Complications arising from splenic embolization after blunt splenic trauma

doi:10.1016/j.amjsurg.2004.11.033

The American Journal of Surgery

Volume 189, Issue 3, March 2005, Pages 335-339

Presented at the 47th Annual Meeting of the Midwest Surgical Association, Mackinac Island, Michigan, August 15–18, 2004

https://doi.org/10.1016/j.amjsurg.2004.11.033 Get rights and content

Abstract

Background

Nonoperative management (NOM) of splenic trauma is now the standard in stable trauma patients. Splenic artery embolization (SAE) is an increasingly used adjunct to NOM. We examined complications arising from SAE.

Methods

Patients admitted to a level I trauma center with splenic trauma over a 26-month period were identified. Management method, operative or nonoperative, was noted. SAE patients were analyzed in detail.

Results

There were 284 splenic trauma admissions. Ninety-three patients underwent operative management, and 191 received NOM. Fifteen patients (7.8%) underwent SAE. Embolization was proximal in 10, distal in 1, and combined in 4 patients. No NOM failures occurred. Major complications (27%) included splenic bleeding, splenic infarction, splenic abscess, and contrast-induced renal insufficiency. Minor complications of fever, pleural effusions, and coil migration occurred in 53% of patients. No relationship between SAE location and the presence of complications was noted.

Conclusions

SAE is an effective and safe procedure. Both major and minor complications can arise after SAE.

Section snippets

Methods

Trauma registry (TraumaBase, Clinical Data Management, Evergreen, Colorado) and medical record information of patients with splenic injuries admitted to Miami Valley Hospital (MVH), an ACS-verified adult and pediatric trauma center, between January 2000 and February 2004 were reviewed. Patients were grouped by management method of their splenic injury: operative or nonoperative. Individuals who underwent SAE were selected for detailed analysis. Age, sex, length of stay, associated injuries,

Results

During the 26-month period of review (January 2000 to February 2004), 284 patients were admitted to MVH with blunt splenic trauma. Ninety-three patients underwent operative management (82 splenectomies, 8 splenorrhaphies, and 3 resuscitative thoracotomies), and 191 underwent NOM.

Fifteen patients in the NOM group underwent SAE (7.8%). In this embolization group, there were 11 men and 4 women with ages ranging from 17 to 84 years (average 36.2). Injury was caused by motor vehicle crashes in 12

Comments

The earliest reports of splenic embolization in the literature were in the settings of hematologic disorders [10]. Typical indications cited in the literature include splenic artery aneurysms [11], portal hypertension with hypersplenism [12], and just before laparoscopic splenectomy [13]. Complications noted after SAE in nontrauma patients include splenic abscess, rupture of the spleen, pancreatitis, pneumonia, and septicemia [14], [15]. These patients undergoing SAE in nontraumatic settings

References (25)

J. Papadimitriou et al.
Treatment of hypersplenism by embolus placement in the splenic artery
Lancet
(1976)
T.A. Salam et al.
Nonoperative management of visceral aneurysms and pseudoaneurysms
Am J Surg
(1992)
M.R. Rudnick et al.
Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial. The Iohexol Cooperative Study
Kidney Int
(1995)
K.L. Killeen et al.
CT findings after embolization for blunt splenic trauma
J Vasc Interv Radiol
(2001)
A.B. Peitzman et al.
Blunt splenic injury in adultsmulti-institutional study of the Eastern Association for the Surgery of Trauma
J Trauma
(2000)
J. Nix et al.
Outcome of the current management of splenic injuries
J Trauma
(2001)
F. Maddison
Embolic therapy of hypersplenism
Invest Radiol
(1973)
S.J. Sclafani
The role of angiographic hemostasis in salvage of the injured spleen
Radiology
(1981)
S.J. Sclafani et al.
Nonoperative salvage of computed tomography-diagnosed splenic injuriesutilization of angiography for triage and embolization for hemostasis
J Trauma
(1995)
J. Haan et al.
Admission angiography for blunt splenic injuryadvantages and pitfalls
J Trauma
(2001)

A. Hagiwara et al.

Nonsurgical management of patients with blunt splenic injuryefficacy of transcatheter arterial embolization

AJR Am J Roentgenol

(1996)

D.G. Spigos et al.

Partial splenic embolization in the treatment of hypersplenism

AJR Am J Roentgenol

(1979)

