Clinical Scorecard: Utilizing Splenic Artery Embolization for Preoperative Management of Portal Hypertension to Facilitate Major Hepatectomy

At a Glance

Key Highlights

• Preoperative splenic artery embolization (SAE) normalizes platelet counts and reduces portal hypertension markers such as varices and splenomegaly.
• SAE is minimally invasive, repeatable, and offers advantages over surgical splenectomy or ligation.
• In three reported cases, SAE facilitated major hepatectomy with acceptable postoperative outcomes, including one case of grade B post-hepatectomy liver failure that resolved with supportive care.

Guideline-Based Recommendations

Diagnosis

• Assess portal hypertension via clinical signs (thrombocytopenia, splenomegaly, varices) and imaging before major hepatectomy.
• Evaluate future remnant liver volume to estimate surgical risk.

Management

• Consider partial or total splenic artery embolization preoperatively to modulate portal flow in patients with portal hypertension.
• Use coils and plugs for embolization to preserve splenic arterial circulation when partial SAE is performed.
• Monitor inflammatory markers post-embolization and manage complications promptly.

Monitoring & Follow-up

• Monitor platelet counts post-SAE to confirm normalization.
• Follow liver function tests and clinical signs for post-hepatectomy liver failure.
• Perform imaging and endoscopy to assess regression of varices and splenomegaly.

Risks

• Potential procedure-related complications of SAE, though rare, should be anticipated and managed preoperatively.
• Post-hepatectomy liver failure remains a risk, especially in patients with preexisting portal hypertension.

Patient & Prescribing Data

Three non-cirrhotic female patients aged 45, 55, and 69 with colorectal liver metastases, perihilar cholangiocarcinoma, and intrahepatic cholangiocarcinoma respectively.

SAE led to normalization of platelet counts within two weeks and regression of portal hypertension signs, enabling successful major hepatectomy with favorable short- and mid-term outcomes.

Clinical Best Practices

• Evaluate portal hypertension status and liver remnant volume before planning major hepatectomy.
• Use SAE as a minimally invasive preoperative intervention to reduce portal pressure in selected patients.
• Tailor embolization extent (partial vs total) based on individual patient anatomy and clinical status.
• Monitor inflammatory response and platelet counts closely after SAE.
• Prepare for supportive management of post-hepatectomy liver failure if it occurs.

References

• Schwarz et al., 2014 - Splenic artery ligation in colorectal liver metastases
• Theodoraki et al., 2022 - Experience with splenic artery ligation
• Junrungsee et al. - Randomized controlled trial on splenic artery ligation
• Splenic artery embolization overview