ADVANCING SCIENCE, ENHANCING LIFE

Role of Arterial Embolization in Non-Operative Management of

Splenic Injuries

Jamaica Hospital Trauma ConferenceJuly 21st, 2014

Greg Eckenrode

Management of Traumatic Spleen Injuries

• Historically, nearly all splenic injuries were managed operatively

• Non-operative management developed in the pediatic population in the late 1960s

• Increasing prevalence in adult population since the 1980s – Currently 50-70% of splenic injuries

Stein DM, Scalea TM J Intensive Care Med. 2006;21(5):296.

Operative Management

• Hemodynamically unstable patients with evidence of abdominal bleeding– Positive FAST or DPA/DPL

• Patients requiring abdominal exploration for other injuries– Intraperitoneal free air– Signs of peritonitis

Operative Management

• Hemodynamically stable patients– CT findings of contrast extravasation or vascular

blush– High grade injuries (generally IV-V)– Age > 55– Unable to safely observe patient

Conventional Non-Operative Management

• Admit to monitored care setting

• Bed rest, NPO

• Serial Hgb/Hct every 6 hours for 24 hours

• Frequent vital signs, serial abdominal exams

Splenic Angiography and Embolization

• First applied to traumatic splenic injuries in 1995

• Multiple techniques– Distal selective– Proximal– Both

• Intended to improve success of non-operative management

Clinical Questions

• Does splenic artery angiography and embolization improve non-operative management outcomes?

• Which patients should undergo angiography and embolization?

Western Trauma Association

• 4 L1 trauma centers in the United States• 155 patients who underwent angiography and

embolization for pseudoaneurysm, active bleeding on CT, significant hemopertoneum, and high grade injuries

• Compared against the results of the Eastern Trauma Association study, which used conventional observation

Comparison Results

Haan, et al; J Trauma. 2004 Mar;56(3):542-7.

Ullevaal University Hospital: 2006

• In 2002, implemented policy that all patients with splenic injury Grades III-V or ongoing bleeding underwent arterial embolization

• Compared to all splenic injuries from 2000-2002, when arterial embolization was no performed at the hospital

Gaardner, C, et al; J Trauma. 2006 Jul;61(1):192-8

Study Outcomes

Complications

Multicenter Variation: 2010

• Compared 4 L1 trauma centers with variation in rates of splenic artery embolization in non-operative management

• Rates ranged from 19% to 1%• Compared rates of splenic salvage and non-

operative failure

Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

Population Comparison

Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

Management Comparison

Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

Splenic Salvage Rate

Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

Wake Forest - 2014

• Single site L1 Trauma Center• Prior to 2010, angiography and embolization

performed for CT contrast blush• Starting in 2010, prospectively performed

angiography and embolization on all Grade III-IV splenic injuries

• Compared non-operative failure rates against recent historical controls from 2007-2009 period

Miller, et al; J Am Coll Surg. 2014 Apr;218(4):644-8

Study Group Comparison

Miller, et al; J Am Coll Surg. 2014 Apr;218(4):644-8

Study Results

• 2010-2012: Non-operative failure rate of 5%– Failure rate of 25% in 16 protocol deviations

(p=0.02)

• 2007-2009: Non-operative failure rate of 15% (p=0.04)

Conclusions

• In historical comparisons, patients with splenic injuries who are candidates for non-operative management have better outcomes when SAE is utilized

• Centers which perform a higher rate of SAE have higher rates of spelic salvage and lower rates of non-operative management failure

Conclusions

• Centers which implement a standard protocol mandating SAE for non-operative splenic injuries experience decreased rates of of non-operative failure and increased rates of splenic salvage

Future Directions

• No prospective, head-to-head randomized clinical trial of SAE in non-operative splenic injuries

• Limited data with respect to cost effectiveness

Splenic Injury Grading

• Grade I:– Hematoma: Subcapsular, < 10% of surface area– Laceration: Capsular tear < 1 cm depth

• Grade II– Hematoma: Subcapsular, 10 - 50 % of surface area– Laceration: Capsular tear 1 - 3 cm depth not

involving trebecular vessel

Splenic Injury Grading

• Grade III– Hematoma• Subcapsular, > 50% of surface area• Subcapsular, expanding• Ruptured subcapsular or parenchymal• Intraparenchymal > 5cm

– Laceration• > 3cm depth• Involving trabecular vessel

Splenic Injury Grading

• Grade IV– Laceration: segmental or hilar vessels with > 25%

devascularization

• Grade V– Hematoma: shattered spleen– Laceration: total devascularization