Splenic Artery Embolization for Unstable Patients with Splenic Injury: A Retrospective Cohort Study

Splenectomy versus angioembolization for severe splenic injuries in a national trauma registry: To save, or not to save, the spleen, that is the question

BACKGROUND

The use of angioembolization as a first approach for treating severe, blunt splenic injuries has increased recently, yet evidence showing its superiority to immediate splenectomy is lacking. We compared the prognosis of angioembolization versus splenectomy in patients presenting hemodynamically unstable with high-grade, image-confirmed, blunt splenic injuries in a nationally representative dataset.

METHODS

We queried the 2017-2022 Trauma Quality Improvement Program database for adults with blunt splenic injury abbreviated injury scale = 4-5, with arrival systolic blood pressure <90 mm Hg, and treated with either angioembolization or splenectomy <6 hours of arrival after a computed tomography scan. Entropy balancing was used to adjust for confounders.

RESULTS

Of 1,360 patients, 328 (24.1%) underwent angioembolization and 1,032 (75.9%) splenectomy. Treatment with angioembolization first was more likely in recent years, in level 1 trauma centers, for less severe spleen injuries, in the absence of head injuries. Angioembolization and splenectomy had similar entropy balancing-adjusted survival (entropy balancing hazard ratio = 1.02; 95% confidence interval: 0.97-1.07, P = .49). One-fifth of those with angioembolization first required rescue splenectomy <6 hours, mostly those with spleen injury grade 5 and additional abdominal injuries. Although this resulted in worse survival (hazard ratio: 1.12; 95% confidence Interval: 0.99-1.26) than successful angioembolization, the survival was not significantly worse than those treated with splenectomy first (entropy balancing hazard ratio: 1.07; 95% confidence Interval: 0.96-1.20).

CONCLUSION

Angioembolization was associated with similar survival to splenectomy first for patients arriving hypotensive with severe, image-confirmed blunt splenic injuries, suggesting that it was an appropriate treatment decision. Although survival was worse after failed angioembolization than after successful angioembolization, it was not worse than splenectomy first, suggesting that the attempt to preserve the spleen was justified.

Transarterial embolization to treat hemodynamically unstable trauma patients with splenic injuries: A retrospective multicenter observational study

PURPOSE

We described clinical outcomes for patients with blunt splenic injuries treated with transarterial embolization (TAE) based on their hemodynamic status.

MATERIALS AND METHODS

This is a retrospective two-center study of adult patients with splenic injuries who underwent emergency TAE between January 2011 and December 2022. Patients were divided into two groups; hemodynamically unstable (HDU) and hemodynamically stable (HDS) patients. HDU patients were defined as transient- or non-responders to fluid resuscitation and HDS as responders. When immediate laparotomy was not possible for HDU patients, angiography and embolization were performed. The primary outcome was the survival discharge rate. Rebleeding and splenectomy rate was also investigated.

RESULTS

Of 38 patients underwent emergency TAE for splenic trauma, 17 were HDU patients and 21 were HDS patients. The survival discharge rate was 88.2 % (15/17) in the HDU- and 100 % in HDS patients (p = 0.193). Rebleeding rate was 23.5 % (4/17) in HDU- and 5.0 % (1/21) in HDS patients (p = 0.15). Splenectomy was required for one HDU patient (5.9 %) for rebleeding.

CONCLUSION

The survival discharge rate of TAE for splenic trauma in HDU patients was acceptable with a low rate of splenectomy. Further comparative studies of TAE versus operative management in HDU patients are needed to prove the usefulness of TAE.

Management and outcomes of splenic injuries secondary to blunt trauma in patients presenting to major trauma hospitals in Aotearoa New Zealand

BACKGROUND

Non-operative management of splenic injuries has significantly increased in the last decade with an increased emphasis on splenic preservation. This shift was assisted by increased availability of angioembolization, however, potential geographical variability in access exists in Aotearoa New Zealand (AoNZ). The aim of this study was to assess the management of splenic injury across AoNZ.

METHOD

Five-year retrospective study of all patients admitted to AoNZ hospitals with blunt major trauma and a splenic injury. Patients were identified using the National Trauma Registry and cross-referenced with the National Minimum Data Set to determine their management. The primary outcome was the non-operative rate.

RESULTS

Seven hundred seventy-three patients were included. Four hundred sixty-nine presented to a tertiary major trauma hospital and 304 to a secondary major trauma hospital. A difference was found in the rate of non-operative management between tertiary and secondary hospitals (P = 0.019). The rate of non-operative management was similar in mild (P = 0.814) and moderate (P = 0.825) injuries, however, significantly higher in severe injuries in tertiary hospitals (P = 0.009). No difference in mortality rate was found.

CONCLUSION

This study found a difference in the management of splenic injuries between tertiary and secondary major trauma hospitals; predominantly due to a higher rate of operative management in patients with severe injuries at secondary hospitals. Despite this, no difference in mortality rate was found between tertiary and secondary hospitals.

Carbon dioxide angiography during angioembolization for trauma patients increases the detection of active bleeding and leads to reliable hemostasis: a retrospective, observational study

BACKGROUND

Angiography with carbon dioxide (CO2) has long been used as an alternative when iodine contrast media (ICM) cannot be used due to allergy to iodine or renal dysfunction. Conversely, CO2 angiography is also known as a provocation method for active bleeding. In this study, we examined the efficacy of CO2 angiography in angioembolization (AE) for trauma patients.

METHODS

This was a single-center, retrospective, observational study of trauma patients who underwent AE at our facility between January 2012 and April 2023.

