A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?

BACKGROUND

Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization.

METHODS

We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions.

RESULTS

Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission.

CONCLUSION

There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

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.

Laparoscopic distal pancreatectomy in a patient with aberrant splenic artery originating from the superior mesenteric artery: A case report

RATIONALE

Splenic artery originating from the superior mesenteric artery is extremely rare. Because of this, its significance in laparoscopic distal pancreatectomy has never been reported. Here, we present the first case of laparoscopic distal pancreatectomy in a patient with a splenic artery arising from the superior mesenteric artery.

PATIENT CONCERNS

A 46-year-old Japanese woman with type 2 diabetes mellitus presented with worsening glycemic control. Abdominal ultrasonography revealed a pancreatic tail mass.

DIAGNOSES

The patient was diagnosed with pancreatic neuroendocrine tumor by endoscopic ultrasound-guided fine needle aspiration. Preoperative computed tomography showed that the splenic artery with branches of dorsal pancreatic artery originated from the superior mesenteric artery.

INTERVENTIONS

The patient underwent laparoscopic distal pancreatectomy. Prior to pancreatectomy, the splenic artery and its dorsal pancreatic branches were clamped using the superior and inferior approaches, respectively, to avoid bleeding and congestion.

OUTCOMES

The postoperative course was uneventful.

LESSONS

Preoperative evaluation of anatomical variants and development of strategies are important to avoid intraoperative complications in pancreatic surgery. Our results revealed that laparoscopic distal pancreatectomy can be performed safely by strategic approach even in a patient with a rare aberrant splenic artery.

The consequences of major visceral vascular injuries on outcome in patients with pancreatic injuries: a case-matched analysis

BACKGROUND

Major pancreatic injuries are complex to treat, especially when combined with vascular and other critical organ injuries. This case-matched analysis assessed the influence of associated visceral vascular injuries on outcome in pancreatic injuries.

METHOD

A registered prospective database of 461 consecutive patients with pancreatic injuries was used to identify 68 patients with a Pancreatic Injury combined with a major visceral Vascular Injury (PIVI group) and were matched one-to-one by an independent blinded reviewer using a validated individual matching method to 68 similar Pancreatic Injury patients without a vascular injury (PI group). The two groups were compared using univariate and multivariate logistic regression analysis and outcome including complication rates, length of hospital stay and 90-day mortality rate was measured.

RESULTS

The two groups were well matched according to surgical intervention. Mortality in the PIVI group was 41% (n = 28) compared to 13% (n = 9) in the PI alone group (p = 0.000, OR 4.5, CI 1.00-10.5). On univariate analysis the PIVI group was significantly more likely to (i) be shocked on admission, (ii) have a RTS < 7.8, (iii) require damage control laparotomy, (iv) require a blood transfusion, both in frequency and volume, (v) develop a major postoperative complication and (vi) die. On multivariate analysis, the need for damage control laparotomy was a significant variable (p = 0.015, OR 7.95, CI 1.50-42.0) for mortality. Mortality of AAST grade 1 and 2 pancreatic injuries combined with a vascular injury was 18.5% (5/27) compared to an increased mortality of 56.1% (23/41) of AAST grade 3, 4 and 5 pancreatic injuries with vascular injuries (p = 0.0026).

CONCLUSION

This study confirms that pancreatic injuries associated with major visceral vascular injuries have a significantly higher complication and mortality rate than pancreatic injuries without vascular injuries and that the addition of a vascular injury with an increasing AAST grade of pancreatic injury exponentially compounds the mortality rate.

Risks and Realities of Delayed Splenic Bleeding

Delayed splenic bleeding (DSB) is a poorly understood complication of blunt splenic injury. Treatment for splenic bleeding may involve splenectomy, but angioembolization is becoming a widely used adjuvant for management. Using the North Carolina Trauma Registry, this study aimed to evaluate the incidence, mortality, and risk factors for DSB in North Carolina. Using ICD-9 and ICD-10 codes, patients were stratified into two cohorts, those who underwent immediate splenectomy and those who were initially managed nonoperatively. DSB was then defined as splenectomy at greater than 24 hours after presentation. Of the 1688 patients included in the study, 269 patients (16%) underwent immediate splenectomy and 1419 (84%) were managed nonoperatively initially, with 32 (2%) having delayed splenectomy. Older age (≥30 years) was associated with increased odds of having delayed splenectomy (odds ratio 4.30; 95% confidence interval 1.08, 17.17; P = 0.04). Four per cent of patients managed nonoperatively and undergoing an angioembolization procedure eventually required splenectomy. Risk factors for DSB remain elusive. Splenic artery embolization may be used as an adjuvant to splenectomy for stable patients, but it is not always a definitive treatment, and patients may still require splenectomy.

