Splenic vein stenting for recurrent chylous ascites in sinistral portal hypertension: a case report

Abstract

Background Sinistral portal hypertension results from obstruction or stenosis of the splenic vein and is characterized by normal portal vein pressures and liver function tests. Gastrointestinal bleeding is the most common presentation and indication for treatment. Although sinistral portal hypertension-related chylous ascites is rare, several cases have described successful treatment with portal venous, rather than splenic venous, recanalization. Splenectomy is effective in the treatment of sinistral portal hypertension-related bleeding, although recent studies have evaluated splenic vein stenting and splenic arterial embolization as minimally-invasive treatment alternatives. Splenic vein stenting may be a viable option for other presentations of sinistral portal hypertension. Case presentation A 59-year-old gentleman with a history of necrotizing gallstone pancreatitis was referred to interventional radiology for management of recurrent chylous ascites. Analysis of ascites demonstrated a triglyceride level of 1294 mg/dL. Computed tomography revealed splenic and superior mesenteric venous stricture. The patient elected to undergo minimally invasive transhepatic portal venography, which confirmed the presence of splenic vein and superior mesenteric vein stenosis. Venography of the splenic vein showed reversal of portal venous flow, multiple collaterals, and a pressure gradient of 14 mmHg. Two 10 mm × 40 mm Cordis stents were placed, which decreased the pressure gradient to 7 mmHg and resolved the portosystemic collaterals. At 6 months follow-up, the patient had no recurrent episodes of ascites. Conclusion The current case highlights the successful treatment of sinistral portal hypertension-related intractable chylous ascites treated with transhepatic splenic vein stenting. Splenic venous stent patency rates of 92.9% at 12 months have been reported. Rebleeding rates of 7.1% for splenic vein stenting, 16% for splenectomy, and 47.8% for splenic arterial embolization have been reported in the treatment of sinistral portal hypertension-related gastrointestinal bleeding. The literature regarding splenic vein stenting for sinistral portal hypertension-related ascites is less robust. Technical and clinical success in the current case suggests that splenic vein recanalization may be a safe and viable option in other sinistral portal hypertension-related symptomatology. Level of Evidence: Level 4, Case Report.

Combined transhepatic and transsplenic recanalization of chronic splenic vein occlusion to treat left-sided portal hypertension: A cases report

“…There are currently literature reports on the successful treatment of LSPH bleeding with splenic vein plasty. [3][4][5] Compared with traditional splenectomy, splenic venoplasty has no surgical complications such as bleeding and infection, and has a shorter hospital stay and relatively lower overall treatment costs. [6] And compared to partial splenic embolization, splenic venoplasty has significant advantages in preventing PSPH rebleeding.…”

Sinistral Portal Hypertension Due to a Pancreatic Pseudocyst: A Rare Cause of Upper Gastrointestinal Bleeding

“… 14 SAE can be used as a primary intervention for SPH or an adjunct to splenectomy to lower intra-operative blood loss and rates of conversion to open surgery. 16 , 17 A lack of local expertise and high incidence of postembolization syndrome limits the wide adoption of SAE in clinical practice. 14 Postembolization syndrome presents as nausea, vomiting, or abdominal pain.…”

“…Splenic vein stenting has the lowest rate of rebleeding and visceral complications when compared to splenectomy and preoperative SAE. 14 , 17 , 18 Covello et al 17 reported an interesting case of SPH-associated refractory chylous ascites that was successfully treated with transhepatic splenic stenting. Even though SVS has a 92% stent patency rates at 12 months, there are still no standardized guidelines for postprocedural anticoagulation.…”

“…Even though SVS has a 92% stent patency rates at 12 months, there are still no standardized guidelines for postprocedural anticoagulation. 17 Similarly, there is no consensus regarding the transjugular versus transhepatic approach of splenic vein stenting. 17 …”

“… 17 Similarly, there is no consensus regarding the transjugular versus transhepatic approach of splenic vein stenting. 17 …”