Splenic trauma in the twenty-first century: changing trends in management

Complications and failure rate of splenic artery angioembolization following blunt splenic trauma: A systematic review

BACKGROUND

Over recent decades, splenic angioembolization (SAE) as an adjunct to non-operative management (NOM) has emerged as a prominent intervention for patients with blunt splenic injuries (BSI). SAE improves patient outcomes, salvages the spleen, and averts complications associated with splenectomy. This systematic review aimed to evaluate the failure rate and complications related to SAE in patients with BSI.

METHODS

A systematic literature search (PubMed, SCOPUS, and Cochrane Library) focused on studies detailing splenic angioembolization in blunt trauma cases. Articles that fulfilled the predetermined inclusion criteria were included. This review examined the indications, outcomes, failure rate, and complications of SAE.

RESULTS

Among 599 identified articles, 33 met the inclusion criteria. These comprised 29 retrospective studies, three prospective studies, and one randomized control trial. The analysis encompassed 25,521 patients admitted with BSI and 3,835 patients who underwent SAE. The overall failure rate of SAE was 5.3 %. Major complications predominantly were rebleeding (4.8 %), infarction (4.6 %), and abscess formation (4 %). Minor complications were fever (18.4 %), pleural effusion (13.1 %), and coil migration (3.9 %). Other complications included splenic atrophy, splenic cyst, hematoma, and access site complications such as splenic/femoral dissection. Overall, post embolization mortality was 0.08 %.

CONCLUSION

SAE is a valuable adjunct in managing BSI, with a low failure rate. However, this treatment modality is not without the risk of potentially serious complications.

Prophylactic embolization versus observation for high-grade blunt trauma splenic injury: a systematic review with meta-analysis

OBJECTIVE

The objective of this systematic review was to compare the effectiveness of prophylactic angioembolization with observation as primary management strategies for patients with high-grade (grades 3-5) blunt trauma splenic injury.

INTRODUCTION

The spleen is frequently injured in abdominal trauma. Historical management practices involved splenectomy, but more recent evidence suggests an increased risk of severe infections and sepsis associated with this approach. Accordingly, non-operative management strategies, including prophylactic splenic artery embolization and clinical observation, have gained prominence. This systematic review with meta-analysis directly compares angioembolization with clinical observation for high-grade splenic injuries only, aiming to provide clarity on this matter amid ongoing debates and variations in clinical practice.

INCLUSION CRITERIA

This review included adult patients aged 15 years or older with high-grade splenic injuries (grade 3-5) due to blunt trauma. Outcomes of interest include the need for further intervention (failure of management), mortality, complications, red blood cell transfusion requirements, hospital length of stay, and intensive care unit length of stay.

METHODS

A comprehensive search of PubMed, Embase, and CINAHL (EBSCOhost), was performed with no restrictions on language or publication date. Gray literature was searched, including trial registries and relevant conference proceedings. After deduplication, 2 reviewers independently assessed titles and abstracts, and, subsequently, full-text articles for eligibility. Methodological quality of the included studies was assessed using standardized instruments from JBI. Data was extracted using predefined templates, and statistical meta-analysis was performed, where possible, using a random effects model. Heterogeneity was assessed using statistical methods, and potential publication bias was tested with a funnel plot. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.

RESULTS

Sixteen studies were included in this review. Methodological quality assessment indicated some risk of bias in most studies, with concerns primarily related to differences in injury severity and potential confounding factors. Meta-analysis revealed that prophylactic angioembolization significantly reduced risk of management failure by 57% (OR 0.43, 95% CI 0.28-0.68, I2=53%, 15 studies) and decreased patient mortality by 37% (OR 0.63, 95% CI 0.43-0.93, I2=0%, 9 studies) compared with clinical observation alone. There was a 47% reduction in risk of complications associated with prophylactic embolization compared with clinical observation (OR 0.53, 95% CI 0.29-0.95, I2=0%, 4 studies). Some statistical heterogeneity was observed, with I2 ranging from 0% to 53%. No significant differences were observed between the 2 management strategies for red blood cell transfusion requirements and hospital length of stay.

