher in the post-transjugular portosystemic shunts scans (99.7 ± 20.9 vs. 88.9 ± 26.3; P < 0.05). CONCLUSION: This study supports the hypothesis that changes in portal venous pressure are related to changes in splenic arterial enhancement. We suggest that this reflects changes in the splenic micro-circulation. This mechanism may be part of the innate immune response and may also be important in the pathogenesis of hypersplenism.

Segmental Arterial Mediolysis with Preceding Symptoms Resembling Viral Infection Hampers the Differentiation from Polyarteritis Nodosa.

A middle-aged man presented with a fever, arthralgia, gastrointestinal symptoms, headache, and rash. After two weeks, the patient suddenly complained of severe abdominal pain, and computed tomography revealed aneurysms in the hepatic and splenic arteries, which increased in size progressively. Given the elevated levels of inflammatory markers and orchitis, polyarteritis nodosa (PN) was initially suspected. Catheter embolization for the ruptured hepatic aneurysm and splenectomy for the large splenic ones were performed, and the pathological finding was consistent with segmental arterial mediolysis (SAM). Changes in inflammatory marker levels and aneurysmal size are also informative to differentiate SAM from PN.

Spontaneous splenoazygos shunt in a patient with portal hypertension: an exceedingly rare occurrence

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Natural course of asymptomatic walled off pancreatic necrosis.

INTRODUCTION: There is paucity of data on natural course of asymptomatic walled off necrosis (WON). OBJECTIVE: To study the natural course as well as outcome of conservative management in patients with asymptomatic WON. METHODS: Retrospective analysis of prospectively maintained data base of patients with asymptomatic WON presenting to us 4-6 weeks after an episode of acute necrotising pancreatitis (ANP). RESULTS: Forty three patients (37 M; mean age: 38.2 ±â€¯10.4 years) with asymptomatic WON were studied. The size of WON ranged from 5 to 16 cm (mean 8.2 ±â€¯2.2 cm). The site of WON was head, body and tail in 5 (11%), 34 (79%) and 4 (10%) patients respectively. Thirty of 43 patients (70%) patients did not have any complications during the expectant management period of 3 weeks-32 months with 13 (30%) patients having spontaneous resolution within 6.2 ±â€¯3.4 months. Thirteen (30%) patients became symptomatic or developed complication within 3.2 ±â€¯1.3 months. These were refractory pain (n = 7), infection (n = 4), spontaneous rupture into gastrointestinal tract (n = 5; stomach in 3, duodenum in 1 and colon in 1 patient respectively) and bleeding from splenic artery pseudoaneursym in 1 patient. CONCLUSIONS: Majority of patients with asymptomatic WON have an uneventful clinical course. However, one third patients will develop symptoms/complications requiring interventional treatment.

Patterns of splenic arterial enhancement on computed tomography are related to changes in portal venous pressure.

OBJECTIVES: One of the striking features of splenic imaging is variable heterogeneous gyriform arterial enhancement on dynamic computed tomography (CT). We speculated that these patterns of arterial enhancement may reflect changes in splenic micro-circulation related to changes in portal venous pressure. PATIENTS AND METHODS: To test this hypothesis, we evaluated arterial phase CT scans performed before and after liver transplantation (n=91), as this is the most effective way of alleviating portal hypertension. We developed novel grading systems to assess heterogeneity. Two control groups were used: patients with cirrhosis undergoing transarterial chemoembolization (TACE) (n=28) and patients with cirrhosis on the liver transplant waiting list who had repeated CT scans (n=28). RESULTS: Splenic arterial heterogeneity increased in 55% of transplant patients compared with 14% in the TACE patients and 4% in the waiting list patients (P<0.0001). Mean Hounsfield units in areas of splenic enhancement were 71.7±2 before transplant and 90.1±2.5 after transplant (P<0.01). In contrast, there were no significant changes following TACE (86.3±4.2 vs. 83.5±4.5; P=NS) or in waiting list patients (80.9±4.6 vs. 73.8±3.7; P=NS). CONCLUSION: We have shown the heterogeneous gyriform enhancement patterns significantly increase following liver transplantation but not after TACE or in waiting list patients. We suggest that these changes are due to the reduction in portal venous pressure and likely reflect changes in splenic micro-circulation. These changes may be important in the pathophysiology of hypersplenism.

Portal Vein Thrombosis after Endovascular Embolization of Splenic Artery for a Symptomatic Arterioportal Fistula: A Case Report and Literature Review.

Arterioportal fistula (APF) can induce severe portal hypertension and therefore requires appropriate and timely management. Endovascular treatment is increasingly used for the treatment of APFs due to its minimally invasive nature, although this procedure can lead to potentially fatal portal vein thrombosis (PVT). Reports of this complication are, however, rare. Here, we describe the case of a 65-year-old woman who experienced an extensive thrombosis from the splenic vein to the right portal vein after embolization of a splenic APF, leading to the requirement for intensive care unit care and a prolonged hospital stay. In addition, the literature was reviewed to describe the clinical manifestations, diagnosis, and treatment of PVT after embolization of APF.

Spleno-pancreatectomy En Bloc with Parcelar Gastrectomy for Splenic Artery Aneurysm - A Case Report and Literature Review.

Splenic artery aneurysms are common arterial lesions which might remain asymptomatic for a long period of time. In certain cases, these lesions might encounter a significant growth and might become symptomatic. Once diagnosed, a therapeutic strategy should be taken in consideration in order to avoid the apparition of life-threatening complications such as aneurysmal rupture. This is a case report of a 45-year-old patient diagnosed with a splenic artery aneurysm who was successfully submitted to an aneurysmal resection en bloc with distal spleno-pancreatectomy and parcelar gastrectomy.