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@MountSinaiIR Splenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD Division of Interventional Radiology Icahn School of Medicine at Mount Sinai New York, NY

Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

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Page 1: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Splenic Trauma

Indications Is Any Spleen Too Far Gone

Aaron M Fischman MD

Division of Interventional Radiology

Icahn School of Medicine at Mount Sinai

New York NY

Aaron Fischman MD

bull ConsultantAdvisory Board Terumo Interventional Systems Embolx Inc Neuwave

Medical

bull Research Grants Merit Medical

MountSinaiIR

Background

39000 adults with blunt splenic injury year in US

Most commonly injured organ in blunt abdominal

trauma

Only 10 go to urgent splenectomy

Splenic embo first described by Scalfani in 1981

MountSinaiIR

Who cares about the spleen

Infection risk is real -

Around 1 lifetime risk

Hospital costs and morbidity

associated with splenectomy

Pancreatic issues

MountSinaiIR

AAST Splenic Injury Grading System

Grade 3-5 without bleeding ndash

Proximal embo decreases risk

of splenectomy by 16-18

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 71 Number 4 October 2011

MountSinaiIR

Nonoperative Management (NOM)

Observation vs Embolization

Hemodynamics is KEY

Unstable ndash Surgery

Stable ndash CT

(predicting intervention

- 100 88 sensspec)

MountSinaiIR

Blunt Splenic Trauma - Indicators for Intervention

Active contrast extravasation

Pseudoaneurysm AV fistula

Splenic vascular injury

AAST III grade or higher

Significant blood in peritoneal

cavity

Polytrauma

Agegt50

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 2: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

Aaron Fischman MD

bull ConsultantAdvisory Board Terumo Interventional Systems Embolx Inc Neuwave

Medical

bull Research Grants Merit Medical

MountSinaiIR

Background

39000 adults with blunt splenic injury year in US

Most commonly injured organ in blunt abdominal

trauma

Only 10 go to urgent splenectomy

Splenic embo first described by Scalfani in 1981

MountSinaiIR

Who cares about the spleen

Infection risk is real -

Around 1 lifetime risk

Hospital costs and morbidity

associated with splenectomy

Pancreatic issues

MountSinaiIR

AAST Splenic Injury Grading System

Grade 3-5 without bleeding ndash

Proximal embo decreases risk

of splenectomy by 16-18

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 71 Number 4 October 2011

MountSinaiIR

Nonoperative Management (NOM)

Observation vs Embolization

Hemodynamics is KEY

Unstable ndash Surgery

Stable ndash CT

(predicting intervention

- 100 88 sensspec)

MountSinaiIR

Blunt Splenic Trauma - Indicators for Intervention

Active contrast extravasation

Pseudoaneurysm AV fistula

Splenic vascular injury

AAST III grade or higher

Significant blood in peritoneal

cavity

Polytrauma

Agegt50

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 3: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Background

39000 adults with blunt splenic injury year in US

Most commonly injured organ in blunt abdominal

trauma

Only 10 go to urgent splenectomy

Splenic embo first described by Scalfani in 1981

MountSinaiIR

Who cares about the spleen

Infection risk is real -

Around 1 lifetime risk

Hospital costs and morbidity

associated with splenectomy

Pancreatic issues

MountSinaiIR

AAST Splenic Injury Grading System

Grade 3-5 without bleeding ndash

Proximal embo decreases risk

of splenectomy by 16-18

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 71 Number 4 October 2011

MountSinaiIR

Nonoperative Management (NOM)

Observation vs Embolization

Hemodynamics is KEY

Unstable ndash Surgery

Stable ndash CT

(predicting intervention

- 100 88 sensspec)

MountSinaiIR

Blunt Splenic Trauma - Indicators for Intervention

Active contrast extravasation

Pseudoaneurysm AV fistula

Splenic vascular injury

AAST III grade or higher

Significant blood in peritoneal

cavity

Polytrauma

Agegt50

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 4: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Who cares about the spleen

Infection risk is real -

Around 1 lifetime risk

Hospital costs and morbidity

associated with splenectomy

Pancreatic issues

MountSinaiIR

AAST Splenic Injury Grading System

Grade 3-5 without bleeding ndash

Proximal embo decreases risk

of splenectomy by 16-18

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 71 Number 4 October 2011

MountSinaiIR

Nonoperative Management (NOM)

Observation vs Embolization

Hemodynamics is KEY

Unstable ndash Surgery

Stable ndash CT

(predicting intervention

- 100 88 sensspec)

MountSinaiIR

Blunt Splenic Trauma - Indicators for Intervention

Active contrast extravasation

Pseudoaneurysm AV fistula

Splenic vascular injury

AAST III grade or higher

Significant blood in peritoneal

cavity

Polytrauma

Agegt50

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 5: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