CONCLUSIONS

The results of this study support the use of prophylactic embolization for high-grade blunt trauma splenic injuries, indicated by lower failure of management rates, reduced need for additional interventions, lower mortality, and fewer complications.

REVIEW REGISTRATION

PROSPERO CRD42023420220.

Initial Hemorrhage Control Procedure for Splenic Injuries May Affect Risk of Venous Thromboembolism

INTRODUCTION

Venous thromboembolism (VTE) continues to be a major cause of morbidity in trauma. It is unclear whether the type of hemorrhage control procedure (i.e., splenectomy versus angioembolization) is associated with an increased risk of VTE. We hypothesize that hemodynamically stable patients undergoing angioembolization for blunt high-grade splenic injuries have lower rates of VTE compared to those undergoing splenectomy.

METHODS

The American College of Surgeons Trauma Quality Program dataset from 2017 to 2019 was queried to identify all patients with American Association for the Surgery of Trauma grade 3-5 blunt splenic injuries. Outcomes including VTE rates were compared between those who were managed with splenectomy versus angioembolization. Propensity score matching (1:1) was performed adjusting for age, sex, initial vital signs, Injury Severity Score, and splenic injury grade.

RESULTS

The analysis included 4698 matched patients (splenectomy [n = 2349] and angioembolization [n = 2349]). The median (interquartile range) age was 41 (27-58) years and 69% were male. Patients were well matched between groups. Angioembolization was associated with significantly lower VTE than splenectomy (2.2% versus 3.4%, P = 0.010) despite less use of VTE chemoprophylaxis (70% versus 80%, P < 0.001), as well as a relative delay in initiation of chemoprophylaxis (44 h versus 33 h, P < 0.001). Hospital and intensive care unit length of stay and mortality were also significantly lower in the angioembolization group.

CONCLUSIONS

Angioembolization is associated with a significantly lower incidence of VTE than splenectomy. Thus, angioembolization should be considered for initial management of hemodynamically stable patients with high-grade blunt splenic injuries in whom laparotomy is not otherwise indicated.

When is it safe to start thromboprophylaxis after splenic angioembolization?

BACKGROUND

Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events.

METHODS

All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05.

RESULTS

In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]).

CONCLUSION

This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.

A case report of successful splenic artery embolization for atraumatic splenic rupture secondary to Epstein Barr virus infection in a haemodynamically unstable patient

Splenic rupture in haemodynamically unstable patients has traditionally been managed with splenectomy. This case report discusses the successful management of atraumatic splenic rupture, a rare but life-threatening complication of Epstein-Barr virus (EBV) infection, in a hemodynamically unstable patient. The patient, diagnosed with infectious mononucleosis (IM) secondary to EBV, presented with severe abdominal pain and a syncopal episode. Imaging revealed an American Association for the Surgery of Trauma (AAST) grade III splenic injury, which was subsequently upgraded to a grade IV injury on repeat imaging. The patient's condition deteriorated even with initial resuscitation, leading to splenic angioembolization. The procedure was successful and the patient was discharged after 5 days. This case highlights the efficacy of splenic artery embolization (SAE) in haemodynamically unstable patients with atraumatic splenic rupture, particularly in centers with interventional radiology resources, offering an alternative to splenectomy and its associated complications.

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.

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.

