Update: Splenic Artery Embolization in Blunt Abdominal Trauma

Case Report: Adrenal gland splenosis mimicking a neuroendocrine tumor on 68Ga-DOTATATE and 18F-FDG PET/CT imaging

Splenosis occurring in adrenal glands is relatively rare and is easily misdiagnosed as neoplastic lesions. Herein, we present a case of a 39-year-old woman who underwent a pancreatic tail resection and splenectomy 8 years ago due to caudal pancreatic neuroendocrine tumor and splenic invasion. She underwent abdominal ultrasound examination in an external hospital a month ago due to abdominal discomfort and found a lump in the left adrenal gland. She was admitted to our hospital for further diagnosis and treatment. Abdominal computed tomography (CT) examination revealed a nodule of equal soft tissue density on her left adrenal gland, which presented obvious uniform enhancement on contra-enhanced CT. Subsequently, she underwent fluorine-18 fluorodeoxyglucose (18F-FDG) and gallium-68 labeld 1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraaceticacid -D-Phel-Tyr3-Thr8-OC (68Ga-DOTATATE) positron emission tomography (PET)/CT imagings, and showed slightly increased 18F-FDG uptake and obviously increased 68Ga-DOTATATE uptake in the lesion, suggesting the possibility of neuroendocrine tumor metastasis. However, postoperative pathology confirmed that the lesion was splenosis. Our case suggests that adrenal gland splenosis should be considered as a differential diagnosis of adrenal tumors, understanding the clinical and imaging features of splenosis can reduce misdiagnosis and avoid unnecessary surgical intervention.

Multidisciplinary management of thoracic aortic injury with hemodynamically unstable pelvic fracture in the elderly

Blunt thoracic aortic injury (BTAI) is a critical clinical emergency often presenting as severe trauma. The early diagnosis and treatment of BTAI pose significant challenges in its management, especially when patients experience early-stage hemodynamic instability. Presently, in the context of multiple traumas, there is an absence of clearly-defined and comprehensive guidelines capable of accurately determining the optimal timing and sequence of interventions for aortic injuries. This issue is particularly prominent when aortic injuries are complicated by abdominal vascular injuries, which exacerbate hemodynamic instability. This study aims to present two distinct cases of patients with BTAI complicated by pelvic vascular injuries, resulting in hemodynamic instability. These cases were treated at different trauma centers. The successful treatment strategies included the implantation of covered stents for aortic repair and arterial embolization for pelvic vascular injuries. By sharing these cases, we intend to enhance the understanding of the complex management of such combined - injury situations. We underscore that comprehensive aortic computed tomography angiography (CTA) is of crucial importance in the early detection of aortic injuries and other major vascular injuries in high-energy trauma scenarios. Although regional trauma centers have demonstrated positive impacts on patient outcomes, the retrospective nature of this study and its limited sample size necessitate further large-scale research to validate our findings and proposed management strategies.

Using Interpretable Artificial Intelligence Algorithms in the Management of Blunt Splenic Trauma: Applications of Optimal Policy Trees as a Treatment Prescription Aid to Improve Patient Mortality

BACKGROUND

The identification of the optimal management for blunt splenic trauma-angioembolization (AE), splenectomy, or observation-remains a challenge. This study applies Optimal Policy Trees (OPT), an artificial intelligence (AI) model, to prescribe appropriate management and improve in-hospital mortality.

METHODS

OPTs were trained on patients with blunt splenic injuries in the ACS-TQIP 2013-2019 to prescribe one of the three interventions: splenectomy, angioembolization (AE), or observation. Prescriptive trees were derived in two separate patient cohorts: those who presented with a systolic blood pressure (SBP) < 70 mmHg and those with an SBP ≥ 70 mmHg. Splenic injury severity was graded using the American Association of Surgical Trauma (AAST) grading scale. Counterfactual estimation was used to predict the effects of interventions on overall in-hospital mortality.

RESULTS

Among 54,345 patients, 3.1% underwent splenic AE, 13.1% splenectomy, and 83.8% were managed with observation. In patients with SBP < 70 mmHg, AE was recommended for shock index (SI) < 1.5 or without transfusion, while splenectomy was indicated for SI ≥ 1.5 with transfusion. For patients with SBP ≥ 70 mmHg, AE was recommended for AAST grades 4-5, or grades 1-3 with SI ≥ 1.2; observation was recommended for grades 1-3 with SI < 1.2. Predicted mortality using OPT-prescribed treatments was 18.4% for SBP < 70 mmHg and 4.97% for SBP ≥ 70 mmHg, compared to observed rates of 36.46% and 7.60%, respectively.