Endovascular treatment of post-laparoscopic pancreatectomy splenic arteriovenous fistula with splenic vein aneurysm

Splenic arteriovenous fistulas (SAVFs) with splenic vein aneurysms are extremely rare entities. There have been no prior reports of SAVFs developing after laparoscopic pancreatectomy. Here, we report the first case. A 40-year-old man underwent a laparoscopic, spleen-preserving, distal pancreatectomy for an endocrine neoplasm of the pancreatic tail. Three months after surgery, a computed tomography (CT) scan demonstrated an SAVF with a dilated splenic vein. The SAVF, together with the splenic vein aneurysm, was successfully treated using percutaneous transarterial coil embolization of the splenic artery, including the SAVF and drainage vein. After the endovascular treatment, the patient’s recovery was uneventful. He was discharged on postoperative day 6 and continues to be well 3 mo after discharge. An abdominal CT scan performed at his 3-mo follow-up demonstrated complete thrombosis of the splenic vein aneurysm, which had decreased to a 40 mm diameter. This is the first reported case of SAVF following a laparoscopic pancreatectomy and demonstrates the usefulness of endovascular treatment for this type of complication.

[Organ-preserving method in the surgical treatment of the spleen injuries]

The authors have experience in organ-preserving operations for spleen rupture with the splenic artery ligation in 156 casualties. They consider that such operations let to preserve the spleen, to avoid the postoperative rebleeding and ischemia of pancreas tail and body. Also it is accompanied by the low indications of lethality and postoperative complications. The authors consider that this operation is alternative to splenectomy and other techniques of organ-preserving operations in case of spleen trauma.

Splenic artery embolisation in children and adolescents--an 8 year experience

BACKGROUND

Non-operative management (NOM) is the treatment of choice in blunt splenic injuries in the paediatric population, with reported success rates exceeding 90%. Splenic artery embolisation (SAE) was added to our institutional treatment protocol for splenic injury in 2002. We wanted to review indications for SAE and the clinical outcome of splenic injury management in children admitted between August 1, 2002 and July 31, 2010.

METHODS

Patients aged <17 years with splenic injury were identified in the institutional trauma and medical code registries. Patient charts and computed tomographic (CT) scans were reviewed.

RESULTS

Of the 72 children and adolescents with splenic injury included during the 8 year study period, 66 patients (92%) were treated non-operatively and six underwent operative management. Severe splenic injury (OIS grade 3-5) was diagnosed in 67 patients (93%). SAE was performed in 22 of the NOM patients. Indications for SAE included - bleeding (n=8), pseudoaneurysms (n=2), contrast extravasation (n=2), high OIS injury grade (n=8) and prophylactic due to specific disease (n=2). NOM was successful in all but one case (98%). For the patients aged ≤ 14 years, extravasation on initial CT scan correlated to delayed bleeding (p<0.001). Two SAE procedure specific complications were registered, but resolved without significant sequelae.

CONCLUSION

After SAE was added to the institutional treatment protocol, 22 of 66 NOM paediatric patients underwent SAE. NOM was successful in 98% and a 90% splenic preservation rate was achieved. Contrast extravasation correlated to delayed splenic bleeding in children ≤ 14 years.

Clinical anatomy of the caudal pancreatic arteries and their relevance in the surgery of the splenic trauma

Splenectomy is the treatment of splenic trauma but is not exempt from intra-operative and post-operative complications. Conservative approach is preferred for paediatric population and for minor trauma. The aim of the present study was to evaluate the vascularisation of the tail of the pancreas, with particular reference to the presence of anastomosis between the pancreatic and splenic vessels, through an anatomoradiologic study performed on 9 unembalmed cadavers (age range 44-77 years). To obtain vascular corrosion casts, the splenic, the gastroduodenal and the superior mesenteric arteries were injected with acrylic and radioopaque resins and computed tomography (CT) of the specimens were acquired. The caudal pancreatic arteries (mean number ± standard deviation: 3.2 ± 2.4) were observable in all the casts, originating from the splenic artery at its distal third (70%) and from its inferior branch (30%). At CT scans analysis the mean calibre of caudal pancreatic arteries was 2.1 ± 1.1 mm. Anastomosis were found with great pancreatic artery in 20%, and with hilar splenic artery in 80%. The pattern of anastomosis between the pancreas tail and the spleen could allow the surgeon to close the splenic artery at the origin and also the short gastric and the left gastroepiploic arteries, in cases of splenic trauma, favouring the hemostasis and allowing splenic preservation at a same time.