Splenic Heterogeneity in Focused Assessment With Sonography for Trauma (FAST) Scan Led to the Diagnosis of Grade 2 Splenic Injury in a Pediatric Blunt Abdominal Trauma

Splenic injuries are one of the most common injuries following blunt abdominal trauma. It occurs in 32% of blunt abdominal trauma, with motor vehicle accidents being the most common cause. The patient may present with generalized abdominal pain or left upper quadrant pain associated with left shoulder pain. Hemodynamic instability is one of the most reliable signs of splenic injuries. A focused assessment with sonography for trauma (FAST) scan is the initial imaging used to assess for solid organ injury in the abdomen, followed by computed tomography (CT) scans. Evidence of free fluid in the abdomen in the FAST scan indicates a solid organ injury. However, the absence of the before-mentioned finding does not rule out the presence of solid organ injury. Hereby a case of a 13-year-old Saudi male with left-sided abdominal pain after falling from a motorbike. A set of the investigation was done with insignificant results. However, FAST revealed a heterogenous appearance in the spleen. Thus, the patient subsequently underwent abdominal CT scans. The patient was managed conservatively and then discharged against medical advice (DAMA). Previously documented cases have mentioned the presence of free fluid in the abdomen in FAST scan in a stable patient leading to undergoing a CT scan and further managing trauma victim patients, which was absent in the present case.

Delayed splenic rupture after a minor blunt trauma: A case report and literature review

Delayed Splenic Rupture (DSR) is a rare but well-known manifestation of Blunt Splenic Injury (BSI), which most commonly occurs following a car accident, a fall from a great height, or a direct blow to the left thorax or abdomen. If the history of trauma is remote or unknown, the diagnosis can be difficult or missed, and a high index of suspicion is not warranted. Regardless of the time and mechanism of the inciting event, DSR should be considered in the differential diagnosis of an acute surgical abdomen. We present a case of DSR in an 81-year-old woman caused by a remote minor blunt abdominal trauma four weeks prior to her admission to our emergency department for acute abdominal pain and hemorrhagic shock (ATLS CLASS III). Starting with this case report, we conducted a literature review on the subject in order to raise awareness, knowledge, and understanding of DSR among emergency clinicians.

Needle in a haystack: a case report of splenic foreign body-associated sepsis

Instances of foreign bodies impacted in solid organs are rare, and rarer still are reports of objects in the spleen. A 42-year-old presented septic with abdominal pain, high inflammatory markers and haemodynamic instability. She was found to have a splenic haematoma and a 4-cm hyperdense foreign body within the spleen. Ultrasound-guided drainage of the haematoma isolated Streptococcus anginosus and conservative management with intravenous antibiotics avoided the need for emergency splenectomy. The bacterium isolated was the same cultured 9 months previously from the patient's empyema fluid. The origin of the foreign body was not identified, though is made of metal and pre-dates any hospital admissions. The case raised the question of how an object might penetrate the spleen without knowledge of the patient and highlighted the risks of foreign body-associated sepsis, the risks and benefits of emergency splenectomy and management of complex cases with paucity of evidence.

Splenic preservation after isolated splenic blunt trauma: The angioembolization paradox

BACKGROUND

The spleen is the most commonly injured organ in blunt abdominal trauma. The management for splenic trauma includes nonoperative management, splenectomy, and splenic artery angioembolization. The aim of this study is to investigate recent trends in the usage of splenic artery angioembolization in patients with isolated blunt splenic trauma.

METHODS

Adult patients (age >15) with isolated blunt splenic trauma were identified from the National Trauma Databank (2007-2015) using International Classification of Diseases, Ninth Revision, codes. The defined groups included nonoperative management, splenectomy, and splenic artery angioembolization. Patient variables collected included year of traumatic injury, age, sex, race, insurance status, and geographic region. Clinical variables collected included vital signs (systolic blood pressure, pulse, respiratory rate) recorded upon arrival to the emergency room, injury severity score, abbreviated injury severity scores, diagnoses, procedures, and mechanism. Outcome measures included mortality, hospital duration of stay, and complications. We performed 2 independent Poisson logistic regression models to assess relative risk for both splenectomy and angioembolization.

RESULTS

A total of 10,812 patients were included in the analysis (nonoperative management: 7,920; splenectomy: 2,083; angioembolization: 809). Angioembolization proportion increased from 2007 (4.6%) to 2015 (10%), while splenectomy proportion remained unchanged (19.2% to 18.3%). Poisson logistic regression suggests the adjusted probability of receiving angioembolization for a splenic injury increased year-to-year, while the adjusted probability of receiving a splenectomy remained unchanged.

