Preoperative Splenic Artery Embolization to Manage Portal Hypertension in Major Hepatectomy

Overview

Preoperative splenic artery embolization (SAE) was successfully used in three non-cirrhotic patients with portal hypertension undergoing major hepatectomy. SAE normalized platelet counts, reduced portal hypertension manifestations, and facilitated safe liver resections with favorable postoperative outcomes.

Background

Post-hepatectomy liver failure (PHLF) is strongly influenced by portal vein pressure, making portal hypertension a significant risk factor in major liver resections. While liver transplantation is preferred for hepatocellular carcinoma with portal hypertension, alternative strategies like splenectomy or splenic artery ligation have been used to modulate portal flow in patients with liver metastases or cholangiocarcinoma. Splenic artery embolization (SAE) offers a minimally invasive, repeatable method to reduce splenic inflow, alleviate portal hypertension, and improve surgical outcomes.

Data Highlights

Key Findings

• All three patients had thrombocytopenia and evidence of portal hypertension prior to SAE.
• Partial SAE was performed in two patients, preserving the upper pole arterial circulation; total SAE was performed in one patient.
• Platelet counts normalized within two weeks post-SAE, with increases from 79, 51, and 58 ×10³/µL to 419, 340, and 159 ×10³/µL respectively.
• Future remnant liver volumes ranged from 47% to 63%, adequate for major hepatectomy.
• One patient developed grade B post-hepatectomy liver failure but recovered with supportive care; all patients were eventually discharged.
• Two patients remain disease-free at 21 and 36 months; one died of recurrent disease at 17 months.

Clinical Implications

Preoperative SAE is a viable, minimally invasive option to modulate portal hypertension in patients undergoing major hepatectomy, especially those with chemotherapy-induced portal hypertension or splenomegaly. Normalization of platelet counts and reduction of portal pressure manifestations can improve surgical safety and postoperative liver function. SAE should be considered as part of preoperative planning in portal hypertensive patients requiring extensive liver resections.

Conclusion

Splenic artery embolization effectively reduces portal hypertension and improves hematologic parameters preoperatively, facilitating safer major hepatectomies in non-cirrhotic patients. This approach may reduce the risk of post-hepatectomy liver failure and improve long-term outcomes.

References

1. Schwarz et al. 2014 -- Splenic artery ligation in colorectal liver metastases
2. Theodoraki et al. 2022 -- Experience with splenic artery ligation
3. Junrungsee et al. -- Randomized trial on splenic artery ligation