Recanalization after successful occlusion by transcatheter arterial embolization with N-butyl cyanoacrylate for traumatic splenic artery injury

A 70-year-old male with advanced pancreatic cancer went into shock after sustaining a traumatic abdominal injury. Computed tomography (CT) showed a hematoma with extravasation around the pancreas and hemorrhagic ascites. After direct catheterization failed due to angiospasm, the ruptured splenic artery was successfully occluded by transcatheter arterial embolization (TAE) using an N-butyl cyanoacrylate (NBCA)-lipiodol mixture and the patient recovered from shock without complications. A follow-up CT obtained 20 days later showed a recurrent splenic artery pseudoaneurysm without extravasation. A repeat angiogram demonstrated recanalization of the splenic artery and pseudoaneurysm via antegrade. We embolized the recanalized pseudoaneurysm using metallic coils for isolation. Our experience indicates that adequate concentration and volume of the NBCA-lipiodol mixture should be considered depending on the vascular spasm in a patient with hypovolemic shock.

Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?

BACKGROUND

Although blunt injury to the spleen and liver can lead to pseudoaneurysm formation, current surgical guidelines do not recommend follow-up imaging. Controversy exists regarding the clinical implications of these traumatic pseudoaneurysms as well as their management.

METHODS

Retrospective review of children treated nonoperatively for isolated blunt liver and spleen trauma between 1991 and 2008 was undertaken. Patient demographics, grade of injury, and follow-up Doppler ultrasound results were obtained.

RESULTS

Three hundred sixty-two children were identified. One hundred eighty-six of them had splenic injuries, and 10 (5.4%) developed pseudoaneurysms. They were associated with grade III (3/39 [8%]) and grade IV (7/41 [17%]) injuries. In 7 patients, the pseudoaneurysm thrombosed spontaneously. Angiographic embolization was required in 2 children, and one underwent emergency splenectomy for delayed hemorrhage. Of the 176 patients who had liver injuries, 3 (1.7%) developed pseudoaneurysms. All 3 were associated with grade IV injuries (3/11 [27%]). One child underwent early embolization, while 2 developed delayed hemorrhage requiring emergent treatment.

CONCLUSIONS

Pseudoaneurysm development after blunt abdominal trauma is associated with high-grade splenic and liver injuries. Routine screening of this group of patients before discharge from hospital may be warranted because of the potential risk of life-threatening hemorrhage.

Proximal-releasing stent insertion under transnasal endoscopic guidance in patients with postoperative esophageal leakage

BACKGROUND

Covered metallic or plastic stent placement has become an important treatment for postoperative esophageal leakage; however, fluoroscopic guidance is also required. Here we present a novel stent insertion technique with a newly designed proximal-releasing, self-expanding metallic stent (PR-SEMS) and transnasal endoscope that can enable stent insertion without fluoroscopy as a new method to prevent stent migration.

OBJECTIVE

To describe our experience with 7 patients who underwent PR-SEMS insertion with the direct-vision technique and our use of the transnasal endoscope without fluoroscopy.

DESIGN

Prospective outcome study.

SETTING

A tertiary-care referral university hospital.

PATIENTS

This study involved all patients at our center who experienced postoperative esophageal leakage after esophagectomy, primary closure, or total gastrectomy.

INTERVENTION

PR-SEMS insertion with the direct vision technique and use of transnasal endoscopy without fluoroscopy.

MAIN OUTCOME MEASUREMENTS

Success rate of stent insertion, healing rate of postoperative esophageal leaks, and stent migration rate.

RESULTS

All stents were placed at the expected location without complications. One patient had massive hematemesis and underwent surgery. The bleeding focus was the splenic artery, which was damaged during gastrectomy. A significant marginal ulcer occurred in one patient, and the stent was immediately retrieved with an endoscope. After stent removal, 4 postoperative leakages were completely healed, and 2 lesions were not occluded. The 2 remaining minimal lesions became completely occluded with conservative management after stent removal. Stent migration did not occur.

