Adverse Events Related to Partial Splenic Embolization for the Treatment of Hypersplenism: A Systematic Review

Clinical question
What is the adverse event profile of partial splenic embolization in patients with hypersplenism?

Take-away point
Despite high technical success rates, partial splenic embolization demonstrated a high risk of minor complications including postembolization syndrome as well as a lower risk of major complications including gastrointestinal bleeding, splenic abscess, peritonitis, pleural effusion, and mortality.

Reference
Talwar A, Gabr A, Riaz A, et al. Adverse Events Related to Partial Splenic Embolization for the Treatment of Hypersplenism: A Systematic Review. J Vasc Interv Radiol. 2020;31(7):1118-1131.e6.

Click here for abstract

Study design
Systematic Review

Funding source
Self-funded or unfunded

Setting
Multiple studies

Summary

Partial splenic embolization (PSE) is a non-surgical alternative to splenectomy in the treatment of hypersplenism. While proven to be an effective alternative with advantages of decreased procedure time, early ambulation, and preservation of spleen function, PSE is not without its risks. Presently, there is limited pooled data on the specific complications associated with this procedure in patients with hypersplenism.

This systematic review analyzed 30 original studies reporting complications of PSE for the treatment of hypersplenism. Outomes included specific adverse events during or after the procedure and technical success rate. Complication rates were calculated only for patients with successful embolization. Complications were classified as either major or minor, with major complications being defined as those requiring surgical intervention, resulting in a hospital stay >30 days post-procedure, or associated with splenic abscess, refractory ascites, massive pleural effusion causing shortness of breath, post-procedure gastrointestinal bleeding, paralytic ileus, vasospasm, pseudoaneurysm, peritonitis, pancreatitis, or sepsis. Results were stratified by both extent of splenic embolization and Child-Pugh class.

Of the 976 PSEs analyzed, 963 procedures were technically successful (99%). Of the remaining 13 procedures, 9 failures were attributed to failure to catheterize the splenic artery, 2 were attributed to splenic artery dissection, 2 were not specified, and 1 was attributed to inadvertent total splenic embolization.

Of the 963 technically-successful procedures, 73.4% experienced postembolization syndrome, 9.4% had pleural effusion, 8.1% had ascites, 2.4% had thrombosis, 1.3% had bacterial peritonitis, 1.3% had splenic abscesses, 0.6% had gastrointestinal bleeding, and 1.0% experienced PSE-related deaths. Causes of death included liver failure, variceal bleeding, sepsis, hepatic encephalopathy, pneumonia, pleural effusion, and myocardial infarction. There were 98 major (10%) and 913 minor (95%) complications. The relative risk of developing a major complication was 10.39 (4.70–22.97, p<.0001) for patients with >70% embolization versus those with ≤70% embolization and 11.63 (3.56–38.01, p<.0001) for Child-Pugh class C patients versus class A or B patients.

Commentary

Most patients undergoing PSE experienced at least minor complications. Major complications, while rare, carried the possibility of death and occurred significantly more often in patients with advanced Child-Pugh class and with greater extent of embolization. This systematic review was limited by the overall quality of the studies included. Additionally, the cited studies had limited post-procedural length of stay data. While PSE is an effective minimally-invasive solution to hypersplenism despite its risks, newer alternatives such as radiofrequency/microwave ablation, radioembolization, and high-intensity focused ultrasound (HIFU) therapy show promise of similar benefit with lower complication rates. Increased outcomes data with their use will confirm their value in reducing procedural risk compared to PSE.

Post Author
Jared Edwards, MD
General Surgery Intern (PGY-1)
Department of General Surgery
Naval Medical Center San Diego, San Diego, CA

@JaredRayEdwards