Emergent splenic embolization for refractory immune thrombocytopenia with critical bleeding: a case report
Hayabusa Takano1
, Naoki Hara1, Eri Nakajima1, Kouhei Katsuda1, Kenki Usami1, Ayaka Hasegawa1, Jun Matsuda1, Satoshi Arino1, Nobuo Sasaki1, Naoki Kojima1, Hiroshi Inagawa1, Yasusei Okada1, Akira Fujita2
Contributions: (I) Conception and design: All authors; (II) Administrative support: H Takano, Y Okada; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: H Takano, Y Okada, A Fujita; (V) Data analysis and interpretation: H Takano, Y Okada, A Fujita; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Immune thrombocytopenia (ITP) is characterized by decreased platelet count due to immunological mechanisms. First-line treatment is corticosteroids, with thrombopoietin receptor agonists, rituximab, and splenectomy as second-line options. While surgical splenectomy is effective, it poses high bleeding risks in severe thrombocytopenia. Splenic embolization (SE) is considered an alternative to splenectomy for the treatment of steroid-refractory chronic ITP and has been reported to be an effective and minimally invasive option. However, there are few reports of SE being performed for acute ITP with life-threatening bleeding.
Case Description: A 63-year-old man presented in shock with oral bleeding, bloody stools, and recurrent syncope. Laboratory tests revealed severe thrombocytopenia (4,000/mm3 platelets) and elevated platelet-associated immunoglobulin G (PA-IgG), leading to ITP diagnosis. Despite platelet transfusions, intravenous immunoglobulin, and high-dose steroids, his condition worsened with alveolar hemorrhage developing on day 3. Given the surgical risks, emergency SE was performed on day 5 using coils and gelatin sponge. Following SE and thrombopoietin receptor agonist administration, platelet counts improved from day 6, allowing discontinuation of transfusions by day 11. The patient was discharged from the intensive care unit on day 12 with stabilized platelets and improved respiratory status.
Conclusions: This case demonstrates that emergency SE can be an effective and safe alternative to splenectomy for refractory ITP with life-threatening bleeding, particularly when severe thrombocytopenia precludes surgical intervention. The rapid improvement in platelet counts suggests SE could be a viable emergency treatment option.
Keywords: Immune thrombocytopenia (ITP); splenectomy; splenic embolization (SE); alveolar hemorrhage; case report
Received: 26 January 2025; Accepted: 09 May 2025; Published online: 15 July 2025.
doi: 10.21037/acr-25-25
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Key findings
• Emergent splenic embolization (SE) can be an effective and safe alternative to splenectomy for refractory immune thrombocytopenia (ITP) with life-threatening bleeding, particularly when severe thrombocytopenia precludes surgical intervention.
What is known and what is new?
• While splenectomy is effective for life-threatening bleeding in ITP, it carries high surgical risks in severe thrombocytopenia cases. SE is considered an alternative to splenectomy for the treatment of steroid-refractory chronic ITP. However, there are few reports of SE being performed for acute ITP with life-threatening bleeding.
• This case reports the first successful emergency SE for ITP with life-threatening alveolar hemorrhage, demonstrating its potential efficacy as an emergency treatment for severe refractory ITP.
What is the implication, and what should change now?
• Emergent SE can be considered for refractory ITP with life-threatening bleeding.
Introduction
Immune thrombocytopenia (ITP) is an acquired disorder characterized by a decreased platelet count due to an immunological mechanism (1). Severe thrombocytopenia can lead to life-threatening bleeding (1,2). According to the guidelines of the American Society of Hematology, corticosteroids are recommended as the first-line treatment, whereas thrombopoietin receptor agonists, rituximab, and splenectomy are recommended as second-line options (3). In cases of life-threatening bleeding associated with ITP, platelet transfusion, intravenous immunoglobulin (IVIG), and high-dose steroid therapy are also administered (2,4). Although surgical splenectomy is known for its effectiveness and rapid action (5), it poses a high risk of bleeding when thrombocytopenia is severe, making surgical splenectomy challenging. Splenic embolization (SE) is considered an alternative to splenectomy for the treatment of steroid-refractory chronic ITP and has been reported to be an effective and minimally invasive option (6,7). However, there are few reports of SE being performed for acute ITP with life-threatening bleeding. We herein report a case in which SE was performed urgently for life-threatening bleeding in a patient with ITP. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-25-25/rc).
Case presentation
A previously healthy 63-year-old man with no history of thrombocytopenia was brought to our emergency room in a state of shock. The day before, he had experienced bloody stool and bleeding from the oral mucosa and had repeatedly lost consciousness and fallen at home. He was not taking any regular medication and had no family history of thrombocytopenia or other hematological disorders. He was a non-smoker and occasionally consumed alcohol.