LIMITATIONS

A small number of patients. Further prospective, randomized, controlled trials are needed.

CONCLUSION

PR-SEMS insertion under transnasal endoscopic guidance is a feasible, safe, and effective treatment for postoperative esophageal leakage, and it can be performed as a bedside procedure. Our anchoring method is effective for the prevention of migration from nonobstructed lesions.

What is the significance of contrast "blush" in pediatric blunt splenic trauma?

PURPOSE

Contrast extravasation (CE) associated with blunt splenic injuries (BSIs) in adults is commonly treated with embolization or splenectomy. Whether this is necessary in children is unclear. We sought to determine if CE on initial computed tomography (CT) is associated with negative outcomes in children with BSI.

METHODS

Blunt splenic injuries presented to our pediatric trauma center between January 21, 1999, and December 31, 2006, were reviewed (minimum follow-up = 2 years). Those with initial CTs available were reviewed by a pediatric radiologist blinded to outcomes. Descriptive analysis and multivariable logistic regression were performed using Stata S/E 10.0 (Stata Corporation, College Station, Tex).

RESULTS

One hundred eighty-two BSIs were treated at our center. One hundred twenty-three had available CTs (mean age, 10.7 years; male, 70.7%; mean Injury Severity Score, 17; median injury grade, 3; transfusion rate, 13.8%; overall mortality, 2.44%). Those with associated injuries comprised 47.1%. No splenectomies or splenorrhaphies were performed. One delayed splenic bleed occurred. Eight patients (6.5%) had CE on initial CT. Multivariable logistic regression controlling for multiple injuries found no association between CE and the need for transfusion, mortality, delayed splenic bleeding, length of hospitalization, or splenectomy. Contrast extravasation was positively associated with low initial and lowest hemoglobin levels (<90 g/L) (odds ratio [OR], 6.45; 95% confidence interval [CI], 1.00-39.47; P = .044 and OR, 5.63; 95% CI, 1.20-26.49; P = .029), respectively.

CONCLUSION

Contrast extravasation occurred in 6.5% of our pediatric patients with BSIs. The presence of contrast "blush" on abdominal CT was not associated with negative outcomes after a minimum of 2 years of follow-up. Pediatric patients with CE can be treated without surgery and can be managed using the standard American Pediatric Surgical Association guidelines.

Management of pediatric blunt splenic injuries in Canada--practices and opinions

PURPOSE

The aim of the study was to compare the self-reported practice patterns of Canadian general surgeons (GSs) and pediatric general surgeons (PGSs) in treating blunt splenic injuries (BSIs) in children.

METHODS

Forty-five PGSs and 690 GSs were surveyed (internet and hard copy). chi(2) was used to compare groups; logistic regression was performed to determine independent factors influencing management variables.

RESULTS

Thirty-three PGSs and 191 GSs completed the survey, for a response rate of 30%. Pediatric general surgeons are more likely than GSs to follow American Pediatric Surgical Association guidelines (52% vs 11%; P < .0001). In diagnosing BSIs, PGSs and GSs are equally likely to use computed tomography (CT) over ultrasound for initial imaging. Pediatric general surgeons are less likely to consider CT injury grade in deciding on nonoperative management (NOM) (odds ratio [OR], 0.2; confidence interval [CI], 0.07-0.5; P = .002) and are more likely to continue NOM for patients with contrast blush on CT (OR, 6.5; CI, 2.5-17; P = .0002). Pediatric general surgeons report more selective intensive care unit use, hospital stay, follow-up imaging, and activity restrictions. No differences were found in the management of splenic artery pseudoaneurysms.

CONCLUSION

Differences exist between PGSs and GSs in the management of pediatric BSIs, resulting in higher operative rates, use of resources, and radiation exposure. Further education of GSs in NOM and establishment of management guidelines are indicated.

Imaging and transcatheter arterial embolization for traumatic splenic injuries: review of the literature

The spleen is the most commonly injured visceral organ in blunt abdominal trauma in both adults and children. Nonoperative management is the current standard of practice for patients who are hemodynamically stable. However, simple observation alone has been reported to have a failure rate as high as 34%; the rate is even higher among patients with high-grade splenic injuries (American Association for the Surgery of Trauma [AAST] grade III-V). Over the past decade, angiography with transcatheter splenic artery embolization, an alternative nonoperative treatment for splenic injuries, has increased splenic salvage rates to as high as 97%. With the help of splenic artery embolization, success rates of more than 80% have also been described for high-grade splenic injuries. We discuss the role of computed tomography and transcatheter splenic artery embolization in the diagnosis and treatment of blunt splenic trauma. We review technical considerations, indications, efficacy and complication rates. We also propose an algorithm to guide the use of angiography and splenic embolization in patients with traumatic splenic injury.