RESULTS

Within this period, 335 AEs were performed. CO2 angiography was performed in 102 patients (30.4%), and in 113 procedures. CO2angiography was used to provoke active bleeding which went undetected using ICM in 83 procedures, and to confirm hemostasis after embolization in 30 procedures. Of the 80 procedures wherein, active bleeding was not detected on ICM, 35 procedures (43.8%) were detected using CO2. The spleen had the highest detection rate of active bleeding by CO2 angiography among the organs. There were 4/102 (1.9%) patients with CO2 contrast who underwent some form of reintervention. Two patients were re-embolized with n-butyl-2-cyanoacrylate because of recanalization after embolization with gelatin sponge. The other two patients had pseudoaneurysm formation which required reintervention, and CO2 angiography was not used. Vomiting was the most common complication of CO2 angiography in 10 patients (9.8%), whereas all were transient and did not require treatment.

CONCLUSIONS

CO2 angiography of trauma patients may have a better detection rate of active bleeding compared with ICM, leading to reliable hemostasis.

Angioembolization for splenic injuries: does it help? Retrospective evaluation of grade III-V splenic injuries at two level I trauma centers

Background

Splenic angioembolization (SAE) has increased in utilization for blunt splenic injuries. We hypothesized lower SAE usage would not correlate with higher rates of additional intervention or mortality when choosing initial non-operative management (NOM) or surgery.

Study design

Trauma registries from two level I trauma centers from 2010 to 2020 were used to identify patients aged >18 years with grade III-V blunt splenic injuries. Results were compared with the National Trauma Data Bank (NTDB) for 2018 for level I and II centers. Additional intervention or failure was defined as any subsequent SAE or surgery. Mortality was defined as death during admission.

Results

There were 266 vs 5943 patients who met inclusion/exclusion criteria at Stanford/Santa Clara Valley Medical Center (SCVMC) versus the NTDB. Initial intervention differed significantly between cohorts with the use of SAE (6% vs 17%, p=0.000). Failure differed significantly between cohorts (1.5% vs 6.5%, p=0.005). On multivariate analysis, failure in NOM was significantly associated with NTDB cohort status, age 65+ years, more than one comorbidity, mechanism of injury, grade V spleen injury, and Injury Severity Score (ISS) 25+. On multivariate analysis, failure in SAE was significantly associated with Shock Index >0.9 and 10+ units blood in 24 hours. On multivariate analysis, a higher risk of mortality was significantly associated with NTDB cohort status, age 65+ years, no private insurance, more than one comorbidity, mechanism of injury, ISS 25+, 10+ units blood in 24 hours, NOM, more than one hospital complications, anticoagulant use, other Abbreviated Injury Scale ≥3 abdominal injuries.

Conclusions

Compared with national data, our cohort had less SAE, lower rates of additional intervention, and had lower risk-adjusted mortality. Shock Index >0.9, grade V splenic injuries, and increased transfusion requirements in the first 24 hours may signal a need for surgical intervention rather than SAE or NOM and may reduce mortality in appropriately selected patients.

Level of evidence

Level II/III.

Transcatheter Arterial Embolization for Blunt Splenic Injury With Resuscitative Endovascular Balloon Occlusion of the Aorta: The Significance of Early Involvement of Radiologists

Splenectomy is a common procedure for managing splenic injury in patients with unstable vital signs. Transcatheter arterial embolization (TAE) has emerged as a limited alternative to splenectomy, although the role of TAE can be expanded upon the stabilization of vital signs. The current case report discusses a man in his 50s, in shock after a motor vehicle accident, who was successfully stabilized using resuscitative endovascular balloon occlusion of the aorta (REBOA), followed by splenic artery embolization (SAE) instead of splenectomy, with early involvement of diagnostic and interventional radiologists from the initial stage of care. We also discuss the difficulties of SAE under REBOA and the significance of the early involvement of radiologists in trauma care.

Splenic artery embolisation for splenic injury during colonoscopy: A systematic review

BACKGROUND

Splenic injury due to colonoscopy is rare, but has high mortality. While historically treated conservatively for low-grade injuries or with splenectomy for high-grade injuries, splenic artery embolisation is increasingly utilised, reflecting modern treatment guidelines for external blunt trauma. This systematic review evaluates outcomes of published cases of splenic injury due to colonoscopy treated with splenic artery embolisation.

METHODS

A systematic review was performed of published articles concerning splenic injury during colonoscopy treated primarily with splenic artery embolisation, splenectomy, or splenorrhaphy from 1977 to 2022. Datapoints included demographics, past surgical history, indication for colonoscopy, delay to diagnosis, treatment, grade of injury, splenic artery embolisation location, splenic preservation (salvage), and mortality.

RESULTS

The 30 patients treated with splenic artery embolisation were of mean age 65 (SD 9) years and 67% female, with 83% avoiding splenectomy and 6.7% mortality. Splenic artery embolisation was proximal to the splenic hilum in 81%. The 163 patients treated with splenectomy were of mean age 65 (SD 11) years and 66% female, with 5.5% mortality. Three patients treated with splenorrhaphy of median age 60 (range 59-70) years all avoided splenectomy with no mortality. There was no difference in mortality between splenic artery embolisation and splenectomy cohorts (p = 0.81).

CONCLUSIONS

Splenic artery embolisation is an effective treatment option in splenic injury due to colonoscopy. Given the known benefits of splenic salvage compared to splenectomy, including preserved immune function against encapsulated organisms, low cost, and shorter hospital length of stay, embolisation should be incorporated into treatment pathways for splenic injury due to colonoscopy in suitable patients.

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.