Splenic artery embolisation can be performed preoperatively in an attempt to decrease thrombocyte destruction, or as an alternative to surgery, to obtain partial or total organ ablation. During this procedure, it is very important to deliver embolising agents distal to the origin of pancreatic branches to avoid the risk of pancreatitis. Therefore, a detailed knowledge of the anatomy of the splenic artery and its branches is required to achieve safe embolisation.
The purpose of our study is to measure the average distance between the origin of the last pancreatic branch and the splenic hilum in digital angiograms and cadaver specimens

Ceken, Kagan

Sarikcioglu, Levent

Sindel, Muzaffer

Yilmaz, Saim

English

Via Medica Journals

Folia Morphol. Vol. 60, No. 4, pp. 333336Copyright ' 2001 Via MedicaISSN 00155659www.fm.viamedica.plO R I G I N A L  A R T I C L E333Address for correspondence: Muzaffer Sindel, Department of Anatomy, Akdeniz University, Faculty of Medicine, 07070 Antalya, Turkey,tel: +90 242 2274343, 44307, fax: +90 242 2274482, 2274495, e-mail: muzaffer@med.akdeniz.edu.trThe importance of the anatomyof the splenic artery and its branchesin splenic artery embolisationMuzaffer Sindel1, Levent Sarikcioglu1, Kagan Ceken2, Saim Yilmaz21Department of Anatomy, Akdeniz University, Faculty of Medicine, Antalya, Turkey2Department of Radiology, Akdeniz University, Faculty of Medicine, Antalya, Turkey[Received 1 August 2001; Revised 29 October 2001; Accepted 29 October 2001]Splenic artery embolisation can be performed preoperatively in an attempt todecrease thrombocyte destruction, or as an alternative to surgery, to obtainpartial or total organ ablation. During this procedure, it is very important todeliver embolising agents distal to the origin of pancreatic branches to avoid therisk of pancreatitis. Therefore, a detailed knowledge of the anatomy of the splenicartery and its branches is required to achieve safe embolisation.The purpose of our study is to measure the average distance between the originof the last pancreatic branch and the splenic hilum in digital angiograms andcadaver specimens.key words: embolisation, splenic arteryINTRODUCTIONThe splenic artery is the largest branch of the coeliactrunk. It lies posterior to the omental bursa and ex-tends along the superior margin of the pancreas tothe splenic hilum. It is composed of 4 anatomic divi-sions, including suprapancreatic, pancreatic, prepan-creatic and prehilar segments. The suprapancreaticsegment is between the origin of the splenic arteryand pancreas, which curves anterior to the aorta andreaches the superior margin of the pancreas [1, 5,17]. The pancreatic segment is the most tortuouspart of the splenic artery (Fig. 1) and extends alonga groove located on the posterosuperior surface ofthe pancreas, although its course may rarely be offthe pancreas. The prepancreatic segment crosses theupper border of the pancreas and lies obliquely andanteriorly. The prehilar segment lies between thepancreatic tail and the splenic hilum and is the ter-minal part of the splenic artery (Fig. 2) [1, 5, 12]. Thereported lengths of the segments of the splenic ar-tery are given in Table 1.Splenic artery embolisations are performed in theform of total or partial organ ablation, either preo-peratively or as an alternative to surgery [2, 8, 9]. Cur-rent indications for splenic artery embolisation and em-Figure 1. Selective coeliac angiography shows the proper hepa-tic artery, left gastric artery, splenic artery and their branches.The most tortuous part (pancreatic segment) of the splenic arterycan be seen.334Folia Morphol., 2001, Vol. 60, No. 4bolisation materials are listed in Table 2 and Table 3.Initial experience with splenic embolisation was asso-ciated with a high rate of complication [11, 18].MATERIAL AND METHODSSplenic artery anatomy was studied in detail withcareful dissection of 10 cadavers. For radiologicTable 2. Indications for splenic embolisationTraumatic parenchymal, capsular and subcapsular splenic haemorrhageHaemorrhage due to portal hypertension and hypersplenismHypersplenism in childrenThalassemia majorVarixial haemorrhage due to splenic vein thrombosisThrombocytopeniaChronic idiopathic thrombocytopenic purpuraGaucher diseaseHodgkin diseaseTable 1. Lengths of splenic artery segments reported inthe literature [4]Segment Length Maximum Minimum[cm] [cm] [cm]Total 