[Successful treatment of splenic haemorrhages with preservation of the spleen by means of selective catheterisation and embolisation of the splenic artery]

Two patients with splenic bleeding were treated with transcatheter embolisation and selective coiling of the splenic artery. These were first of all a 78-year-old woman who was on anticoagulants for atrial fibrillation and suffered a laceration of the spleen with extravasation of contrast medium and a falling haemoglobin level. The second patient was a 23-year-old woman who suffered laceration of the spleen as the result of a traffic accident. Embolisation made it possible to avoid surgical treatment and preserve the spleen in both patients. Selective embolisation of the splenic artery is a useful adjunct to the non-operative management of patients with traumatic splenic injury. However, the proper patient selection still needs to be established.

Fatal rupture of an undiagnosed aneurysm of the splenic artery--medico-legal implications

Aneurysms of the visceral arteries are a rather common feature appearing in 0.1-2% of the population. The clinical relevance of those anomalies varies a lot. The wide range of descriptions reaches from asymptomatic cases to fatalities in particular due to haemorrhages. The latter will be discussed in a case report concerning a 60-year-old man who collapsed at his work place and died 4 h after admission to the intensive care unit of a hospital nearby. The ruptured aneurysm remained undiagnosed in hospital and was found by autopsy. The case is presented and discussed in view of medico-legal questions.

Novel computed tomography scan scoring system predicts the need for intervention after splenic injury

BACKGROUND

The purpose of this study was to develop a computed tomography (CT) scan screening test to predict the need for intervention in patients with splenic injury.

METHODS

CT scans of 20 patients with blunt injury to the spleen were reviewed to identify findings that correlated with the need for intervention (surgery or embolization). A screening test was created and then validated in CT scans from 56 consecutive patients.

RESULTS

Three findings correlated with the need for intervention: 1) devascularization or laceration involving 50% or more of the splenic parenchyma, 2) contrast blush greater than one centimeter in diameter (from active extravasation of intravenous contrast material or pseudoaneurysm formation), and 3) a large hemoperitoneum. The sensitivity of the screening test was 100%, specificity was 88%, and overall accuracy was 93%.

CONCLUSIONS

These CT scan grading criteria appears to reliably predict the need for invasive management in patients with blunt injury to the spleen.

The development and clinical features of splenic aneurysm associated with liver cirrhosis

OBJECTIVES

Splenic artery aneurysm (SAA) is usually asymptomatic, but can be fatal if it ruptures. Portal hypertensive patients with varix or splenomegaly are sometimes complicated by SAA. However, there have been no large-scale clinical studies regarding whether liver cirrhosis itself is associated with splenic aneurysm regardless of varix or splenomegaly.

METHODS

In the present study, we retrospectively analyzed 303 cirrhotic patients examined with arteriography. The diagnosis and characteristics of SAAs were determined, and the relation with splenic artery diameter was evaluated.

RESULTS

Nine patients (2.97%) had 12 complicated SAAs. The aneurysms, which measured 4-22 mm in diameter, were all saccular, and occurred commonly in the splenic hilum (50.0%). A correlation was noted between splenic artery diameter and aneurysm diameter (R(2)=0.706). Aneurysm growth was strongly associated with an increase in diameter of the splenic artery trunk (R(2)=0.705), which is closely related to arterial flow.

CONCLUSIONS

SAA is considered a complication of cirrhosis. The increase in splenic artery diameter may result in SAA enlargement and rupture. Elective procedures should be considered based on the follow-up of main trunk or diameter of the splenic artery in addition to SAA size, a known risk factor of aneurysmal rupture.

Nonoperative management of pediatric splenic injury with angiographic embolization

A 12-year-old girl was admitted after a bicycle accident, and a grade 4 splenic injury was diagnosed. She became hemodynamically unstable within the first hours after arrival and remained so despite fluid resuscitation and transfusions. As an alternative to laparotomy, splenic artery embolization was performed. The patient had an uneventful recovery without the need for further transfusions. Nonoperative management of blunt splenic trauma remains the gold standard in pediatric trauma care. In hemodynamically unstable patients, splenic artery embolization should be considered as an adjunct to that strategy.

