A pilot randomized controlled trial of endovascular coils and vascular plugs for proximal splenic artery embolization in high-grade splenic trauma

Splenic artery embolization for trauma: a narrative review

The management of traumatic splenic injuries has evolved significantly over the past several decades, with the majority of these injuries now being treated nonoperatively. Patients who exhibit hemodynamic instability upon initial evaluation typically require surgical intervention, while the remainder are managed conservatively. Conservative treatment for traumatic splenic injuries encompasses both medical management and splenic artery angiography, followed by embolization in cases where patients exhibit clinical signs of ongoing splenic hemorrhage. Splenic artery embolization is generally divided into two categories: proximal and distal embolization. The choice of embolization technique is determined by the severity and location of the splenic injury. Patients who retain functioning splenic tissue after trauma do not routinely need immunization. This is in contrast to post-splenectomy patients, who are at increased risk for opportunistic infections.

Preventive Proximal Splenic Artery Embolization for High-Grade AAST-OIS Adult Spleen Trauma without Vascular Anomaly on the Initial CT Scan: Technical Aspect, Safety, and Efficacy-An Ancillary Study

The spleen is the most commonly injured organ in blunt abdominal trauma. Its management depends on hemodynamic stability. According to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS ≥ 3), stable patients with high-grade splenic injuries may benefit from preventive proximal splenic artery embolization (PPSAE). This ancillary study, using the SPLASH multicenter randomized prospective cohort, evaluated the feasibility, safety, and efficacy of PPSAE in patients with high-grade blunt splenic trauma without vascular anomaly on the initial CT scan. All patients included were over 18 years old, had high-grade splenic trauma (≥AAST-OIS 3 + hemoperitoneum) without vascular anomaly on the initial CT scan, received PPSAE, and had a CT scan at one month. Technical aspects, efficacy, and one-month splenic salvage were studied. Fifty-seven patients were reviewed. Technical efficacy was 94% with only four proximal embolization failures due to distal coil migration. Six patients (10.5%) underwent combined embolization (distal + proximal) due to active bleeding or focal arterial anomaly discovered during embolization. The mean procedure time was 56.5 min (SD = 38.1 min). Embolization was performed with an Amplatzer™ vascular plug in 28 patients (49.1%), a Penumbra occlusion device in 18 patients (31.6%), and microcoils in 11 patients (19.3%). There were two hematomas (3.5%) at the puncture site without clinical consequences. There were no rescue splenectomies. Two patients were re-embolized, one on Day 6 for an active leak and one on Day 30 for a secondary aneurysm. Primary clinical efficacy was, therefore, 96%. There were no splenic abscesses or pancreatic necroses. The splenic salvage rate on Day 30 was 94%, while only three patients (5.2%) had less than 50% vascularized splenic parenchyma. PPSAE is a rapid, efficient, and safe procedure that can prevent splenectomy in high-grade spleen trauma (AAST-OIS) ≥ 3 with high splenic salvage rates.

Vascular plugs are associated with reduced fluoroscopy times compared to endovascular coils in proximal splenic artery embolization in trauma

Purpose:

Proximal splenic artery embolization plays an important role in the treatment of hemodynamically stable blunt splenic trauma patients with medium- to high-grade injuries. Proximal splenic artery embolization is most often performed utilizing endovascular coils or vascular plugs. The objective of this study was to compare technical and clinical outcomes of proximal splenic artery embolization using either endovascular coils or vascular plugs in patients with traumatic splenic injuries.

Materials and methods:

A single-institution retrospective review of all proximal splenic artery embolizations for trauma over a 5-year period was performed. Patients who underwent embolization using both endovascular coils and vascular plugs were excluded. Baseline characteristics, including patient age, sex, and grade of splenic injury, were recorded. Complication rates, rates of splenic salvage, and total fluoroscopy time were recorded and compared.

Results:

A total of 26 patients were included in the analysis (17 males, 9 females, median age: 50 years). Of these, 15 patients were treated with vascular plugs (57.7%), while 11 patients (42.3%) were treated with endovascular coils. Mean grade of injury was 3.5 and 4.1 in the vascular plug and endovascular coils groups, respectively. There were no differences between the groups regarding these baseline characteristics. Splenic salvage was 100% in both groups. No major complications were identified in either group. Mean fluoroscopy time was significantly lower in the vascular plug group (14.5 versus 34.0 min; p < 0.0001).

Conclusion:

Proximal splenic artery embolization for splenic trauma can be satisfactorily achieved with either vascular plugs or endovascular coils with no differences in splenic salvage or complication rates in this retrospective study. However, embolization utilizing vascular plugs had significantly reduced fluoroscopy times.