Splenic artery embolization: technically feasible but not necessarily advantageous

Clinical Outcomes of Splenic Artery Embolization Versus Splenectomy in the Management of Hemodynamically Stable High-Grade Blunt Splenic Injuries: A National Analysis

INTRODUCTION

This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries.

METHODS

This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival.

RESULTS

Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001).

CONCLUSIONS

SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy.

Non-operative management of high-grade splenic injury: a systematic review protocol

OBJECTIVE

The objective of this review is to establish whether embolization is more effective than clinical observation for adult patients with grade III-V splenic injuries. The findings will be used to guide future practice and, if necessary, inform future research design and conduct.

INTRODUCTION

The spleen is one of the most frequently injured intra-abdominal organs, with a reported adult mortality of 7% to 18% following trauma. Non-operative management has become a standard of care for hemodynamically stable patients. In clinical practice, the decision whether to prophylactically embolize or manage high-grade injuries with observation alone remains controversial.

INCLUSION CRITERIA

Sources including adult patients with grade III-V splenic injuries secondary to blunt trauma will be included in this review. Eligible studies must include comparisons between 2 cohorts of patients undergoing either prophylactic embolization or clinical observation only. Outcomes will include mortality rate, failure of treatment, intensive care unit admission, length of hospital stay, blood transfusion requirements, and patient satisfaction.

METHODS

A systematic review with meta-analysis will be conducted. PubMed, Embase, and CINAHL will be searched for eligible studies, as will trial registries and sources of gray literature. Study selection, quality appraisal, and data extraction of outcomes will be performed in duplicate. Methodological quality will be evaluated using JBI critical appraisal tools. Studies will, where possible, be pooled in statistical meta-analysis. A random effects model will be used and statistical analysis will be performed. The certainty of the findings will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

REVIEW REGISTRATION

PROSPERO CRD42023420220.

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.

Long-Term Effects of Proximal Splenic Artery Embolization on Splenic Volume and Platelet Count

BACKGROUND

The spleen is the most commonly injured visceral organ in blunt abdominal trauma. Post-splenectomy infection risk has led to the shift toward spleen preserving procedures and splenic artery embolization (SAE) is now the treatment of choice for hemodynamically stable patients with splenic injury. This study aims to assess the long-term effect of SAE on splenic volume and platelet count.

MATERIALS AND METHODS

Using CPT codes, 66 patients who underwent SAE were identified, and 14 of those who had the necessary imaging and laboratory follow-up were included in the study. Indications for SAE were portal hypertension in 8 patients, bleeding in 4 patients, and thrombocytopenia in 1, and one patient had a separate indication. Splenic volume was calculated by automated volumetric software (Aquarius, TeraRecon, Inc.). Paired t-tests were performed to compare splenic volume and platelets before and after SAE.

RESULTS

Fourteen patients (7 males, 7 females) with a mean age of 51 ± 11.95 years underwent SAE and were followed by a repeat computed tomography scan at an average of 733.57 days. Nine SAEs were performed using vascular plugs, 3 using micro coils, and 2 out of that were with Gelfoam slurry, and 2 using coils only. All embolizations were technically successful with complete cessation of flow. Mean splenic volumes pre- and post-SAE were 903.5 ± 523.73 cm³ and 746.5 ± 511.95 cm³, respectively, representing a mean decrease of 8.31% compared to baseline [P = 0.346]. Minimum platelet counts (x10³) pre-SAE (within 3 months) and post-SAE (2 weeks to 3 months after the procedure) were 55.79 ± 57.11 and 116 ± 145.40, respectively. The minimum platelet count showed a statistically significant mean increase of 134.92% (P = 0.033).

CONCLUSIONS

The splenic volume is not altered significantly by SAE in the long term. Similarly, the platelet count is also not significantly altered at 3 months follow-up. This study, although small, suggests that SAE is a safe intervention that can preserve splenic volume and function in the long term.

Refractory Ascites with Intrahepatic Portal Thrombosis after Living Donor Liver Transplantation Successfully Treated by Splenic Artery Embolization and Apixaban (Case Report)

Refractory ascites is a rare complication after liver transplantation, and its incidence ranges from 5% to 7%. A 56-yearold man diagnosed with HBV-LC with massive ascites underwent living donor liver transplantation. After transplantation, more than 1000 ml/day of ascites was steadily drained until two weeks after LT. CT showed intrahepatic Rt. portal vein thrombosis and many remnant collaterals with splenomegaly. We decided to embolize the proximal splenic artery and use apixaban to reduce portal flow and resolve the intrahepatic portal thrombosis. One day after splenic artery embolization, the patient's ascites dramatically decreased. Three days later, he was discharged from the hospital. Three months later, a follow-up liver CT showed resolution of thrombosis and no ascites. Splenic artery embolization was an effective and safe procedure for portal flow modulation in portal hyertension. Apixaban was effective for partial portal vein thrombosis in a liver transplant recipient.