MRI for the diagnosis of blunt abdominal trauma: a case report

Blunt abdominal trauma is a leading cause of trauma related mortality. Currently, the gold standard in the radiographic evaluation of intra-abdominal injury is computed tomography (CT) with iodinated contrast material. However, in the setting of renal failure or a previous anaphylactic reaction to contrast material, radiographic evaluation of the trauma patient may prove difficult. Without contrast material, the sensitivity of CT in the diagnosis of solid organ injury is diminished. We present a case report and literature review of magnetic resonance imaging in the evaluation of blunt abdominal trauma.

Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

Super-selective transcatheter arterial embolization of a traumatic splenic arteriovenous fistula

We report a 61-year-old woman with arteriovenous fistula (AVF) of a splenic artery caused by traumatic injury, which was successfully occluded by percutaneous transcatheter arterial embolization (TAE). We embolized the AVF with a coaxial system using six microcoils. This case suggests that super-selective TAE for traumatic AVF of a splenic artery is an effective and primary choice of first treatment. The use of a microcatheter and microcoils is an alternative to surgery.

Splenic Artery Embolization for Post-Traumatic Splenic Artery Pseudoaneurysm in Children

Although rare, traumatic splenic artery pseudoaneurysm (SAP) can be life threatening. The diagnostic approaches as well as the methods of treatment of SAP are yet to be determined. We present the case of a 10-year-old boy treated conservatively for a grade III blunt splenic injury (BSI). The child was discharged to home after a 5-day uneventful hospitalization but was found on routine follow-up CT scan to have a large SAP. The pseudoaneurysm was successfully angiographically embolized and subsequent abdominal CT demonstrated successful resolution of the pseudoaneurysm with a small residual splenic cyst. We reviewed the eight cases of post-traumatic SAP in children that have been published in the English literature. Unlike SAP in adult patients, the severity of the splenic injury does not have predictive value for development of SAP in children. Abdominal pain was the most frequent symptom of SAP, but three children were asymptomatic at the time of diagnosis. Therefore, the possibility of SAP should be investigated even in the asymptomatic child with mild splenic injury. When a splenic pseudoaneurysm is diagnosed, we believe splenic artery embolization is indicated.

Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature

INTRODUCTION

Splenic artery pseudoaneurysm is uncommon. We report our institution's recent 18-year experience with these aneurysms and review the literature.

METHODS

We reviewed the records for 37 patients with visceral artery pseudoaneurysm evaluated at our institution from 1980 to 1998. From this group we found only 10 patients (27%) with splenic artery pseudoaneurysm. We also reviewed 147 cases of splenic artery pseudoaneurysm reported in the English literature.

RESULTS

In this series of 10 patients, 5 were men. Mean age was 51.2 years (range, 35-78 years). Causes of aneurysm included chronic pancreatitis in 4 patients, trauma in 2 patients, iatrogenic cause in 1 patient, and unknown cause in 3. The most common symptom was bleeding in 7 patients and abdominal or flank pain in 5 patients; 2 patients had no symptoms. Aneurysm diameter was known for four pseudoaneurysms, and ranged from 0.3 to 3 cm (mean, 1.7 cm). Splenectomy and distal pancreatectomy were performed in 4 patients, splenectomy alone in 2 patients, endovascular transcatheter embolization in 2 patients, and simple ligation in 1 patient. One patient with a ruptured pseudoaneurysm died before any intervention could be performed; there were no postoperative deaths. Follow-up data were available for 7 patients, with a mean of 46.3 months (range, 4.5-120 months).

CONCLUSIONS

Splenic artery pseudoaneurysm is rare and usually is a complication of pancreatitis or trauma. Average aneurysm diameter in our series of 10 patients was smaller than previously reported (1.7 cm vs 5.0 cm). Although conservative management has produced excellent results in some reports, from our experience and the literature, we recommend repair of all splenic artery pseudoaneurysms.