CONCLUSIONS

Interpretable AI models may serve as a decision aid to improve mortality in patients presenting with a blunt splenic injury. Our data-driven prescriptive OPT models may aid in prescribing the appropriate management in this patient cohort based on their characteristics.

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.

Research trends in pediatric splenic trauma in Brazil: how much has changed in the last two decades?

PURPOSE

Research in high-income countries has extensively documented the non-operative management of spleen injuries in children, resulting in low splenectomy rates (5%). However, there is a lack of literature on this topic in low- and-middle-income countries (LMICs), including Brazil. This scoping review analyzed pediatric spleen trauma research trends in Brazil and the United States of America (USA).

METHODS

Search strategy was conducted across five databases, considering articles published in English or Portuguese from January 1968 to 2023 that reported spleen injury in patients younger than 18 years old in Brazil or the USA. Two pairs of independent reviewers screened the title and the abstract, followed by a full-text review.

RESULTS

The total of 7,150 studies was identified, of which 295 were eligible for data extraction. Most papers (98.64%, 301) originated from the USA, while only 1.36% (4) were from Brazil. In addition, 46.44% (137) articles reported intrabdominal injury, including splenic trauma, 16.27% (48) liver and spleen injury, and 37.29% (110) reported isolated spleen injury. The operative rate for spleen injury was 11.33% in American studies (40,812/359,926) compared to 98.57% (137/139) in Brazilian studies.

CONCLUSIONS

Brazil contributed only with four studies on pediatric splenic trauma over two decades. Future studies should explore the incidence and management of splenic trauma in LMICs.

Contemporary Management of Blunt Splenic Trauma in Adults: An Analysis of the Trauma Quality Improvement Program Registry

PURPOSE

The aim of this study was to evaluate the effectiveness of management strategies for blunt splenic injuries in adult patients.

METHODS

Patients 18 years and older with blunt splenic injuries registered via the Trauma Quality Improvement Program (2013-2019) were identified. Management strategies initiated within 24 hours of hospital presentation were classified as watchful waiting, embolization, surgery, or combination therapy. Patients were stratified by injury grade. Linear models estimated each strategy's effect on hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality.

RESULTS

Of 81,033 included patients, 86.3%, 10.9%, 2.5%, and 0.3% of patients received watchful waiting, surgery, embolization, and combination therapy, respectively. Among patients with low-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (9.4 days, Q < .001, Cohen's d = .30) and ICU LOS (5.0 days, Q < .001, Cohen's d = .44). Among patients with high-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (8.7 days, Q < .001, Cohen's d = .12) and ICU LOS (4.5 days, Q < .001, Cohen's d = .23). Among patients with low- and high-grade injuries, the odds ratios for in-hospital mortality associated with surgery compared with embolization were 4.02 (Q < .001) and 4.38 (Q < .001), respectively.

CONCLUSIONS

Among patients presenting with blunt splenic injuries and compared with surgery, embolization was associated with shorter hospital LOS, shorter ICU LOS, and lower risk for mortality.

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.

Retrospective Evaluation of Splenic Artery Embolization Outcomes in the Management of Blunt Splenic Trauma: A Single Centre Experience at a Large Level 1 Trauma Centre

PURPOSE

Retrospective review of splenic artery embolization (SAE) outcomes performed for blunt abdominal trauma.

MATERIALS AND METHODS

11-year retrospective review at a large level-1 Canadian trauma centre. All patients who underwent SAE after blunt trauma were included. Technical success was defined as angiographic occlusion of the target vessel and clinical success was defined as successful non-operative management and splenic salvage on follow-up.

RESULTS

138 patients were included of which 68.1% were male. The median age was 47 years (interquartile range (IQR) = 32.5 years). The most common mechanisms of injury were motor vehicle accidents (37.0%), mechanical falls (25.4%), and pedestrians hit by motor vehicles (10.9%). 70.3% of patients had American Association for the Surgery of Trauma (AAST) grade 4 injuries. Patients were treated with proximal SAE (n = 97), distal SAE (n = 23) or combined SAE (n = 18), and 68% were embolized with an Amplatzer plug. No significant differences were observed across all measures of hospitalization (Length of hospital stay: x2(2) = .358, P = .836; intensive care unit (ICU) stay: x2(2) = .390, P = .823; ICU stay post-procedure: x2(2) = 1.048, P = .592). Technical success and splenic salvage were achieved in 100% and 97.8% of patients, respectively. 7 patients (5%) had post-embolization complications and 7 patients (5%) died during hospital admission, but death was secondary to other injuries sustained in the trauma rather than complications related to splenic injury or its management.