Splenic Artery Embolisation for the Emergency Treatment of Sinistral Portal Hypertension: A Systematic Review

Objectives Sinistral portal hypertension (SPH) is caused by increased pressure on the left portal system secondary to splenic vein stenosis or occlusion and may lead to gastric varices. The definitive management of SPH is splenectomy, but this is associated with significant mortality and morbidity in the acute setting. In this systematic review, we investigated the efficacy and safety of splenic artery embolisation (SAE) in managing refractory variceal bleeding in patients with SPH.

Methods A comprehensive literature search was conducted using MEDLINE and Embase databases. A qualitative analysis was chosen due to heterogeneity of the studies.

Results Our search yielded 339 articles, 278 of which were unique. After initial screening, 16 articles relevant to our search remained for full text review. Of these, 7 were included in the systematic review. All 7 papers were observational, 6 were retrospective. Between them they described 29 SAE procedures to control variceal bleeding. The technical success rate was 100% and there were no cases of rebleeding during follow up. The most common complication was post-embolisation syndrome. Four major complications occurred, two resulting in death. These deaths were the only 30-day mortalities recorded and were in patients with extensive comorbidities.

Conclusions Although there is a distinct lack of randomized controlled studies comparing SAE to other treatment modalities, it appears to be safe and effective in treating hemorrhage secondary to SPH.

Post-traumatic Splenic Injury Outcomes for Nonoperative and Operative Management: A Systematic Review

BACKGROUND

Splenectomies are widely performed, but there exists controversy regarding care for splenic injury patients. The purpose of this study is to provide a comprehensive review of the literature over the last 20 years for operative management (OM) versus nonoperative management (NOM) versus splenic artery embolization (SAE) for traumatic splenic injuries and associated outcomes.

METHODS

A review of literature was performed following the PRISMA guidelines through a search of PubMed, EMBASE, Cochrane Library, JAMA Network, and SAGE journals from 2000 to 2020 regarding splenic injury in trauma patients and their management. Articles were then selected based on inclusion/exclusion criteria with GRADE criteria used on the included articles to assess quality.

RESULTS

Twenty retrospective cohorts and one prospective cohort assessed patients who received OM versus NOM or SAE. Multiple studies indicated that NOM, in properly selected patients, provided better outcomes than its operative counterpart.

CONCLUSION

This review provides additional evidence to support the NOM of splenic injuries for hemodynamically stable patients with benign abdomens as it accounts for consistently shorter hospital length of stay, fewer complications, and lower mortality than OM. For hemodynamically unstable patients, management continues to be intervention with surgery. More studies are needed to further investigate outcomes of post-splenectomy patients based on grade of injury, hemodynamic status, type of procedure (i.e., SAE), and failure of NOM in order to provide additional evidence and improve outcomes for this patient population.

Non-operative management of blunt splenic trauma: The role of splenic artery embolization depending on the severity of parenchymal injury

PURPOSE

To address the disagreement about the need for splenic artery embolization (SAE) in medium grade blunt splenic trauma this retrospective study evaluates the clinical outcome of non-operative management (NOM) and the possible impact of a more liberal indication for primary SAE.

METHOD

From 01/2010 to 12/2019 186 patients presented with splenic injury on computed tomography (CT) after blunt abdominal trauma. The extent of splenic injuries according to Marmery, vascular pathologies, active bleeding as well as clinical and laboratory parameters were recorded and analyzed with regard to the success rates of NOM and SAE. Procedural complications and clinical outcome were noted. The number needed to treat (NNT) was determined for a possible extension of the indication for SAE to grade 3 injuries.

RESULTS

Of 186 patients 126 were managed non-operatively, 47 underwent primary SAE and twelve splenectomy. NOM was successful in 119/126 (94 %) patients. Conversion rate was significantly higher in patients with active bleeding or vascular pathology. Patients with failed NOM had a significantly greater decrease in haemoglobin and haematocrit levels. Primary SAE was successful in 45/47 (96 %) cases. Major complications occurred in four cases (9%), all managed without sequela. The NNT in grade 3 splenic injuries equals 13.