[Embolization of the splenic artery after splenic gunshot wound]

Computed tomography (CT) of the abdomen is a reliable method for evaluation of spleen injuries and has the potential to exclude further abdominal injuries. Blunt and penetrating injuries of the spleen have to be managed immediately due to a high mortality rate. Two therapeutical options, conservative or operative, are currently available. In general, a hemodynamic stable patient, no further injuries of the abdominal organs or the skull as well as no history of abdominal surgery of the abdomen are prerequisites for a non-surgical therapy. Catheter-based angiography gives the possibility to diagnose and to treat injuries of blood vessels of the spleen, which were seen on the CT scans. Gunshots are relatively rare in Europe, but the mortality of such traumas is high. The present case demonstrates a patient with a penetrating gunshot trauma of the left hemiabdomen with a bleeding injury of the spleen. Due to the stable hemodynamic conditions, absence of further injuries of the abdomen or the skull and, because of previous pancreas surgery a non-surgical therapy was chosen, consisting of proximal embolisation of the splenic artery.

Splenic infarction following laparoscopic Nissen fundoplication: management strategies

Techniques for mobilizing the greater curve of the stomach during laparoscopic Nissen fundoplication (LNF) include division of the short gastric vessels (SGV). The splenic artery and vein lie directly posterior to the proper plane of dissection. Uncontrolled bleeding during SGV division places the splenic vessels at risk for inadvertent injury or ligation. We report herein on 2 patients referred to our institution who had left upper quadrant pain and radiographic evidence of segmental splenic infarction (SI) that resulted from a peripheral splenic artery branch injury during LNF. Management strategies included a trial of conservative management and splenectomy for persistent symptoms or complications resulting from SI. Intense inflammation and adhesion formation making laparoscopic splenectomy difficult should be anticipated when operating on the infarcted spleen.

Anatomical rationale for spleen salvage by lobe/segment dearterialization in inferior pole spleen injury during left hemicolectomy: a post-mortem study

The aim of this study was to determine the rationale for spleen salvage by lobe/segment dearterialization without resection for inferior pole injury during left hemicolectomy. One hundred and two consecutive human cadavers were dissected. Corrosion case and post-mortem arteriography with computerized planimetry were employed. Lobe/segment size, artery diameter and length and anastomoses between arteries were measured. The mean inferior terminal splenic artery had a significantly smaller diameter than the superior (2.8 vs. 3.4 mm, p<0.01). An inferior polar artery was found in 22.5% of the specimens (mean diameter, 1.9 mm; mean length, 33 mm). The inferior lobe and inferior polar segment comprised 41.3% and 12.6% of the spleen, respectively. Anastomoses were detected in 34 of 102 spleens (3% extraparenchymal, 88% intraparenchymal, 9% combined). The mean diameter and length of intrasplenic anastomoses were 0.3 mm and 20 mm, respectively. In conclusion, there was a positive correlation between diameters of lobar/segmental arteries and vascular zones ( p<0.05). The rationale for splenic lobe/segment dearterialization without resection is found in the presence of intrasplenic anastomoses.

Massive upper gastrointestinal haemorrhage due to intragastric rupture of a splenic artery aneurysm

Most cases of splenic artery aneurysm are asymptomatic, being found incidentally at the time of investigations (e.g. ultrasound, computed tomography, angiography) or laparotomy for other conditions. Rupture of a splenic artery aneurysm with erosion into the stomach is a rare cause of massive upper gastrointestinal haemorrhage. This case report is, to our knowledge, only the second case of splenic artery aneurysm presenting with massive upper gastrointestinal haemorrhage due to erosion into the stomach in a nulliparous woman.

Massive intraperitoneal hemorrhage from traumatic intrasplenic pseudoaneurysms: treatment using superselective embolotherapy

The importance of splenic preservation in the setting of penetrating and blunt trauma has led to the development of more sophisticated and noninvasive methods for controlling splenic hemorrhage. Although controversy exists, transcatheter embolotherapy has challenged the use of splenectomy in patients suffering from persistent bleeding after splenic trauma. We describe a case of a 41-year-old man with hepatitis C, ethanol-induced liver disease, and portal hypertension who presented with splenic rupture secondary to blunt trauma. Continued intra-abdominal hemorrhage was successfully controlled by superselective embolotherapy using microcoils and gelatin sponge pledgets.