17.3 33 8.5Suprapancreatic 2.5 7 1Pancreatic 10.4 22.5 5Prepancreatic 2.5 6 0.4Prehilar 1.5 4.5 0.3Figure 2. Prepancreatic and prehilar segments of the splenicartery; SA  splenic artery, SV  splenic vein, P  pancreas,arrow  splenic artery branches, LGEA  left gastroepiploicartery, GB  gastric branch of the splenic artery,*last pancreatic branch coming from splenic artery.evaluation, selective splenic arteriograms of 12 pa-tients obtained during splenic embolisations wereretrospectively studied. Angiograms were printedin digital subtraction mode to eliminate the su-perimposition of extravascular tissues. For eachexamination, the splenic artery was selectively cath-eterised and 3040 ml non-ionic contrast mediaTable 3. Embolisation materialsAbsorbable NonabsorbableParticular materials Enjectable materialsOtolog fat or muscle Isobuthyl 2 cyanoacrilate (IBCA)Polivinyl alcohol (PVA) Occlusive amino acid gelMicrometric magnetic spheres Microfibrillar collagenAcrylic spheres Silicone rubberMethyl metacrilate spheresCylastic spheresSclerosing materials Non-particular materialsAbsolute ethanol Stainless steel coilsHot contrast media Platinum coilsDetachable balloonsOtolog clotOxygelGelfoam335Muzaffer Sindel et al., Anatomy of the splenic arterywas injected at the proximal part of the splenic ar-tery.In all anatomical and radiological examinations, thedistance between the origin of pancreatic branches andthe splenic hilum was measured by an experiencedanatomist and radiologist respectively. Radiologicalmeasurements were corrected by the magnificationfactor, determined using the patient to image distance(PID) and the source to image distance (SID). All statis-tical analyses were done by using Student t test.RESULTSIn anatomical measurements, the average distancebetween the origin of the last pancreatic branch andthe splenic hilum was 3.9 – 0.78 cm (mean – stan-dard deviation). In one cadaver, the last pancreaticbranch originated from the gastroepiploic artery.On selective splenic angiograms, the average dis-tance between the origin of the last pancreaticbranch and the splenic hilum was 3.75 – 0.68 cm(mean – standard deviation).There was no statistically significant difference(p > 0.05) between the results of the anatomicaland radiological measurements.Out of 12 patients in whom splenic embolisationwas performed, 1 developed pancreatitis and onea splenic abscess, which is not rare despite the pro-phylactic use of antibiotics. In the former patient,pancreatitis responded to medical therapy and in thelatter, splenectomy was performed.DISCUSSIONIn subsequent years, it was reported that complica-tions such as septicaemia, rupture and abscess for-mation can significantly be reduced with the use ofantibiotics and aseptic techniques [15, 16]. In thepresent study, 1 out of 12 patients developed ab-scess following splenic embolisation and was treat-ed with splenectomy.For splenic embolisations and the embolisationof other organs, like the parathyroid gland, adrenalgland and kidneys, a number of embolic materialsare used [4, 6, 7, 10, 11, 13, 19, 20] (Table 3). In ourpatients, distal intrasplenic vessels were embolisedwith polyvinyl alcohol (PVA), followed by occlusionof the prehilar segment with metallic coils. PVA par-ticles were delivered via a microcatheter located inthe distal splenic artery, trying to avoid inadvertentembolisation of the pancreatic branches. Despitemeticulous attention, 1 patient developed pancre-atitis following the procedure, which was treatedmedically.Preoperative angiographic embolisation of thesplenic artery for massive splenomegaly has beenadvocated as a means to decrease this morbidity andmortality [3]. In every embolisation procedure, inad-vertent passage of the embolic material to the ves-sels of the non-target organs is the most dangerouscomplication. In splenic embolisation, this compli-cation may occur in pancreatic branches of the sple-nic artery. To avoid this potentially life-threateningcomplication, a good knowledge of the vascularanatomy of the splenic artery and its branches isrequired. Of particular importance is the locationof the last pancreatic branch in the splenic artery,since the tip of the microcatheter should be distalto the origin of this vessel to achieve a safe embo-lisation. Besides, temporary splenic artery balloonocclusion can be used for the protection of nons-plenic vascular