Left-sided portal hypertension: what an interventional radiologist can offer?

Ranjan Kumar Patel; Taraprasad Tripathy; Karamvir Chandel; Uday Kumar Marri; Suprabhat Giri; Hemanta Kumar Nayak; Manas Kumar Panigrahi; Bramhadatta Pattnaik; Tanmay Dutta; Sunita Gupta; Suprava Naik

doi:10.1007/s00330-024-11196-3

Left-sided portal hypertension: what an interventional radiologist can offer?

Eur Radiol. 2024 Nov 19. doi: 10.1007/s00330-024-11196-3. Online ahead of print.

Affiliations

¹ Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, 751019, India. ranjanair1@gmail.com.
² Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
³ Department of Radiodiagnosis, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India.
⁴ Department of Interventional Radiology, AIG Hospitals, Hyderabad, India.
⁵ Department of Gastroenterology, Kalinga Institute of Medical sciences, Bhubaneswar, 751019, India.
⁶ Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
⁷ Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.

PMID: 39562367
DOI: 10.1007/s00330-024-11196-3

Abstract

Left-sided portal hypertension (LPH) refers to increased splenic venous pressure caused by splenic vein stenosis or occlusion. Pancreatitis is the leading cause of LPH. Typically, LPH remains asymptomatic, but it can lead to life-threatening hemorrhage from ruptured fundal varices in about 10% of patients. Further, it may be complicated by hypersplenism. Interventional radiology plays an essential role in LPH patients with failed endoscopic treatment. Variceal embolization is an effective salvage measure in bleeding gastric varices, but it carries a risk of recurrence and worsening of hypersplenism. Considering the pathophysiology, splenic vein recanalization (SVR) appears to be the best treatment; nevertheless, its lower technical success rate limits its utility only to a subgroup of LPH patients. Partial splenic embolization (PSE), a non-surgical alternative to splenectomy, reduces the splenic volume and venous outflow, thereby lowering variceal pressure. PSE is technically easier, which may explain its widespread use. Nonetheless, PSE can be complicated by life-threatening sepsis and portal vein thrombosis. Despite all attempts, some LPH patients eventually require a splenectomy. Importantly, the choice of therapy requires multidisciplinary discussion and is often influenced by availability, expertise, and clinical context. This article discusses various interventional strategies for managing LPH with the available evidence. KEY POINTS: Question Pressure within the main portal vein is normal in left-sided portal hypertension; thus, transjugular intrahepatic portosystemic shunt is ineffective. Findings Splenic vein stent placement can restore hepatopetal splenic blood flow and decompress splenic venous pressure. Clinical relevance Partial splenic embolization (PSE) is the most widely used interventional approach to manage left-sided portal hypertension-related complications.

Keywords: Embolization; Gastric varices; Interventional radiology; Left-sided portal hypertension (LPH); Sinistral portal hypertension (SPH).

Publication types

Review