Arterial erosions in acute pancreatitis

Acute pancreatitis was observed in 492 patients. Fourteen (2.8%) developed an arterial erosion revealed by a haemorrhage either in the digestive lumen, in the peritoneum or via previously placed drainage. The eroded artery was the splenic artery in six patients, a pancreatico-duodenal artery in five patients. An initial haemostasis was attempted by: a) embolization in four patients: one died; the three others had bleeding recurrence. b) splenocorporeal pancreatectomy in four patients, three had bleeding recurrence. c) arterial ligature in four patients: three had bleeding recurrence. Secondary haemostatic procedures were performed in ten patients but a durable haemostasis was achieved in only five patients: two had a pancreatic resection and three were treated by a redo-binding. It is noteworthy that durable haemostasis could not be obtained neither by embolization nor by ligature in necrotic tissues. This could explain the difference in the results of arterial erosion treatments in chronic and in acute pancreatitis. Therefore, it is suggested that haemostatic procedures should be performed away from necrotic tissues, or eventually done after their removal.

Remote vascular catastrophes after neurovascular interventional therapy for type 4 Ehlers-Danlos Syndrome

Type 4 Ehlers-Danlos Syndrome (EDS 4) is the most malignant form of Ehlers-Danlos Syndrome, often accompanied by neurovasacular complications secondary to vessel dissection or aneurysms. The fragile nature of connective tissue in these patients makes exovascular and endovascular treatment hazardous. We have treated four patients with EDS 4 over the last 8 years by using neuroendovascular procedures. Two of these individuals suffered remote vascular injuries around the time of their procedures and ultimately died. The circumstances surrounding their deaths will make up the body of this report.

Pulmonary microthromboembolism by injection of sonicated autologous blood in rabbits with splenic artery ligations

Chronic pulmonary thromboembolism (PTE) has been reported to play an important role in cardiac failure in thalassemic patients after splenectomy. However, the mechanism of PTE in these patients remains unclear. In this study, we attempted to establish an animal model of PTE seen in thalassemic patients after splenectomy. We divided New Zealand white rabbits into three groups: Group 1 was injected sonicated blood, II was injected non-sonicated blood after ligation of the splenic artery, and III was injected sonicated blood after ligation of the splenic artery. After injection of the sonicated blood, we counted the platelet number until 1 hour and the rabbits were sacrificed for histological examination. Platelets significantly decreased in number immediately after injection of the sonicated blood in Groups I and III. Many pulmonary thromboemboli composed mainly of platelets were found in Group III but not in other groups. These pathological changes seem to be partly similar to those of thalassemic patients after splenectomy. This animal model is thought to be useful to study the pathogenesis of pulmonary thromboembolism, especially in thalassemic patients after splenectomy.

[Post-traumatic arteriovenous fistula between splenic artery and vein as a rare cause of acute myocardial ischemia]

Arteriovenous fistulas of the portal system are rare. Congenital fistulas have to be differentiated from acquired fistulas; the latter are of posttraumatic or iatrogenic origin. The case presented demonstrates a history of diffuse abdominal pain and the first description of myocardial ischemia caused by a posttraumatic splenic arterioportal fistula. After diagnostic and therapeutic difficulties, the definitive treatment consisted in resection of the fistula system including the pancreatic tail.

[Isolated trauma of the pancreas and splenic artery]

Isolated ruptures of the pancreas and splenic artery resulted from a strike to the abdomen with a blunt instrument. The patient (aged 36 years) died in 24 h from slow bleeding from the ruptured splenic artery into the omental sac cavity closed with adhesions.

Aneurysmatic arteriovenous fistula complicating splenic injury

A child with a posttraumatic aneurysmatic arteriovenous (AV) fistula located in the spleen is presented. The fact that the increased use of more conservative diagnostic and therapeutic approaches in splenic injuries might lead to underestimation of some uncommon complications is discussed.

Splanchnic artery pseudo-aneurysms secondary to blunt abdominal trauma in children

Traumatic splanchnic artery pseudo-aneurysms are uncommon; only two cases have been reported among the pediatric population. The authors describe their experience with four patients in whom splanchnic artery pseudoaneurysms developed after blunt abdominal trauma. Splenic artery pseudo-aneurysms were found in a 6-year-old boy and an 8-year-old girl after blunt splenic injuries. In both cases, spontaneous thrombosis of the pseudo-aneurysms occurred after a period of observation. Hepatic artery pseudoaneurysms were found in a 7-year-old boy and a 10-year-old girl after major liver lacerations. The boy had successful angiographic embolization of the lesion, but the girl required direct ligation of the pseudo-aneurysm after nearly exsanguinating from acute hemorrhage. All four children have recovered completely, with no long-term sequelae. Traumatic splanchnic artery pseudo-aneurysms are potentially life-threatening complications that can occur after blunt abdominal trauma. The investigation and management of these lesions must be individualized according to the clinical scenario.