CONCLUSION

We report that SAE as an adjunct to non-operative management of blunt splenic trauma can be performed safely and effectively with a high rate of clinical success.

Grading Abdominal Trauma: Changes in and Implications of the Revised 2018 AAST-OIS for the Spleen, Liver, and Kidney

According to the Centers for Disease Control and Prevention, trauma is the leading cause of fatal injuries for Americans aged 1-44 years old and the fourth leading overall cause of death. Accurate and early diagnosis, including grading of solid organ injuries after blunt abdominal trauma (BAT), is crucial to guide management and improve outcomes. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted BAT scoring system at CT both within the United States and internationally, and its uses include stratification of injury severity, thereby guiding management, and facilitation of clinical research, billing, and coding. Furthermore, this system also plays a role in the credentialing process for trauma centers in the United States. The newly revised 2018 OIS provides criteria for grading solid organ damage into three groups: imaging, operation, and pathology. The final grade is based on the highest of the three criteria. If multiple lower-grade (I or II) injuries are present in a single organ, one grade is advanced to grade III. The most substantial change in the revised 2018 AAST-OIS is incorporation of multidetector CT findings of vascular injury, including pseudoaneurysm and arteriovenous fistula. The authors outline the main revised aspects of grading organ injury using the AAST-OIS for the spleen, liver, and kidney after BAT, particularly the role of multidetector CT and alternative imaging in organ injury detection, the importance of vascular injuries in grade change, and the impact of these changes on patient management and in prediction of operative treatment success and in-hospital mortality. ©RSNA, 2023 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available through the Online Learning Center.

Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

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.

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

PURPOSE

To compare the outcomes of splenic artery embolization (SAE) for acute splenic injury (ASI) between patients who are hemodynamically stable (HDS) and hemodynamically unstable (HDU). Nonoperative management with SAE has become an accepted practice for patients who are HDS with ASI; however, SAE for the treatment of patients who are HDU with ASI has not been well studied.

MATERIALS AND METHODS

A retrospective cohort study was performed, including 52 patients who were HDU and HDS who underwent SAE for ASI at a Level 1 trauma center. HDU was defined as the lowest recorded systolic blood pressure prior to intervention <90 mm Hg. Utilizing the American Association for Surgery of Trauma (AAST) splenic injury scale, AAST Grades 1-3 were defined as low grade, and Grades 4-5 were defined as high grade. The primary outcomes were survival at 30 days and the need for subsequent splenectomy.

RESULTS

Seventy-five percent (n = 39) of the patients were HDS, and 25% (n = 13) were HDU. The majority (69%) of patients who were HDU who underwent SAE did not require splenectomy, compared with 95% of patients who were HDS (P = .03). No significant difference in 30-day survival between patients who were HDU and HDS was noted. No major adverse events were recorded. There was no significant difference in 30-day patient survival or the rate of subsequent splenectomy between high-grade and low-grade splenic injuries.

CONCLUSIONS

In this retrospective cohort study, there was no statistically significant difference in the adverse events or 30-day post-SAE survival rates between patients who were HDS and HDU with ASI. The authors conclude that SAE can be a safe and effective treatment option for patients who are HDU with ASI, including high-grade splenic injury.

Comparing Outcomes in Transcatheter Embolization for the Management of Penetrating versus Blunt Trauma

Purpose This article assesses potential factors associated with successful embolization and/or mortality benefit among patients with penetrating (PT) compared to those with blunt abdominal trauma (BT) undergoing emergent angiography.

Methods A retrospective study of arterial embolization for BT and PT at a tertiary care academic center in an urban setting between 2018 and 2020 was conducted. Fischer's exact and Student's t-tests were used to assess differences between PT and BT, regarding technical success, in-hospital mortality, number of vessels embolized, and requirement of Operating Room (OR) for bleeding control after embolization.

Results Forty-three patients underwent embolization. Twenty-three presented with BT versus 20 with PT. There was no difference in the rate of success between the two groups (91.3% vs. 100%; p = 0.49). No difference was observed in mean days of survival among BT and PT patients treated by embolization (mean [standard deviation]: 13.7 [2.6] vs. 19.1 [2.79] days; p = 0.160). There was no difference in mortality between the two groups (13.0% vs. 10.5%; p = 1.00). Mean number of vessels embolized was higher in the BT group compared to PT (2.26 [1.32] vs. 1.44 [1.03], p = 0.044). The rate of BT patients who required subsequent OR intervention for hemorrhage control after embolization was similar to those with PT (8.7% vs. 10.5%; p = 0.84).