beds, like pancreatic and gastric ar-terial branches, during splenic embolisation [14].In our study, the distance of the origin of the lastpancreatic branch to the splenic hilum was mea-sured on splenic angiograms and cadavers, tryingto define a safe region in which splenic embolisa-tion can be performed. Our results show that theaverage distance between the origin of the lastpancreatic branch and the splenic hilum was 3.75 –– 0.68 cm (mean – standard deviation) on splenicangiograms and 3.9 – 0.78 cm (mean – standarddeviation) in cadavers. The smallest distance mea-sured was 3.07 cm on angiograms and 3.12 cm incadavers.In conclusion, in order to achieve a safe splenicembolisation and avoid the risk of pancreatitis, em-bolic materials should be delivered through a cathe-ter whose tip is located in the distal 3.07 cm of thesplenic artery.ACKNOWLEDGEMENTSWe thank Mr H Gezer and Mr N Sagiroglu for theirtechnical assistance.REFERENCES1. Arinci K, Elhan A (1995) Anatomi. Günes Kitabevi Ltd.Sti., Ankara, p. 71.2. Bader-Meunier B, Husseini K, Nouyrigat V, Pariente D(2001) Partial splenic embolization in lymphangioma-tosis. J Pediatr, 138: 613614.3. Farid H, OConnell TX (1996) Surgical management ofmassive splenomegaly. Am Surg, 62: 803805.336Folia Morphol., 2001, Vol. 60, No. 44. Frippiat F, Donckier J, Vandenbossche P, Stoffel M,Boland B, Lambert M (1996) Splenic infarction: reportof three cases of atherosclerotic embolization origi-nating in the aorta and retrospective study of 64 ca-ses. Acta Clin Belg, 51: 395402.5. Goss MC (1973) Anatomy of the human body. Lee& Febirger, Philadelphia, pp. 633634.6. Ha-Kawa SK, Kariya H, Murata T, Tanaka Y (1998) Suc-cessful transcatheter embolotherapy with a new pla-tinum microcoil: the Berenstein Liquid Coil. CardiovascIntervent Radiol, 21: 297299.7. Han MJ, Zhao HG, Ren K, Zhao DC, Xu K, Zhang XT(1997) Partial splenic embolization for hypersplenismconcomitant with or after arterial embolization ofhepatocellular carcinoma in 30 patients. CardiovascIntervent Radiol, 20: 125127.8. Harned RK, Thompson HR, Kumpe DA, Narkewicz MR, SokolRJ (1998) Partial splenic embolization in five children withhypersplenism: effects of reduced-volume embolization onefficacy and morbidity. Radiology, 209: 803806.9. Hickman MP, Lucas D, Novak Z, Rao B, Gold RE, ParveyL, Tonkin IL, Hansen DE (1992) Preoperative emboliza-tion of the spleen in children with hypersplenism.J Vasc Interv Radiol, 3: 648652.10. Mazer M, Smith CW, Martin VN (1985) Distal splenicartery embolization with a flow-directed balloon cath-eter. Radiology, 154: 245.11. McCarron DA, Rubin RJ, Barnes BA (1976) Therapeuticbilateral renal infarction in end-state renal disease.N Engl J Med, 294: 652.12. Meschan I (1975) An atlas of anatomy basic to radio-logy. W.B. Saunders Company, Philadelphia, London,Toronto, pp. 982987.13. Poulin EC, Mamazza J, Schlachta CM (1998) Splenicartery embolization before laparoscopic splenectomy.An update. Surg Endosc, 12: 870875.14. Rose SC, Lim GM, Arellano RS, Easter DB, RobertsAC (1998) Temporary splenic artery balloon occlu-sion for protection of nonsplenic vascular beds dur-ing splenic embolization. AJR Am J Roentgenol, 170:11861188.15. Spigos DG, Jonasson O, Mozes M (1979) Partial sple-nic embolization in the treatment of hypersplenism.AJR, 132: 777.16. Spigos DG, Tan WS, Mozes MF, Pringle K, Iossifides I(1980) Splenic embolization. Cardiovasc Intervent Ra-diol, 3: 282287.17. Waizer A, Beniel J, Ziv Y, Dintsman M (1989) Clinicalimplications of anatomic variations of the splenic ar-tery. Surg Gynecol Obstet, 168: 5758.18. Wholey MH, Chamorraw HA, Rao G (1978) Splenic in-farction and spontaneous rupture of the spleen aftertherapeutic embolization. Cardiovasc Intervent Radiol,1: 249.19. Yamauchi T, Furui S, Irie T, Kusano S (1994) Partial sple-nic embolization with Y-shaped silicone particles. ActaRadiol, 35: 335339.20. Zimmerman CE, Eisenberg H, Spark R (1974) Trans-venous adrenal destruction: Clinical trials in patientswith metastatic malignancy. Surgery, 75: 550.

The importance of the anatomy of the splenic artery and its branches in splenic artery embolisation

https://journals.viamedica.pl/folia_morphologica/article/download/16470/13106

The importance of the anatomy of the splenic artery and its branches in splenic artery embolisation

Abstract

Similar works

Full text

Available Versions

Via Medica Journals