Splenic Artery Embolisation in Trauma: It is Time to Stand Alone as its Own Treatment

A retrospective observational study assessing mortality after pelvic trauma embolisation

INTRODUCTION

Trauma to the pelvic ring and associated haemorrhage represent a management challenge for the multidisciplinary trauma team. In up to 10% of patients, bleeding can be the result of an arterial injury and mortality is reported as high as 89% in this cohort. We aimed to assess the mortality rate after pelvic trauma embolisation and whether earlier embolisation improved mortality.

METHODS

Retrospective study at single tertiary trauma and referral centre, between 1 January 2009 and 30 June 2022. All adult patients who received embolisation following pelvic trauma were included. Patients were excluded if angiography was performed but no embolisation performed.

RESULTS

During the 13.5-year time period, 175 patients underwent angiography and 28 were excluded, leaving 147 patients in the study. The all-cause mortality rate at 30-days was 11.6% (17 patients). The median time from injury to embolisation was 6.3 h (range 2.8-418.4). On regression analysis, time from injury to embolisation was not associated with mortality (OR 1.01, 95% CI 0.952-1.061). Increasing age (OR 1.20, 95% CI 1.084-1.333) and increasing injury severity score (OR 1.14, 95% CI 1.049-1.247) were positively associated with all-cause 30-day mortality, while non-selective embolisation (OR 0.11, 95% CI 0.013-0.893) was negatively associated.

CONCLUSION

The all-cause mortality rate at 30-days in or cohort was very low. In addition, earlier time from injury to embolisation was not positively associated with all-cause 30-day mortality. Nevertheless, minimising this remains a fundamental principle of the management of bleeding in pelvic trauma.

A systematic review assessing incorporation of prophylactic splenic artery embolisation (pSAE) into trauma guidelines for the management of high-grade splenic injury

BACKGROUND

Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with high-grade injury. However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed, and SAE only used only if a patient re-bleeds. This systematic review aimed to assess published practice management guidelines which recommend pSAE, stratified according to their quality.

METHODS

The study was registered and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors. Identified guidelines were graded according to the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument.

RESULTS

Database and internet searches identified 1006 results. After applying exclusion criteria, 28 guidelines were included. The use of pSAE was recommended in 15 guidelines (54%). This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275.

CONCLUSIONS

This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems rather than the available evidence. This reflects biases with interpretation of data and lack of multidisciplinary system inputs, including from interventional radiologists.

Immune Function After Splenic Artery Embolization for Blunt Trauma: Long-Term Assessment of CD27+ IgM B-Cell Levels

Splenic artery embolization (SAE) plays a critical role in the treatment of high-grade splenic injury not requiring emergent laparotomy. SAE preserves splenic tissue, and growing evidence demonstrates preserved short-term splenic immune function after SAE. However, long-term function is less studied. Patients who underwent SAE for blunt abdominal trauma over a 10-year period were contacted for long-term follow-up. Sixteen participants (sex: women, 10, and men, 6; age: median, 34 years, and range, 18-67 years) were followed up at a median of 7.7 years (range, 4.7-12.8 years) after embolization. Splenic lacerations were of American Association for the Surgery of Trauma grades III to V, and 14 procedures involved proximal embolization. All individuals had measurable levels of IgM memory B cells (median, 14.30 as %B cells), splenic tissue present on ultrasound (median, 122 mL), and no history of severe infection since SAE. In conclusion, this study quantitatively demonstrated that long-term immune function remains after SAE for blunt abdominal trauma based on the IgM memory B cell levels.

Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury

The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.

Early Pharmacologic Venous Thromboembolism Prophylaxis after Splenic Artery Embolization Is Not Associated with an Increased Risk of Rebleed

Venous thromboembolism (VTE) prophylaxis in the setting of blunt traumatic visceral injury remains controversial. A total of 181 patients underwent splenic artery embolization (SAE) and began pharmacologic VTE prophylaxis at a median time of 59.5 hours (interquartile range, 46 hours). Six patients required splenectomy for rebleed. Fifty-one patients underwent SAE but did not receive anticoagulation therapy since they were considered low risk for VTE, and no splenectomies were performed (P = 1). Multivariate analysis showed no increased risk of need for splenectomy after beginning anticoagulation within 24 hours after SAE (P =.441). This study suggests that patients found to be at a high VTE risk should be considered for thromboprophylaxis within 24 hours after SAE.

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.