CONCLUSION

The use of angioembolization for isolated blunt splenic injuries has increased over the past decade without a reciprocal change in splenectomy. Based on this study, angioembolization may be an overused resource without a significant benefit.

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.

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.

Management of a delayed, post-traumatic rupture of splenic artery pseudoaneurysm in a patient with life threatening co-morbidities: A treatment challenge

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Even high-grade splenic injuries are manageable using interventional radiology with selective splenic artery embolization.

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Patient co-morbidities and other associated injuries affect the outcomes.

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Very morbid patients could be salvaged by judiciously executed ICU care and non-invasive procedure undertaken with informed risks.

Introduction

Splenic artery embolization (SAE) is an accepted intervention for patients with traumatic injury AAST III-IV in hemodynamically stable patients, splenic artery aneurysm and pseudoaneurysm (Brian and Charles, 2012). Unusual circumstances may pose different challenges in individual cases.

Case presentation

A 52-year-old male on anticoagulants for past mitral valve replacement presented to us with history of blunt trauma sustained a month prior, was found to have grade IV splenic injury with delayed pseudo-aneurysmal rupture. In addition, his cardiac evaluation revealed an ejection fraction of 20%. A potential life threatening unstable cardiac status and hemodynamic irregularities accentuated due to the hemoperitoneum was an unusual challenge to deal with. After initial stabilization in ICU, the option of distal embolization of splenic artery was undertaken in a well-planned manner.

Discussion

Unstable cardiac condition, anticoagulant therapy and delayed pseudo aneurysmal bleed led us into undertaking this procedure as a semi-emergency with calculated risks. We discuss this case due to the complexities and dilemmas on various aspects which we faced in his management.

Conclusion

Patient tolerated the procedure well and was discharged on the third day of embolization. Our experience taught us the judicious implementation of a viable and only lifesaving option for an otherwise inoperable patient due to multiple co-morbidities and would strongly recommend this interventional radiological, relatively innocuous procedure for salvaging such patients.

Splenic Artery Angioembolization is Associated with Increased Venous Thromboembolism

BACKGROUND

Angioembolization has become an increasingly utilized adjunct for splenic preservation after trauma. Embolization of the splenic artery may produce a transient systemic hypercoagulable state. This study was designed to determine the risk of venous thromboembolism (VTE) in blunt trauma patients managed nonoperatively with splenic angioembolization, relative to those managed without.

METHOD

Retrospective review of the American College of Surgeons Trauma Quality Improvement Performance (TQIP) Database from 2013 to 2016. Adult (>16 years) patients with isolated, severe (Grades III-V) blunt splenic injuries managed nonoperatively who received pharmacological VTE prophylaxis formed the study population. Outcomes included deep venous thrombosis (DVT), pulmonary embolism (PE), or any VTE.

RESULTS

A total of 2643 patients met inclusion criteria (69.1% Grade III, 26.5% Grade IV, 4.5% Grade V). The incidence of DVT was 4.5% in patients who underwent angioembolization, compared to 1.4% in patients who did not (p<0.001). Multivariable analysis showed that angioembolization was an independent risk factor for both DVT (OR 2.65, p = 0.006) and any VTE (OR 2.04, p = 0.01). Analysis according to splenic injury Grades showed that angioembolization remained an independent risk factor for DVT (p = 0.004) in the Grade IV-V injury group, and for VTE (p<0.01) in the Grade III injury group. Initiation of pharmacological VTE prophylaxis 48 h after admission was associated with increased VTE rates in comparison to early initiation (OR 1.75, p = 0.02) CONCLUSIONS: Splenic artery angioembolization may be an independent risk factor for VTE events in isolated, severe blunt splenic trauma managed nonoperatively. Early prophylaxis with LMWH after intervention should be strongly considered.