Conclusion The rate of mortality, technical success, and requirement of subsequent OR intervention for hemorrhage control was comparable between BT and PT. BT was associated with a higher mean number of vessels embolized compared to PT. Our case series may provide insight in the use of embolization for PT, but further investigation is needed with larger cohorts.

Predictors of transfer from a remote trauma facility to an urban level I trauma center for blunt splenic injuries: a retrospective observational multicenter study

Background

The decision-making for admission versus emergent transfer of patients with blunt splenic injuries presenting to remote trauma centers with limited resources remains a challenge. Although splenectomy is standard for hemodynamically unstable patients, the specific criterion for non-operative management continues to be debated. Often, lower-level trauma centers do not have interventional radiology capabilities for splenic artery embolization, leading to transfer to a higher level of a care. Thus, the aim of this study was to identify specific characteristics of patients with blunt splenic injuries used for admittance or transfer at a remote trauma center.

Methods

A retrospective observational study was performed to examine the management of splenic injuries at a mountainous and remote Level III trauma center. Trauma patients ≥ 18 years who had a blunt splenic injury and initially received care at a Level III trauma center prior to admittance or transfer were included. Data were collected over 4.5 years (January 1, 2016 – June 1, 2020). Patients who were transferred out in > 24 h were excluded. Patient demographics, injury severity, spleen radiology findings, and clinical characteristics were compared by decision to admit or transfer to a higher level of care ≤ 24 h of injury. Results were analyzed using chi-square, Fisher’s exact, or Wilcoxon tests. Multivariable logistic models were used to identify predictors of transfer.

Results

Of the 73 patients included with a blunt splenic injury, 48% were admitted and 52% were transferred to a Level I facility. Most patients were male (n = 58), were a median age of 26 (21–42) years old, most (n = 62) had no comorbidities, and 47 had been injured from a ski/snowboarding accident. Compared to admitted patients, transferred patients were significantly more likely to be female (13/38 vs. 3/36, p = 0.007), to have an abbreviated injury scale score ≥ 3 of the chest (31/38 vs. 7/35, p = 0.002), have a higher injury severity score (16 (16–22) vs. 13 (9–16), p = 0.008), and a splenic injury grade ≥ 3 (32/38 vs. 12/35, p < 0.001). After adjustment, splenic injury grade ≥ 3 was the only predictor of transfer (OR: 12.1, 95% CI: 3.9–37.3, p < 0.001). Of the 32 transfers with grades 3–5, 16 were observed, and 16 had an intervention. Compared to patients who were observed after transfer, significantly more who received an intervention had a blush on CT (1/16 vs. 7/16, p = 0.02) and a higher median spleen grade of 4 (3–5) vs. 3 (3–3.5), p = 0.01).

Conclusions

Our data suggest that most patients transferred from a remote facility had a splenic injury grade ≥ 3, with concomitant injuries but were hemodynamically stable and were successfully managed non-operatively. Stratifying by spleen grade may assist remote trauma centers with refining transfer criteria for solid organ injuries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-022-00339-4.

Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma

Background

Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery.

Materials and methods

Retrospective review was performed of PSAE for blunt splenic trauma (2015–2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test.

Results

Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01).

Conclusion

The results support the proposed optimal embolisation location as being between the DPA and GPA.

Splenic trauma: endovascular treatment approach

The spleen is a commonly injured organ in blunt abdominal trauma. Splenic preservation, however, is important for immune function and prevention of overwhelming infection from encapsulated organisms. Splenic artery embolization (SAE) for high-grade splenic injury has, therefore, increasingly become an important component of non-operative management (NOM). SAE decreases the blood pressure to the spleen to allow healing, but preserves splenic perfusion via robust collateral pathways. SAE can be performed proximally in the main splenic artery, more distally in specific injured branches, or a combination of both proximal and distal embolization. No definitive evidence from available data supports benefits of one strategy over the other. Particles, coils and vascular plugs are the major embolic agents used. Incorporation of SAE in the management of blunt splenic trauma has significantly improved success rates of NOM and spleen salvage. Failure rates generally increase with higher injury severity grades; however, current management results in overall spleen salvage rates of over 85%. Complication rates are low, and primarily consist of rebleeding, parenchymal infarction or abscess. Splenic immune function is felt to be preserved after embolization with no guidelines for prophylactic vaccination against encapsulated bacteria; however, a complete understanding of post-embolization immune changes remains an area in need of further investigation. This review describes the history of SAE from its inception to its current role and indications in the management of splenic trauma. The endovascular approach, technical details, and outcomes are described with relevant examples. SAE is has become an important part of a multidisciplinary strategy for management of complex trauma patients.

Splenic Artery Embolization after Delayed Splenic Rupture Following Blunt Trauma: Is Nonoperative Management Still an Option in This Cohort?