On examination, he was drowsy, blood pressure was 73/54 mmHg, pulse was 100 beats per minute and regular, respirations were 22 per minute, oxygen saturation was 99% on 6 L of oxygen, and temperature was 36.2 ℃. His radial pulse was weak, and there was peripheral coldness along with extensive subcutaneous hematoma and purpura throughout the body.
Laboratory data showed a hemoglobin level of 9.4 g/dL, a white blood cell count of 15,500/mm3, and a platelet count of 4,000/mm3. Platelet aggregation and schistocytes were not observed. The platelet size was within the normal range. Serum albumin was 2.6 g/dL, and there were no abnormalities in liver enzymes, kidney function, electrolyte levels, or coagulation tests. Platelet-associated immunoglobulin G (PA-IgG) was abnormally elevated at 1,327 ng/107 (normal value: ≤46 ng/107) cells, whereas antinuclear antibodies and heparin-induced thrombocytopenia antibodies were negative. Computed tomography (CT) revealed mild traumatic subarachnoid hemorrhaging and a subdural hematoma, and conservative management was chosen. Splenomegaly was not observed. A bone marrow examination revealed normal morphology with no dysplasia or an increased number of blast cells. Based on these findings, we diagnosed the patient with ITP and admitted him to the intensive care unit.
The course after admission is shown in Figure 1. Immediately after admission, repeated platelet transfusions were administered to maintain the platelet count and prevent the progression of intracranial hemorrhaging. On day 2 of hospitalization, IVIG and high-dose steroid therapy were initiated. However, there was minimal improvement in the platelet count, and on hospital day 3, alveolar hemorrhaging developed, leading to worsening oxygenation, necessitating noninvasive positive pressure ventilation. The PaO2/FiO2 ratio fluctuated between 80 and 250.
Although splenectomy was considered to further improve the platelet count, persistently low platelet levels made surgery challenging. Consequently, SE was performed on day 5 of hospitalization. The procedure involved femoral artery access, followed by embolization of the splenic artery using coils and a crushed gelatin sponge. No apparent complications were observed. Subsequently, a thrombopoietin receptor agonist was administered from day 7 of hospitalization.
On day 6 of hospitalization, the platelet count began to increase. Platelet transfusions were terminated following the day 11 of hospitalization. By day 12 of hospitalization, the platelet count had stabilized, bleeding symptoms had improved, and the respiratory status had recovered, allowing for discharge from the intensive care unit.
All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Discussion
In cases in which urgent intervention is required for bleeding due to ITP, conditions such as intracranial hemorrhaging, alveolar hemorrhaging, and massive gastrointestinal bleeding are involved (2). Although there has been a report of SE performed in patients with intracranial hemorrhaging associated with ITP (8), there have been no reported cases of SE performed in patients with alveolar hemorrhage. Some reports indicate that medical treatment, including high-dose steroid administration, may show effects within a few days or a week (2,4). Based on this, we determined that medical treatment was ineffective after 4 days and performed SE on day 5. However, the severity of bleeding must also be taken into consideration, which also influenced our decision-making.
For patients with ITP who present with critical bleeding and are refractory to medical treatment, splenectomy should be considered as a treatment option because of its rapid onset and high remission rates (9). However, the procedure may be challenging owing to the risk of intraoperative bleeding, making SE a potentially safer alternative (7). In fact, a recent report indicates that SE demonstrates effectiveness comparable to that of splenectomy (7). However, as randomized controlled studies in this field do not currently exist, further investigation is necessary.
Generally, splenectomy is associated with a platelet increase within days, making it a more rapid option than other recommended treatments (5). Although there is limited information regarding the time required for SE to take effect, a recent review paper has reported multiple case studies showing increased platelet counts several hours after SE (10). The fact that SE is considered “functional splenectomy” and that platelet counts also began to increase the day after SE in this case suggests that SE could be a rapid and effective treatment for critical and emergent bleeding. Therefore, emergent SE may be a treatment option for refractory ITP with life-threatening bleeding.
Conclusions
It is possible that emergent SE can be effective and safe for refractory ITP with critical bleeding.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-25-25/rc
Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-25-25/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-25-25/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Takano H, Hara N, Nakajima E, Katsuda K, Usami K, Hasegawa A, Matsuda J, Arino S, Sasaki N, Kojima N, Inagawa H, Okada Y, Fujita A. Emergent splenic embolization for refractory immune thrombocytopenia with critical bleeding: a case report. AME Case Rep 2025;9:105.
