Superselective embolization of a traumatic intrasplenic arteriovenous fistula

Successful management of a symptomatic splenic artery aneurysm with transcatheter embolization

We describe a symptomatic splenic artery aneurysm (SAA) with occasional left-sided abdominal pain which was successfully treated with transcatheter embolization. A 65-year-old man was referred to a nearby clinic because of left shoulder and abdominal pain developing the day after blunt trauma to the shoulder and abdomen. Radiography revealed no fracture, and the patient went home. He stopped working for 7 months. Left-sided abdominal pain then developed several times after strenuous physical labor, and the patient was referred to a nearby hospital. The patient had a history of asthma and untreated hypertension; the use of iodinated contrast material was therefore avoided. Unenhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a hematoma in the splenic hilum. The patient was referred to Nippon Medical School Hospital. His neurologic status was stable. Unenhanced CT of the abdomen at a nearby hospital revealed a low-density area in the splenic hilum. Fat-suppressed, T1-weighted images showed a hyperintense lesion adjacent to the splenic hilum. Fat-suppressed, T2-weighted images showed a dark hemosiderin rim, a bright ring, and an intermediate central core, which indicated a recurrent chronic hematoma in the abdomen. Dynamic contrast-enhanced MRI revealed a small hyperenhanced lesion adjacent to the hematoma, which appeared to be an SAA. After an injection of corticosteroids, selective splenic arteriography was performed. The splenic artery was catheterized via a right femoral approach. Arteriography showed an SAA, 1 cm in diameter with extravasation of contrast material. The neck of the SAA was catheterized with a microcatheter, and coils were placed successfully into the SAA to prevent recurrent bleeding. Postembolization angiography showed total occlusion of the SAA. The patient was discharged 7 days after embolization and has since resumed normal activities, with no residual symptoms.

Posttraumatic splenic pseudoaneurysm and arteriovenous fistula: diagnosis by computed tomography angiography and treatment by transcatheter embolization

The current treatment of splenic injury in children is conservative. The common concern with nonoperative management of splenic injury involves increased risk of posttraumatic splenic complications. Computed tomography angiography is a noninvasive and useful technique for the detection of the vascular abnormalities in conservatively managed splenic injuries. We present a case of posttraumatic splenic pseudoaneurysm and arteriovenous fistula (AVF) in a 12-year-old boy, which were prediagnosed by color Doppler ultrasound and consecutively shown by computed tomography angiography. The treatment of splenic AVF is indicated to avoid portal hypertension, high output cardiac failure, and related complications. To preserve the splenic immune function and to avoid the risk of surgery and splenectomy complications, splenic pseudoaneurysm and AVF were successfully occluded by transcatheter embolization.

[Inferior mesenteric arteriovenous fistulas. Report of a case]

We report a case of postoperative inferior mesenteric arteriovenous fistula. Arteriovenous fistula represents a rare disease. Symptoms are due to portal hypertension and distal ischemy. Treatment of these fistulas is embolization. Surgery is possible by ligature or excision of the fistula because vascularisation is obtained by Riolan arcade and hypogastric artery.

Autologous thrombin: a new embolization treatment for traumatic intrasplenic pseudoaneurysm

PURPOSE

To report the use of autologous thrombin for transcatheter embolization of a traumatic parenchymal splenic pseudoaneurysm.

CASE REPORT

A 15-year-old boy presented with a splenic parenchymal laceration after blunt abdominal trauma. The patient was managed conservatively but developed an intrasplenic pseudoaneurysm (grade III AAST scale) with subcapsular contrast extravasation after 3 weeks. Autologous thrombin was isolated from the patient's blood and subsequently delivered to the lesion by transcatheter superselective injection into the aneurysm neck. The patient was asymptomatic after the procedure. Nine months' follow-up demonstrated a normal spleen with completely homogenous parenchyma.

CONCLUSIONS

Autologous thrombin injection to induce thrombosis of intrasplenic pseudoaneurysm represents a new treatment option for traumatic abdominal organ injuries. Intrasac thrombosis can be safely induced to successfully restore the splenic parenchymal integrity without introduction of foreign material and associated risks of adverse reactions or infection that might accompany the use of commercial thrombin preparations.

Implications of the "contrast blush" finding on computed tomographic scan of the spleen in trauma

BACKGROUND

The "contrast blush" (CB) computed tomographic (CT) scan finding has often been used clinically as an indicator for therapeutic splenic intervention (SI) (splenectomy, splenorrhaphy, or angiographic embolization). We sought to examine the prognostic significance of this finding.

METHODS

The records and CT scans of 324 trauma patients from two Level I trauma centers who had blunt splenic injury and a CT scan of the abdomen within 24 hours of admission were reviewed and screened for CB.

RESULTS

CB was identified in 11% of patients, and its incidence was significantly related to the grade of injury: grade I/II, 3.2%; grade III, 11.8%; and grade IV/V, 26.3% (p < 0.001). SI was also related to the grade: grade I/II, 7.7%; grade III, 37.6%; and grade IV/V, 69.7% (p < 0.001). The chance of having SI was greater in those with CB (75.0%) when compared with those without CB (25.0%) (p < 0.001; odds ratio, 9.2). A multivariate logistic regression analysis revealed that SI correlated independently with splenic grade, emergency department hypotension, and age, but did not demonstrate a correlation with CB.

CONCLUSION

CB is not an absolute indication for an operative or angiographic intervention. Factors such as patient age, grade of injury, and presence of hypotension need to be considered in the clinical management of these patients.