Patients treated with splenic artery embolization (SAE) >48 hours after a blunt injury for a delayed splenic rupture (DSR) were assessed for the need for a subsequent splenectomy. Thirty-four patients underwent SAE for DSR over 10 years at our level 1 trauma center, performed at a median of 4.5 days after the injury (interquartile range = 5.5), and the patients were followed up for a median of 11 months (interquartile range = 31). There were 3 occurrences of rebleeds, and 2 patients required splenectomy (5.9%). This study showed that treatment with SAE after DSR results in splenic salvage in 94.1% of patients.

The cost to perform splenic artery embolisation following blunt trauma: Analysis from a level 1 Australian trauma centre

INTRODUCTION

Splenic artery embolisation (SAE) has been shown to be an effective treatment for haemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. The purpose of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma at an Australian level 1 trauma centre.

METHODS

This was a single-centre retrospective review of 10 patients who underwent splenic embolisation from December 2017 to December 2018 for the treatment of isolated blunt splenic injury, including cost of procedure and the entire admission. Costs included angiography costs including equipment, machine, staff, and post-procedural costs including pharmacy, general ward costs, orderlies, ward nursing, allied health, and further imaging.

RESULTS

During the study period, patients remained an inpatient for a mean of 4.8 days and the rate of splenic salvage was 100%. The mean total cost of splenic embolisation at our centre was AUD$10,523 and median cost AUD$9959.6 (range of $4826-$16,836). The use of a plug as embolic material was associated with increased cost than for coils. Overall cost of patients requiring ICU was mean AUD$11,894 and median AUD$11,435.8. Overall cost for those not requiring ICU was mean AUD$7325 and median AUD$8309.8.

CONCLUSION

Splenic embolisation is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our centre was much lower than previously modelled data from overseas studies. From a cost perspective, the use of ICU for monitoring after the procedure significantly increased cost and necessity may be considered on a case-by-case basis. Further research is advised to directly compare the cost of SAE and splenectomy in an Australian setting.

The Role of Interventional Radiology in Treatment of Patients with Acute Trauma: A Pictorial Essay

Acute trauma is a common cause of mortality in individuals aged < 40 years. As organ preservation has become important in treating trauma patients, the treatment is shifting from surgical management to non-operative management. A multidisciplinary team approach, including interventional radiology (IR), is essential for the optimal management of trauma patients, as IR plays an important role in injury evaluation and management. IR also contributes significantly to achieving the best clinical outcomes in critically ill trauma patients. This pictorial essay aims to present and summarize various interventional treatments in trauma patients requiring critical care.

SPLEnic salvage and complications after splenic artery EmbolizatioN for blunt abdomINal trauma: the SPLEEN-IN study

BACKGROUND

As an adjunct to non-operative management, splenic artery embolization (SAE) has been increasingly utilized throughout the world and is now the standard of care for hemodynamically stable patients. This study aimed to retrospectively assess the rate of splenic salvage and complications after SAE for blunt trauma at a level 1 trauma center using the 2018 update to the AAST criteria, and further sub-stratify the role of angiography in AAST grade III injuries with significant hemoperitoneum. All patients between 1 January 2009 and 1 January 2019 who underwent blunt trauma and proceeded to embolization were included. Data was collected concerning initial injury grade, location of embolization, type of embolic material used, complications, and need for subsequent splenectomy. Technical success was defined as successful angiographic occlusion of the target artery at the conclusion of embolization. Clinical success was defined as splenic salvage at discharge. Vascular lesions were characterized including those with active bleeding, pseudoaneurysm, and arterio-venous fistula.

RESULTS

Two hundred thirty-two patients were included in the study. Treatments were performed at a median of 0 days (range 0-28 days) and the median AAST grade was IV (range III-V). Technical success was achieved in all patients. There were 13 complications (5.6%) consisting of re-bleed (9, 3.9%), infarction (3, 1.3%), and access site haematoma (1, 0.43%). Clinical success was achieved in 97% of patients with 7 patients requiring splenectomy after SAE (3.0%) at a median time of 4 days (range 0-17 days). Angiography in patients with grade III injuries identified 18 occult vascular injuries not identified at initial CT (p < 0.0001).

CONCLUSIONS

The SPLEEN-IN study shows that treatment of intermediate-high grade blunt force traumatic splenic injuries using SAE resulted in a low rate of complication and splenic salvage in 97% of patients, providing a safe and effective treatment in stable patients. In addition, angiography of grade III injuries identified occult vascular lesions and may warrant treatment of select patients in this cohort.

LEVEL OF EVIDENCE

Level 3.