CONCLUSIONS

NOM of low to medium-grade blunt splenic trauma has a low failure rate. Presence of active haemorrhage is the most important predictor for failure of NOM. SAE should be reserved for high-grade injuries and visible vascular pathology or active bleeding to avoid a disproportionate increase in the NNT.

Outcomes Following Blunt Traumatic Splenic Injury Treated with Conservative or Operative Management

INTRODUCTION

Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries.

METHODS

A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ² analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively.

RESULTS

Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization.

CONCLUSIONS

Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.

An experimental rat model of hilar splenic vessel ligation versus splenectomy for spleen trauma

BACKGROUND

The most prevalent method of treating splenic injury is by splenectomy. This method is followed by postoperative complications. Therefore, less invasive procedures such as splenic angioembolization are introduced. This technique needs appropriate training, a high-tech setting and could be followed by complications. Thus, not all surgeons agree to do this procedure. Splenic hilar ligation of main vessels is a non-invasive procedure which has similarities to a splenectomy with unknown results.

OBJECTIVES

We aim to evaluate and compare splenectomy and hilar ligation.

METHODS

Thirty rats were divided into splenectomy and splenic hilar ligation groups. An identical grade 3-spleen injury was performed on all rats. After 6 weeks blood samples were obtained and hematologic and immunologic aspects were measured in their serum. Giemsa stained peripheral blood smears were obtained from the ligation group.

RESULTS

Comparing the above-mentioned variables before and after the surgery in each groups showed statistical significance in all aspects except IgM, C4 and platelets levels in ligation group (P value: 0.213, 0.059 and 0.649 respectively). Analysis revealed significant deference in postoperative WBC, IgM and C4 levels between splenectomy and ligation group (P value: < 0.001, < 0.001 and 0.026 respectively).

CONCLUSION

Splenic hilar ligation of main vessels is an easy way of treating splenic injury in hemodynamically stable patients with less postoperative complications. Therefore, it can be performed by all surgeons in all kind of medical centers. Spleen remains viable and continues its role although some aspects of its function become interrupted.

How should we manage a delayed presentation of blunt splenic injury?

A delayed presentation of a blunt splenic injury can refer to either an initially missed injury that manifests later with symptoms or latent insignificant injury that then becomes clinically symptomatic. This is a small patient group and there is some controversy about how these injuries should be managed. We present a case of a patient with an initially missed blunt splenic injury who represented two weeks later with hemorrhage and pain. He was treated non-operatively but returned with persistent symptoms and eventually required a difficult splenectomy. Through this case, we raise the question of whether patients who present with rebleeding in a delayed fashion from an initially missed blunt splenic injury are best treated with surgery and a splenectomy.

Nonoperative Management of Blunt Splenic Trauma: Outcomes of Gelfoam Embolization of the Splenic Artery

Context:

Nonoperative management (NOM) is the standard of care in hemodynamically stable trauma patients with blunt splenic injury. Gelfoam splenic artery embolization (SAE) is a treatment option used in trauma patients.

Aims:

The primary aim of this study was to retrospectively examine the use and outcomes of Gelfoam SAE in adult patients with blunt splenic injury.

Settings and Design:

One hundred and thirty-two adult patients with blunt splenic injury admitted to a Level 1 trauma center between January 2014 and December 2015 were included in the study. Patients treated with Gelfoam SAE, NOM, and splenectomies were reviewed. Descriptive statistics including patient age, Glasgow Coma Scale, Injury Severity Score (ISS), hospital days, Intensive Care Unit (ICU) days, splenic grade, and amount of blood products administered were recorded. Complications, defined as any additional factors that contributed to the patient's overall length of hospital stay, were compared between the three groups. Technical aspects of Gelfoam SAE and associated complications were reviewed.

Subjects and Methods:

Gelfoam SAE was performed in 25 (18.9%) of the 132 patients. Gelfoam SAE patients had fewer ICU days compared with those patients who had a splenectomy or NOM. There was no statistical difference in complications between patients who underwent Gelfoam SAE and those who did not. Patients who underwent Gelfoam SAE tended to have fewer complications including deep venous thrombosis's, PE, and infections and yielded no complications in 64% of the Gelfoam group.

Statistical Analysis:

Statistical analysis included descriptives, ANOVA, and nonparametric tests as appropriate.

Conclusion:

Gelfoam SAE can be used for blunt splenic injury for intermediate ISS and splenic grade as it reduced hospital and ICU days.