S6370 Delayed Splenic Abscess Following Splenic Artery Aneurysm Embolization in a Patient With Decompensated Cirrhosis: A Case Report

Introduction: Splenic artery aneurysm is a known complication of cirrhosis. Various endoluminal techniques are employed for aneurysm exclusion, with the choice guided by anatomical and patient-specific factors. Embolization is a commonly used approach with a generally favorable safety profile. We present a rare case of splenic abscess 2 months following splenic artery embolization. Case Description/Methods: A 64-year-old man with a complex medical history including cirrhosis secondary to hepatitis C virus (eradicated in 2016), esophageal and gastric varices, status-post CARTO, hepatocellular carcinoma status post transarterial chemoembolization and recent Y-90 radioembolization, and a splenic artery aneurysm >3cm status post embolization 2 months prior, presented to the emergency department with worsening abdominal distention, left upper quadrant abdominal pain, and shortness of breath over 3 days. On presentation, the patient was tachypneic (respiratory rate 40s), tachycardic (heart rate 150s), and hypotensive, requiring vasopressors and BiPAP support. Physical examination revealed a distended, diffusely tender abdomen with maximal tenderness in the left upper quadrant. Laboratory results showed leukocytosis (white blood cells 10.8) with 46% bandemia, international normalized ratio 1.35, lactate 10.4 mmol/L, and mild renal and hepatic dysfunction. A computed tomography (CT) scan of the abdomen and pelvis demonstrated moderate ascites, cirrhotic liver with 2 hypodense lesions, and a large splenic fluid collection near the previously embolized hilum. Diagnostic paracentesis revealed neutrophilic ascites without malignant cells. Ultrasound-guided drainage of the splenic cyst yielded 1L of purulent fluid, and a catheter was placed for continuous drainage; cultures were negative. The patient completed a 2-week course of piperacillin-tazobactam. His hospital course was complicated by coronavirus disease 2019 requiring intensive care unit care. Follow-up imaging showed resolution of the collection, and the catheter was removed 2 months later. He was discharged home in stable condition. Discussion: Splenic abscess is a rare but serious complication of splenic artery embolization, often due to ischemia from reduced splenic perfusion. The risk is higher in patients with poor collateral circulation and is influenced by both patient factors and embolization technique. Hayes et al found a higher rate of perisplenic abscess with gelfoam compared to coil embolization. While most abscesses occur within 6 months, delayed presentations are possible. Management usually involves percutaneous drainage and antibiotics, though splenectomy may be necessary in resistant cases.