AAST Splenic Injury Grading System

Grade 3-5 without bleeding ndash

Proximal embo decreases risk

of splenectomy by 16-18

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 71 Number 4 October 2011

MountSinaiIR

Nonoperative Management (NOM)

Observation vs Embolization

Hemodynamics is KEY

Unstable ndash Surgery

Stable ndash CT

(predicting intervention

- 100 88 sensspec)

MountSinaiIR

Blunt Splenic Trauma - Indicators for Intervention

Active contrast extravasation

Pseudoaneurysm AV fistula

Splenic vascular injury

AAST III grade or higher

Significant blood in peritoneal

cavity

Polytrauma

Agegt50

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 6: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Nonoperative Management (NOM)

Observation vs Embolization

Hemodynamics is KEY

Unstable ndash Surgery

Stable ndash CT

(predicting intervention

- 100 88 sensspec)

MountSinaiIR

Blunt Splenic Trauma - Indicators for Intervention

Active contrast extravasation

Pseudoaneurysm AV fistula

Splenic vascular injury

AAST III grade or higher

Significant blood in peritoneal

cavity

Polytrauma

Agegt50

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 7: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Blunt Splenic Trauma - Indicators for Intervention

Active contrast extravasation

Pseudoaneurysm AV fistula

Splenic vascular injury

AAST III grade or higher

Significant blood in peritoneal

cavity

Polytrauma

Agegt50

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 8: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Curative vs Preventive Embolization

Curative

Distal ndash close to bleeding source

Gelfoam particles coils glue onyx

Preventive

Proximal ndash bw dorsal pancreatic

and pancreatic magna

Vascular plugs large coils (035)

gelfoam

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 9: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Splenic Arterial Anatomy

Near the splenic hilum ndash

superior and inferior terminal branches

each terminal branch dividing into four-to-six intrasplenic segmental branches

pancreatic branches including the dorsal pancreatic artery and greater pancreatic artery (arteria pancreatica magna)

supply neck body and tail of the pancreas

short gastric arteries

arising before splenic artery enters the splenic hilum

run in gastrosplenic ligament to supply fundus and upper part of greater curvature of the stomach and anastomose with LGA over the fundus

supplies cardia and fundal regions of the stomach

left gastroepiploic artery

runs in greater omentum along greater curvature of stomach to anastomose with right gastroepiploic artery

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 10: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Splenic Artery Anatomy

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 11: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Important Collateral Pathway to the Spleen

Dorsal pancreatic rarr

transverse pancreatic rarr

arteria pancreatica magna rarr

splenic artery

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 12: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Splenic Arterial Anatomy

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 13: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Proximal vs Distal

Proximal

Decrease perfusion pressure

(around 40mmHg)

Distal to dorsal pancreatic

Distal

Preserve as much spleen as

possible

No difference in major complications

Infection major infarction or

rebleeding

More minor infarctions with

distal

The Journal of TRAUMA Injury Infection and Critical Care bull

Volume 70 Number 1 January 2011

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 14: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Proximal Distal

Proximal is good enough

Shorter procedure

Technically less challenging

Other medical

needspolytrauma

Young patientsflouro time

What if they rebleed

Technology allows us to be

selective

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 15: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Distal Embolization ndash Initial Angio

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 16: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Distal Embolization ndash Post n-BCA

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 17: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Proximal Embolization ndash Initial Angio

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 18: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Plug Deployment ndash 5F Sarah Radial Catheter (038)

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 19: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Proximal Embolization

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 20: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Ideal Location for Proximal Embolization

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 21: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Proximal Embolization ndash Amplatzer I (guide)

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 22: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Complications

Persistent Hemorrhage

requiring splenectomy

Splenic Infarct

Delayed Splenic Rupture

InfectionAbscess

Non-target embolizationcoil migration

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 23: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Migration of Coil Mass

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 24: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Efficacy and Outcomes

1-2 lifetime risk of sepsis after

splenectomy

90 success rate of SA

embolization

Decreased mortality and hospital

stay

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 25: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Non-traumatic Splenic Embolization Indications

Hypersplenism

ITP Thalassemia

idiopathic cancer

therapy

Portal Hypertension

Improve liver fx

decrease variceal

bleed encephalopathy

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN

Page 26: Splenic Trauma Indications: Is Any Spleen Too Far Gone? · PDF fileSplenic Trauma Indications: Is Any Spleen Too Far Gone? Aaron M. Fischman MD ... Young patients/flouro time What

MountSinaiIR

Summary

Proximal embolization is probably a

good strategy in majority of patients

If active extrav psuedoaneursym AV

fistula is seen distal embolization may

be appropriate

Keep in mind patient factors

PRESERVE THE SPLEEN