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The spleen is the most commonly injured organ in abdominal trauma. Guidelines suggest non-operative management (NOM) is preferred over splenectomy for all haemodynamically stable patients, regardless of injury severity. The availability of splenic angioembolization has been shown to improve outcomes for high-grade splenic injuries by decreasing failure rates of NOM. Trauma incidence and fatality rates are higher in regional and remote areas, and rurality is associated with increased mortality from trauma. Additionally, rural hospitals have difficulty with staff retention and may offer less specialist services compared with urban centres.
A single-centre retrospective cohort study was conducted at the Royal Darwin Hospital, using the National Critical Care and Trauma Response Centre database. All patients with splenic injury admitted between January 2018 and December 2021 were selected, and divided into control and intervention cohorts, before and after January 1, 2020, correlating with interventional radiology availability. Demographic information included age, gender, mechanism of injury, AIS grade of splenic injury, injury severity score, and shock index. The primary outcome was management of splenic injury and failure rate of NOM. Secondary outcomes included mortality, ICU length of stay and hospital length of stay.
Sixty-six patients met inclusion criteria, 32 controls and 34 interventions. Intervention and control groups were statistically similar for baseline demographics, and outcome measures of mortality and ICU length of stay. There was significant difference in the management of splenic injury, either OM or NOM, between intervention and control cohorts among high-grade splenic injury patients (AIS grade 4 and 5). In logistic regression analysis, the absence of interventional radiology was associated with increased OM (OR 12.8, SE 15.7, p = 0.04, 95%CI 1.15–142).
The absence of an interventional radiology service was associated with an increased risk of operative management, suggesting interventional radiology helps to prevent splenectomy, improving long term outcomes for splenic trauma patients in regional settings. The effects of availability of IR seen in international publications on decreased mortality and shorter length of stay were not replicated in this study.
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Citation Excerpt :
To our knowledge, failure of angioembolization requiring subsequent splenectomy for devastating hemorrhage has not been reported in the literature. Studies have reported splenectomy for post-embolization complications such as persistent intra-parenchymal PSA and abscess formation with overall reported 90–100 % success rates of IR management [16–18]. Reported major complications of splenic angioembolization include bleeding, infarction, or abscess formation in the spleen as well as contrast-induced nephropathy, and minor complications have included fever, pleural effusions, and coil migration [17].
A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously.
A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well.
High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team.
The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury.
Complications Following Splenic Embolization for Trauma: Have Things Changed Over Time?
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With the increasing use of splenic artery embolization, recognition of its complication rate is imperative. Previous studies at Miami Valley Hospital in Dayton, Ohio have examined complication rates with the most recent examining complications from 2000 to 2010.16,17 The goal of the current study was to examine the rates of major and minor complications in patients who underwent splenic artery embolization from January 2011 through November 2018 and to compare this data to the prior period studied.
Splenic artery embolization (SAE) is a routinely used adjunct in the nonoperative management (NOM) of blunt splenic injury (BSI). The purpose of this study was to evaluate the rate and type of adverse events that occur in patients undergoing SAE and to compare this with the previous data.
Patients who had SAE for BSI between 2011 and 2018 were identified. Splenic abscess, splenic infarction, and contrast-induced renal insufficiency were considered major complications. Coil migration, fever, and pleural effusions were regarded minor complications. The results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010.
There were 716 patients admitted with BSI. SAE was performed in 74 (13.3%) of the 557 (78%) NOM patients. The overall complication rate was 33.8%. Major complications occurred in 11 patients (14.9%) and minor in 13 patients (18.9%). There was no association between complications and coil location by logistic regression.
SAE continues to be a useful adjunct in the NOM of BSI though complications continue to occur. Fewer minor complications were noted in the period studied compared to past similar studies.
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The spleen is one of the most commonly injured organs in the setting of blunt trauma. Endovascular management of bleeding in splenic trauma is not a new concept and was first described in 1981. Since the original descriptions of angiography and embolisation, there has been a significant paradigm shift in the management of splenic trauma towards more emphasis on splenic preservation and salvage to preserve the immunologic and haematologic functions of the spleen. Nonoperative management and endovascular intervention has largely superseded splenectomy as the gold standard for management. Open operative management is typically now reserved for patients who are significantly haemodynamically compromised, or when nonoperative management or embolisation fails. The increased uptake in angiography and embolisation, particularly in high grade injuries, has led to significant variation in the management of splenic injuries between clinicians. This paper aims to provide a contemporary overview of the endovascular management of traumatic splenic injuries.
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Regardless of the various advances in the field of medicine in terms of newer drugs, latest endoscopic techniques, promising critical care management, as well as novel surgical interventions, gastrointestinal bleeding continues to remain a potential life-threatening event requiring prompt diagnosis and treatment. Angioembolization can achieve hemostasis and salvage organs, thus reducing morbidity. Evolution, cultivation, and expansion of different embolization techniques have widened the spectrum of indications offering nonoperative, minimally invasive management in these patients.
Several embolization agents like gelfoam pledgets, liquid embolics, coils, vascular plugs, or a combination of these can be chosen to tackle the root cause of mesenteric hemorrhage, traumatic solid organ injury, and pelvic bleeding. In this chapter, we discuss the imperative inventory used for delivery of different embolization materials and the innovative techniques for their optimal use. Most importantly, we highlight how to handle the intraprocedural challenges as well as the undesired consequences.

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Scientific papersComplications arising from splenic embolization after blunt splenic trauma

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Lancet

Am J Surg

Kidney Int

J Vasc Interv Radiol

Blunt splenic injury in adultsmulti-institutional study of the Eastern Association for the Surgery of Trauma

J Trauma

Outcome of the current management of splenic injuries

J Trauma

Embolic therapy of hypersplenism

Invest Radiol

The role of angiographic hemostasis in salvage of the injured spleen

Radiology

Nonoperative salvage of computed tomography-diagnosed splenic injuriesutilization of angiography for triage and embolization for hemostasis

J Trauma

Admission angiography for blunt splenic injuryadvantages and pitfalls

J Trauma

Nonsurgical management of patients with blunt splenic injuryefficacy of transcatheter arterial embolization

AJR Am J Roentgenol

Partial splenic embolization in the treatment of hypersplenism

AJR Am J Roentgenol

Scientific papers
Complications arising from splenic embolization after blunt splenic trauma